What is the appropriate management and treatment for a patient diagnosed with prepatellar bursitis (maid's knee), considering their occupation and the need to prevent future episodes?

Management of Prepatellar Bursitis (Maid's Knee)

For prepatellar bursitis, initial management should consist of conservative treatment with rest, NSAIDs for pain relief, and protective padding during activities, with corticosteroid injections reserved for persistent cases and surgical intervention only for refractory or septic cases. 1

Initial Assessment and Differentiation

The critical first step is distinguishing septic from non-septic bursitis, as this fundamentally alters management 2:

Clinical findings suggesting septic bursitis:

• Fever >37.8°C 2
• Prebursal temperature difference >2.2°C compared to surrounding skin 2
• Visible skin lesions or breaks in skin integrity 2
• History of recent trauma with skin penetration 3

Bursal aspirate analysis (when septic bursitis suspected):

• Purulent appearance of fluid 2
• White cell count >3,000 cells/μL 2
• Polymorphonuclear cells >50% 2
• Fluid-to-serum glucose ratio <50% 2
• Positive Gram staining or culture 2

Treatment Algorithm

For Non-Septic (Chronic/Traumatic) Bursitis

First-line conservative management (all patients): 1, 2

• Rest and activity modification
• NSAIDs for pain control 1
• Protective padding during kneeling activities 1
• Compression and immobilization 4
• Bursal aspiration if significant fluid accumulation 2

Second-line for persistent symptoms:

• Intrabursal corticosteroid injection may be considered, particularly for patients with high athletic or occupational demands requiring kneeling 1, 2
• Must use strict aseptic technique given limited high-quality evidence for benefit 1

Surgical intervention (only for refractory cases):

• Reserved for chronic/recurrent cases failing conservative management 2
• Endoscopic bursectomy under local anesthesia is effective with superior cosmetic outcomes compared to open procedures 5
• Open bursectomy carries significant risk of skin necrosis and should be avoided when possible 6

For Septic Bursitis

Conservative management with antibiotics (preferred initial approach): 2

• Bursal aspiration for diagnostic confirmation and therapeutic drainage 2
• Intravenous antibiotics (oral antibiotics often inadequate) 3
• Immobilization and compression 3, 4
• NSAIDs for pain control 2

Surgical drainage/bursectomy indications: 2

• Severe cases not responding to conservative treatment
• Refractory or recurrent infections 3
• Note: Immediate bursectomy is NOT supported by evidence and should be avoided 2

Occupational Considerations and Prevention

For workers who kneel regularly: 3

• Seventeen of 47 patients in one series were employed in jobs requiring kneeling 3
• These patients had worse long-term outcomes with persistent symptoms months to years after treatment 3
• Protective knee padding is essential during work activities 1
• Consider job modification or ergonomic interventions to minimize direct knee pressure
• Patients with preexisting chronic bursitis who continue kneeling work have particularly poor prognosis 3

Important Caveats

Treatment failures and complications:

• Oral antibiotics alone frequently fail in septic cases 3
• Twelve of 47 patients (26%) in one series had persistent symptoms long-term, particularly those with chronic bursitis or occupational kneeling 3
• Open bursectomy carries considerable surgical-site morbidity risk, especially skin necrosis 6
• Little difference exists between treatment groups in long-term outcomes, emphasizing importance of prevention 3

Key pitfall to avoid:

• Do not rush to surgical bursectomy, especially in septic cases—conservative management with IV antibiotics and aspiration is usually successful 3, 2