Prepatellar Bursitis


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Definition/ Description 

In general, a bursa is a closed pocket fill with a liquor which ensures there is less friction between body parts. The inflamation of a bursa is called a bursitis. This inflamation can take form by either a infectious nature (30%) or from a non-infectious nature (70%). The infectious prepatellar bursitis is caused by a bacterial invasion from the immediately overlying skin.

Clinically Relevant Anatomy

The kneecap is a triangular shaped bone in front of the knee. It moves up and down in the groove of the femur when you bend en straighten your knee. The patellar tendon is a thick structure that connects the bottom of the patella with the tibia. The upper part of the patella is connected to the quadriceps, who provokes the knee extension and moves the patella upwards.
A bursa is a small fluid filled sac that decreases friction between two tissues. This can be between skin an a tendon or between bony structures. There are a lot of bursae around the knee. For example the semimembranosus bursa, the subsartorial bursa, the deep infrapatellar bursa, the subcutaneous infrapatellar bursa, the suprapatellar bursa and the prepatellar bursa.
The prepatellar bursitis is the most commonly injured bursa. 

Epidemiology/Etiology

Prepatellar bursitis is a also called housemaid knee or carpenters knee. The prepatellar bursitis is an ailment that often occurs in specific jobs which involve a position where they sit on their knees. Also constant friction between the skin and the patella, pressure and impacts of the anterior knee can be a cause of this condition. By an impact the damages blood vessels in the knee results in inflammation and swelling of the bursa. Another cause of a prepatellar bursitis can be a wound on the front of the knee or kneecap. The bacteria can enter the bursa due to the wound and can infect the bursa. Chronic prepatellar bursitis is caused by repeated blows or friction on the knee. The prepatellar bursitis occurs  more often in men than in women and it can emerge at all ages. An infectious prepatellar bursitis emerges more often with children than grown-ups.

We can conclude prepatellar bursitis occurs with: 
- Sudden, singular knee-injury
- Small returning injuries in the knee
- Infection, see above
- Arthritis
- Gout 

Characteristics/Clinical Presentation

The two most common symptoms are pain and swelling.  The bursa can occur an hour after a blow and can build up over weeks when there is daily friction on the knee. The pain is often present during movements, in rest and at night. The pain is shallow but there are moments where a very sharp, stinging pain can arise. On top of these two symptoms irritation and sensitivity surrounding the patella can occur. When the bursitis is infectious because of the bacterial infection of the bursa, the pains can be associated with fever. A bursitis isn’t often connected with a change in the ‘range of motion’. The flexion and extension of the knee can in some serious cases be gravely reduced, this can be caused by pain. The knee can also feel warm and the knee will feel painful while bending and stretching.

Differential Diagnosis

Medial Collateral and Lateral Collateral Ligament Injury, Osteoarthritis, Pes Anserinus, Bursitis, Posterior Cruciate Ligament Injury, Rheumatoid Arthritis, Patellar tendon rupture, Chondromalacia patella, Patellofemoral pain

Diagnostic Procedures

A bursitis can be established through anamnesis and a physical examination. The therapist has to try and determine the origin and the course of the pain during the anamnesis. It’s imperative that the therapist can exclude an infection during the diagnosis. In doubt of an infection, the therapist will extract some fluids out of the knee and send this substance to a laboratory for further examination. When the patella is under pressure the patient will feel a stinging pain in this exact spot. The pain is connected with local swelling. It is also imperative to check if there is a reduction in mobility. The testing of the patella is often not possible with patients who carry a serious prepatellar bursitis, because the tissue around the patella is very sensitive.

To make sure that the injury is a prepatellar bursitis, that the patella isn’t broken or that there aren’t any ruptures in the tendons in and around the knee, an x-ray, MRI and CAT-scan can be taken. A arthogram, aspiration or blood test can be used to rule out other injuries.

Outcome Measures

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Examination

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Medical Management

A bursitis prepatellaris should in general heal all by itself. In the first place an anti-inflammatory medication is often used. After that the doctor will advise to decrease physical activity to avoid any kind of overload. It is often suggested to use theR.I.C.E regime  in the first 72 hours after the injury or when the first signs of inflammation appear. In case that rest isn’t sufficient for full rehabilitation, the doctor may send the patient on to a physiotherapist (look at Physical Therapy Management).
In case the physiotherapist’ therapy doesn’t help, other measures must be taken.

