Prepatellar Bursitis

Prepatellar Bursitis

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The prepatellar bursa is a superficial bursa with a thin synovial lining located between the skin and the patella. In cadaveric studies, a trilaminar prepatellar bursa was found in 78-93% of people, and a bilaminar bursa was found in 7-22% cases. [1] Normally, the prepatellar bursa does not communicate with the joint space and contains a minimal amount of fluid; when it becomes inflamed, however, there is a marked increase of fluid within its space. It is clinically very important in prepatellar bursitis to differentiate between chronic nonseptic bursitis (NSB) and acute septic bursitis (SB).

Prepatellar bursitis is historically called “housemaid’s knee,” although it is also known as “coal miner’s knee” [2] and “carpet layer’s knee.” [3] In the literature, the earliest reference to the condition and its management occurred in 1861. [4] (See the image below.)

Laboratory studies are not usually indicated to diagnose prepatellar bursitis. However, aspiration of prepatellar bursa fluid may be indicated to differentiate NSB from SB. Evaluate the aspirated fluid for white blood cell (WBC) count, protein, lactate, glucose, crystals, and Gram stain results.

Plain radiographs may show soft tissue swelling; however, radiographs are necessary only if other conditions are suggested (eg, fracture and/or dislocation).

Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are reserved for cases that have been difficult to manage (eg, failure of initial treatment for septic prepatellar bursitis). [5, 6] Ultrasonography may be a useful technique for evaluating synovial fluid in the knee.

Conservative Management:

Conservative management consists of protection, rest, ice, compression, and elevation (PRICE); nonsteroidal anti-inflammatory drugs (NSAIDs); and bursal aspiration. Intrabursal steroid injection may be indicated for the treatment of chronic NSB. For acute SB, antibiotic therapy is the key treatment and should be started as soon as infection is suspected after the bursal fluid aspiration. Transient immobilization of the knee in the neutral position with a posterior splint may be needed in cases of acute prepatellar SB. [7]

Physical therapy

After the initial period of rest, the goal of physical therapy is to regain any loss of range of motion (ROM) while increasing the flexibility of the quadriceps and hamstrings. Use of therapeutic modalities can be helpful to assist stretching in this period.

Occupational therapy

The role of the occupational therapist in this scenario is to address modifications of activities in patients diagnosed with prepatellar bursitis secondary to overuse. Emphasize patient education, avoidance of kneeling, and use of kneepads if kneeling is necessary.

Surgical intervention:

Incision and drainage of the prepatellar bursa usually is performed when symptoms of acute SB have not improved significantly within 36-48 hours of antibiotic administration. Surgical removal of the bursa (ie, bursectomy) may be necessary for chronic or recurrent prepatellar bursitis. [8] Arthroscopic or endoscopic excision of the bursa has been reported to have satisfactory results with less trauma than open excision. [9, 10]

The prepatellar bursa is a flat, round, synovial-lined structure; its main function is to separate the patella from the patellar tendon and skin. This bursa is superficial, suggesting that it is undeveloped at birth. Within the first few months to years of life, the bursa arises from direct pressure and friction. It reduces friction between the skin and the patella and allows maximal range of motion (ROM).

Nonseptic bursitis (NSB) is a sterile inflammation that develops secondary to occupational or athletic trauma, crystal deposition (gout, pseudogout), or systemic disease, such as rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, [11] or uremia. Most cases of NSB result from chronic microtrauma caused by repetitive friction. Particularly vulnerable are individuals continually exposed to compressive and sheer forces between the skin and the patella bone, including members of occupational groups whose job requires frequent kneeling or crawling (eg, carpenters, gardeners, roofers) and athletes participating in sports such as ice hockey, volleyball, and wrestling. The inflammatory response causes an overproduction of bursal fluid and subsequent bursal swelling, resulting in NSB. [12, 13]

