Best Initial Management for Prepatellar Bursitis
For chronic microtraumatic prepatellar bursitis, start with conservative management including rest, NSAIDs for pain relief, and padding to protect the knee during activities. 1
Initial Conservative Approach
The cornerstone of treatment for non-septic prepatellar bursitis involves:
- Rest and activity modification to prevent further microtrauma, particularly avoiding kneeling positions that perpetuate the condition 1, 2
- Cryotherapy with repeated applications of melting ice water through a wet towel for 10-minute periods for acute pain relief 2
- NSAIDs for short-term pain control, though these don't alter long-term outcomes 2
- Protective padding during activities to shield the bursa from ongoing trauma 1
Critical Distinction: Rule Out Septic Bursitis First
Before proceeding with conservative management, you must distinguish septic from aseptic bursitis 3:
- If infection is suspected (fever, warmth, erythema, recent skin break), perform bursal aspiration with Gram stain, culture, cell count, and crystal analysis 3
- Septic bursitis requires antibiotics effective against Staphylococcus aureus, with hospitalization and IV antibiotics for acutely ill patients 3
- Ultrasonography can help distinguish bursitis from cellulitis when the diagnosis is unclear 3
When Conservative Management Fails
For persistent cases after initial conservative treatment:
- Corticosteroid injections may be considered, though high-quality evidence for benefit is lacking and must be performed with strict aseptic technique 1
- Avoid aspiration of chronic microtraumatic bursitis due to risk of iatrogenic septic bursitis 3
- Reserve surgical intervention for cases failing 6 weeks of conservative therapy 2
Important Caveats
- Do not immobilize completely for extended periods as this causes muscular atrophy 2
- Aspiration is generally not recommended for chronic microtraumatic bursitis despite being appropriate for acute traumatic/hemorrhagic bursitis 3
- Address underlying occupational factors in patients whose work involves kneeling, as they have worse long-term outcomes 4