- Infiltration.
This part of the therapy is not done by the physiotherapist himself, but he has to know the existence of it. In other serious cases the patient will have to undergo infiltration. In order to do this de doctor will inject corticosteroids into the inflamed bursa of the patient. After this infiltration has taken place, a solid pressure bandage must be placed and it is suggested that the patient rests for 48 hours.

 

- Operation.
In case of a chronic bursitis prepatellaris the doctor will suggest an operation. This only happens occasionally in heavy cases. Either the bursa shall be removed or the tendon will be extended during the operation. The extension of the tendon will reduce the pressure that is placed on the bursa, which in turn will reduce the patient’s pain. After the operation, the process of healing shall take from 6 to 8 weeks. Over time a new bursa will grow back.

Physical Therapy Management

The therapist will often begin with soft tissue massages, this is important for the trophicity and better vascularity. This is followed by some mobilisations in flexion; it is the only anatomic position where a movement restriction can occur. This is possible because of the swelling. When the passive mobilisations are done the physiotherapist will give some light exercises to the patient. A nice example of such an exercise is when the patient sits on the edge of the table and lightly lifts and then drops the knee again. As soon as the patient can fulfil the exercises without any pain, the physiotherapist will step on to more specific exercises based on muscle-strengthening en flexibility.
An important exercise is the static contraction of the quadriceps. This should be an exercise that the patient can fulfil at home 1 to 3 times a day. The objective of the rehabilitation is that patient can resume their everyday activities. The patient must push a towel into the table by using his quadriceps. To see if the exercise is working you have to put your fingers on the inner side of the quadriceps, you will feel the muscle tighten during the contraction of the muscle. The patient has to hold his contraction during 5 seconds; the exercise can be repeated 10 times as hard as possible. It is important not to forget this exercise must be pain free. The physiotherapist can also help the patient by using electrotherapy, schooling and giving advice. This advice shall mostly be about how to make the right movements. 

Besides the R.I.C.E method is a common used treatment for prepatellar bursitis. Also the stretching of the quadriceps is a good exercise for the patient, it reduces the friction between the skin and the patella tendon. There is less friction when the patella tendon is more flexible.
Ultrasound on the prepatellar bursitis is a treatment that’s not often used. Click on ‘therapeutic ultrasound’ or ‘ultrasound therapy’ for more information about this technique. 

Prevention

Avoid injury or an overload of your muscles. When you play sports, an appropriate warm-up and cool down is necassary.
See that the flexibility of the knee, the strength and edurance of the leg muscles stay optimal.
Prevent blows on the kneecap.
Use proper equipment, including kneepads when you spent of lot of your time one your knees.

Key Research

From Web of knowledge

• Infectious olecranon and patellar bursitis: short-course adjuvant antibiotic therapy is not a risk factor for recurrence in adult hospitalized patients http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=2&colname=WOS
  
• Cloxacillin-based therapy in severe septic bursitis: Retrospective study of 82 cases http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=3&colname=WOS
  
• Ossifying Bursitis Praepatellaris of the Knee Joint http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=4&colname=WOS
  
• Hemorrhagic prepatellar bursitis: a rare case report and review of the literature http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=8&colname=WOS
  
• Prepatellar Septic Bursitis: A Case Report of Skin Necrosis Associated With Open Bursectomy http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=7&colname=WOS
  
• Olecranon and prepatellar bursitis - Treating acute, chronic, and inflamed http://apps.isiknowledge.com.ezproxy.vub.ac.be:2048/full_record.do?product=UA&search_mode=GeneralSearch&qid=1&SID=S24LCBd8ahiI4bB3hJ7&page=1&doc=30&colname=WOS

Clinical Bottom Line

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Recent Related Research (from Pubmed)


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References 

• Reid, d.c, Injury Assesment and Rehabilitation, New York, 1992, p 416-438, Cuchil Levington Inc(C)
• Goroll, Allan H.; Mulley, Albert G.. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. Lippincott Williams & Wilkins. p. 1058. ISBN 9-7807-8177-5137
• Koopman, William, et al., eds. Clinical Primer of Rheumatology. Philadelphia: Lippincott Williams & Wilkins, 2003.
• Babak Shadgan, Bernard J. Feldman, and Siavash Jafari, Wrestling Injuries During the 2008 Beijing Olympic Games, Am J Sports Med September 2010 38 1870-1876; published online before print June 3, 2010, doi:10.1177/0363546510369291
• Kelley's Textbook of Rheumatology, W B Saunders Co, edited by Shaun Ruddy, et al., 2000.
• Allen KL, Fried GW; Prepatellar Bursitis. eMedicine. Article dated 2009.
• Rennie, WJ, Saifuddin, A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol 2005; 34:395.