Prepatellar Bursitis - clinical pattern sheet PDF

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clinical pattern sheet...

Description

Condition Prepatellar Bursitis Definition / Description A bursa is a small sac of fibrous tissue with a thin synovial lining that is filled with synovial fluid. They are found between bones, tendons and skin and help to reduce friction by lubricating the area and acting as a barrier to aid gliding. They also help to dissipate force by spreading it through their fluid content. There are many bursae (plural of bursa) located around the knee joint and all are susceptible to bursitis but the prepatellar bursa is most commonly affected. The prepatellar bursa is located superficially on the anterior aspect of the knee between the skin and the patella. The bursa does not communicate with the knee joint and the knee joint itself is normal in prepatellar bursitis.

Bursitis is inflammation within a bursa. The inflammation leads to an increase in synovial fluid production and causes the bursa to swell. Prepatellar bursitis can be caused by a bacterial invasion from the immediately overlying skin or from a fall or recurrent trauma such as prolonged kneeling forwards. Populations / Risk Factors All age groups can be affected by Prepatellar bursitis however septic (infected) bursitis is more common in children and the immunocompromised. This form of bursitis is usually caused by a break in the skin near the bursa which allows bacteria to enter. Chronic prepatellar bursitis (also known as ‘housemaids knee’ or ‘carpenters knee’) is common amongst people who have to frequently (or for prolonged periods of time) kneel and lean forwards as it causes repeated blows or friction to the bursa.

People who have suffered an acute trauma like a fall or direct blow onto the knee can also suffer from prepatellar bursitis. People who suffer from other inflammatory conditions like rheumatoid arthritis, gout, syphilis and tuberculosis are also susceptible to prepatellar bursitis. Symptoms      

The two most common symptoms are pain and swelling The pain is often present during movement, at rest and at night. It can be shallow but there are moments where a very sharp, stinging pain can arise. Redness and increased warmth of the area can also occur (particularly if it is septic) When the bursitis is septic, the pain can be associated with fever Irritation and sensitivity surrounding the patella can occur In serious cases, any movement of the knee is reduced because the compression of the bursa during the movement causes pain

Clinical Signs Physical examination:  Tenderness on palpation and swelling superficial to the patella  Swelling may be significant enough that patella becomes impalpable  Skin overlying bursa may be warmer than expected and red suggesting sepsis  Joint range of movement may be normal as the knee joint itself is normal  However ROM (especially extreme knee flexion) can be reduced due to compression of bursa causing pain  Sometimes AROM is affected but PROM is fine History      

History of other inflammatory diseases such as rheumatoid arthritis, gout, syphilis and tuberculosis Is the patient immunocompromised? Has there been a recent cut/injury to the skin over the patella Has there been a recent trauma to the knee Does their occupation or daily activities involve excessive kneelingBursitis can build up over weeks when there is daily friction on the knee Pain, swelling and tenderness over area

Investigations    

Palpation of bursa and patella (check site of pain) Check the integrity of knee joint to rule out joint damage- passive movement and ligament stability tests ROM is normally okay but extreme flexion should be uncomfortable/painful due to pressure on the bursa Important to distinguish between septic and non-septic bursitis. If has

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any of the following it could be septic: o The patient has any symptoms of fever such as tachycardia, hypotension or increased respiratory rate o Localized swelling and erythema overlying the patella o Increased warmth of skin overlying the affected bursa compared to the contralateral knee o Aspiration (take a sample of fluid) of the prepatellar bursa and aspirate should be sent for examination In cases of trauma an x-ray should be taken to eliminate a patella fracture An MRI, ultrasound of CT scan can also be taken if unsure whether the symptoms are caused by bursitis or another condition

Atypical Presentations Prepatellar bursitis can have similar symptoms to:  Rheumatoid Arthritis: A systematic autoimmune inflammatory disease which causes persistent inflammation of synovial tissue  Osteoarthritis: an inflammation of the bone and knee joint  Septic arthritis of the knee: The swelling in bursitis is usually distinguishable as being prepatellar but, if very large, the whole knee can appear swollen and so appear as septic arthritis  Patellar tendon rupture  Chondromalacia patella/ Patellofemoral Pain Syndrome (“runner’s knee”, Pain caused by cartilage on the undersurface of the patella deteriorates and softens/ ill tracking of patella)  Cellulitis- An infection of the dermis and subcutaneous tissue (but may co-exist with septic prepatellar bursitis)  Knee joint effusion secondary to trauma  Pes Anserinus bursitis  Infrapatellar bursitis

Management Options and Levels of Evidence

Important to work out whether bursitis is septic or not  If septic, immediate medical care (antibiotics) is necessary to make sure the infection does not spread  If symptoms of septic bursitis have not improved significantly within 3648 hours of antibiotic treatment, incision and drainage are usually performed Initial steps for non-septic/ non-urgent septic bursitis:  Should, in general, heal all by itself  An anti-inflammatory medication is often used  Advise to decrease physical activity to avoid any kind of overload  RICE 72 hours after the injury or when the first signs of inflammation appear  Provide knee pads or mats if bursitis caused by occupation to reduce irritation Conservative management/ therapy:  May begin with soft tissue massage  Mobilizations in flexion  Light ROM exercises  When patient can do them, focus more on improving muscular strength that may have been lost  Also increase flexibility of quadriceps as this can reduce friction between patella tendon and skin  Electrotherapy (such as ultrasound) can also be used to decrease healing time and pain- but there is limited evidence supporting this  Progressive rehab back to ADL and usual function Medical management:  Aspiration (drainage) for those unresponsive to physio  Infiltration (injection of a corticosteroid) to reduce inflammation- But do not use if bursitis is septic and even so it can cause complications Surgical management: If the patient does not respond to any of the above or has severe chronic bursitis, then surgical treatment is an option.  Arthroscopic bursectomy: can be performed under local anesthetic on an outpatient basis and the cosmetic effect is better than open bursectomy  Open bursectomy: the traditional open surgical approach of removing a bursa Useful Resources https://patient.info/doctor/prepatellar-bursitis http://www.physio-pedia.com/Prepatellar_bursitis http://emedicine.medscape.com/article/2145588-clinical#b3

https://bestpractice.bmj.com/best-practice/monograph/523/diagnosis/historyand-examination.html?locale=tr https://cks.nice.org.uk/pre-patellar-bursitis#!diagnosissub:1 https://www.physioadvisor.com.au/injuries/knee/prepatellar-bursitis/...