What is the best treatment approach for a patient with bilateral anterior knee bursa swelling who requires frequent kneeling for their job and is currently using knee pads (Non-Steroidal Anti-Inflammatory Drugs, NSAIDs)?

Treatment of Bilateral Anterior Knee Bursa Swelling in Occupational Kneeling

For a patient with bilateral prepatellar bursitis who must continue kneeling for work despite using knee pads, combine NSAIDs (oral or topical) with quadriceps strengthening exercises, and if symptoms persist after 4-6 weeks of conservative therapy, proceed to corticosteroid injection into the inflamed bursa. 1, 2

Initial Conservative Management (First 4-6 Weeks)

Pharmacological Approach

• Start with topical NSAIDs (diclofenac gel) as first-line therapy, particularly if the patient is ≥75 years old, due to superior safety profile while maintaining efficacy 1, 3
• Oral NSAIDs (ibuprofen or naproxen) should be used if topical agents are insufficient for pain control and inflammation reduction 1, 3
• Acetaminophen (up to 4,000 mg/day) serves as an alternative for patients who cannot tolerate NSAIDs 1, 4

Non-Pharmacological Interventions

• Quadriceps strengthening exercises are strongly recommended to preserve normal knee mobility and reduce pressure on the bursa 1, 4
• Continue using knee pads during work, but ensure they are properly fitted and provide adequate cushioning without creating additional pressure points 1
• Consider additional protective appliances such as knee sleeves or elastic bandages for supplemental support during occupational activities 4
• Activity modification during acute flares by minimizing direct kneeling pressure when possible, though complete avoidance may not be feasible given occupational requirements 2

Second-Line Treatment for Persistent Symptoms

Corticosteroid Injection

• If conservative measures fail after 4-6 weeks, ultrasound-guided corticosteroid injection (24 mg betamethasone with 1% lidocaine or equivalent) into the prepatellar bursa is indicated 5, 2, 6
• This approach shows significant pain improvement with documented efficacy in bursitis management, though recurrence rates of 20-40% exist 7, 6

Emerging Biologic Therapies

• Platelet-rich plasma (PRP) or PRP combined with hyaluronic acid (PRP+HA) may be considered for refractory cases that fail corticosteroid injection, as these show improved pain relief and reduced recurrence compared to steroids alone 7
• These biologic options are supported by Level II evidence specifically for knee bursitis, though protocols remain heterogeneous 7

Surgical Consideration for Intractable Cases

• Surgical excision (bursectomy) is reserved for chronic, massive, or recalcitrant bursitis that fails all conservative and injection-based therapies 8, 2
• This is rarely necessary but has shown successful outcomes with no recurrence in properly selected cases 8

Critical Pitfalls to Avoid

• Do not bypass topical NSAIDs in favor of oral agents without trial, as topical formulations have superior safety profiles, especially in older adults 3
• Ensure adequate duration of conservative therapy (minimum 4-6 weeks) before proceeding to injections, as premature escalation may expose patients to unnecessary procedural risks 2
• Rule out septic bursitis before corticosteroid injection through clinical assessment (fever, warmth, erythema) and aspiration if infection is suspected, as steroid injection into infected bursa can worsen outcomes 2
• Document that knee pads are properly fitted and adequate, as improper protective equipment may contribute to ongoing trauma despite compliance 1

Combination Therapy Rationale

• Optimal management requires combining pharmacological and non-pharmacological modalities rather than relying on single interventions 9
• The combination of NSAIDs with exercise therapy shows additive benefit beyond either treatment alone, with effect sizes supporting this multimodal approach 9