Septic bursitis (SB) results from infection of the bursal sac, which is frequently caused by skin lesions but can also arise from secondary spread of infection from initial cellulitis into a pretraumatized superficial bursa or, in rare cases, from hematogenous seeding. Infection is commonly caused by bacteria (most often Staphylococcus aureus) but can in rare cases result from fungi. [14]  The prepatellar bursa is the bursa most commonly involved in Brucella infection. [15, 16, 17]  In addition, tuberculosis of the patella may present as prepatellar bursitis. [18]

Up to 50% of all SB cases occur in immunocompromised patients. Other risk factors include chronic rheumatic inflammatory diseases.  

Hemobursa is a rare cause of acute prepatellar bursitis, except in cases of trauma or anticoagulation.

Prepatellar bursitis is the second most common superficial bursitis after olecranon bursitis.

Mortality associated with prepatellar bursitis is rare. Morbidity usually is secondary to pain and limited function. [19] In the case of septic prepatellar bursitis, failure to diagnose in a timely manner may lead to increased morbidity secondary to infectious etiology.

Prepatellar bursitis is more common in males than females.

Prepatellar bursitis can affect all age groups; however, in the pediatric age group, it is likely to be septic and to develop in an immunocompromised host.

The prognosis in prepatellar bursitis is generally good with prompt diagnosis and treatment.

Aguiar RO, Viegas FC, Fernandez RY, Trudell D, Haghighi P, Resnick D. The prepatellar bursa: cadaveric investigation of regional anatomy with MRI after sonographically guided bursography. AJR Am J Roentgenol. 2007 Apr. 188 (4):W355-8. [Medline].

SHARRARD WJ. Haemobursa in kneeling miners. Proc R Soc Med. 1961 Dec. 54:1103-4. [Medline].

Myllymaki T, Tikkakoski T, Typpo T, Kivimaki J, Suramo I. Carpet-layer’s knee. An ultrasonographic study. Acta Radiol. 1993 Sep. 34 (5):496-9. [Medline].

Richard W Martyn. Treatment of “Housemaid’s Knee”. Br Med J. 1861 Nov 23. 2:565.

Ciaschini M, Sundaram M. Radiologic case study. Prepatellar Morel-Lavallée lesion. Orthopedics. 2008 Jul. 31(7):626, 719-721. [Medline].

Borrero CG, Maxwell N, Kavanagh E. MRI findings of prepatellar Morel-Lavallée effusions. Skeletal Radiol. 2008 May. 37(5):451-5. [Medline].

Wilson-MacDonald J. Management and outcome of infective prepatellar bursitis. Postgrad Med J. 1987 Oct. 63 (744):851-3. [Medline].

Gendernalik JD, Sechriest VF 2nd. Prepatellar septic bursitis: a case report of skin necrosis associated with open bursectomy. Mil Med. 2009 Jun. 174(6):666-9. [Medline].

Huang YC, Yeh WL. Endoscopic treatment of prepatellar bursitis. Int Orthop. 2011 Mar. 35(3):355-8. [Medline]. [Full Text].

Gendernalik JD, Sechriest VF 2nd. Prepatellar septic bursitis: a case report of skin necrosis associated with open bursectomy. Mil Med. 2009 Jun. 174(6):666-9. [Medline].

Diering N, Klinger HM, Schon MP, Mossner R. Calcific prepatellar bursitis in a patient with limited cutaneous systemic sclerosis. J Dtsch Dermatol Ges. 2017 Dec. 15 (12):1248-50. [Medline].

Khodaee M. Common Superficial Bursitis. Am Fam Physician. 2017 Feb 15. 95 (4):224-31. [Medline]. [Full Text].

Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011 Jun. 19 (6):359-67. [Medline].

Cariello PF, Wickes BL, Sutton DA, Castlebury LA, Levitz SM, Finberg RW, et al. Phomopsis bougainvilleicola prepatellar bursitis in a renal transplant recipient. J Clin Microbiol. 2013 Feb. 51 (2):692-5. [Medline].

Almajid FM. A Rare Form of Brucella Bursitis with Negative Serology: A Case Report and Literature Review. Case Rep Infect Dis. 2017. 2017:9802532. [Medline].

Wallach JC, Delpino MV, Scian R, Deodato B, Fossati CA, Baldi PC. Prepatellar bursitis due to Brucella abortus: case report and analysis of the local immune response. J Med Microbiol. 2010 Dec. 59 (Pt 12):1514-8. [Medline].

Traboulsi R, Uthman I, Kanj SS. Prepatellar Brucella melitensis bursitis: case report and literature review. Clin Rheumatol. 2007 Nov. 26 (11):1941-2. [Medline].

MacLean S, Kulkarni S. Tuberculosis of the patella masquerading as prepatellar bursitis. Ann R Coll Surg Engl. 2013 Jan. 95 (1):e17-9. [Medline].

Wood LR, Peat G, Thomas E, et al. The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults. Osteoarthritis Cartilage. 2008 Jun. 16(6):647-53. [Medline].

Tuff T, Chrobak K. Septic olecranon and prepatellar bursitis in hockey players: a report of three cases. J Can Chiropr Assoc. 2016 Dec. 60 (4):305-10. [Medline]. [Full Text].

Krishna R, Rathod A, Preetham. Massive pre-patellar bursitis – a case report. Indian J Orthop Surg. 2015 Apr-Jun. 2(2):124-6. [Full Text].

Northam MC, Gaskin CM. Presumed prepatellar fibrosis in collegiate wrestlers: imaging findings and clinical correlation. Skeletal Radiol. 2015 Feb. 44 (2):271-7. [Medline].

Baumbach SF, Lobo CM, Badyine I, et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg. 2014 Mar. 134(3):359-70. [Medline].

von Dach E, Uckay I, Agostinho A, et al. One- versus two-stage bursectomy for septic olecranon and pre-patellar bursitis: a prospective randomized study. American Society for Microbiology. Available at http://www.asm.org/index.php/asm-newsroom/journal-tip-sheets/371-news-room/icaac-releases/93720-one-versus-two-stage-bursectomy-for-septic-olecranon-and-pre-patellar-bursitis-a-prospective-randomized-study. Sep 18, 2015; Accessed: Oct 20, 2015.

Uckay I, von Dach E, Perez C, et al. One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial. Mayo Clin Proc. 2017 Jul. 92 (7):1061-9. [Medline].

[Guideline] Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1. 52 (3):e18-55. [Medline]. [Full Text].

Martinez-Taboada VM, Cabeza R, Cacho PM, et al. Cloxacillin-based therapy in severe septic bursitis: retrospective study of 82 cases. Joint Bone Spine. 2009 Jul 1. [Medline].

Characteristic

Septic bursitis (SB)

Nonseptic bursitis (NSB)

Appearance

Purulent

Serosanguineous, straw colored, or bloody

White blood cell count per µL

1500-300,000; mean 75,000

50-10,000; usually < 3000

Differential count

Polymorphonuclear (PMN) cells

Predominantly mononuclear cells

Bursal fluid–to–serum glucose ratio

< 50%

>50%

Gram stain

Positive in 70%

Negative

Culture

Positive

Negative

Divakara Kedlaya, MBBS Medical Director, Physical Medicine and Rehabilitation and Pain Management, St Mary Corwin Medical Center

Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Kelly L Allen, MD † Medical Director, Medevals

Disclosure: Nothing to disclose.

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Texas Medical Association

Disclosure: Nothing to disclose.

Guy W Fried, MD Professor, Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University; Chief Medical Officer, Outpatient Medical Director, Medical Director of Incontinence and Respiratory Care Programs, Magee Rehabilitation Hospital

Guy W Fried, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Prepatellar Bursitis

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