Bursitis of the Knee

What are the signs & symptoms of knee bursitis?

A bursa is a small fluid-filled sac that acts as a cushion between the bone and muscles, tendons and skin. They allow your joints to move freely and ease rubbing.

Occasionally this sac can become inflamed or irritated and this is called ‘Bursitis’. This is commonly seen in the major joints of your body: shoulders, elbows, hips, knees or the ankle. It is often mistaken as arthritis due to the location of the pain experienced.

There are a few locations of bursa in the knee. The most commonly implicated is the ‘prepatellar bursa’ (aka housemaids or carpenters knee), this is in front of the knee cap and reduces friction in flexion and extension of the knee but due to its location it is prone to trauma from kneeling and blunt force impact.
Just above the kneecap, is the ‘suprapatellar bursa’, this bursa allows the quadriceps to glide over the lower part of the thigh bone when flexing and extending and is generally implicated in the same way as the prepatellar bursa.
As well as this, there is the ‘infrapatellar bursa’ below the kneecap. This can develop due to kneeling, chronic overuse and irritation and is commonly associated with ‘jumper’s knee’ and patellar tendonitis. Lastly is the ‘pes anserine bursa’; with this patients report medial knee pain around the knee joint line.

The most common signs and symptoms of knee bursitis are:
A dull, ache around your knee. This can build up slowly or can be acute and severe.
Redness and increased warmth around the area.
Tender to touch.
Swelling around the knee.
Stiffness and difficulty/pain when moving the knee.

Chronic bursitis occurs when there are repeated attacks of bursitis. This can lead to surrounding musculature deterioration due to lack of use at the joint due to pain experienced.

Bursitis is most common in adults over the age of 40.

It is usually caused by repetitive pressure over an area or due to overuse. You can also get bursitis as a result of a sudden injury, but it isn’t uncommon to be caused by sitting or standing in the wrong way for long, extended periods at work or home or not stretching adequately prior to exercising.

This is due to age related change in your body. Your tendons are less elastic and aren’t able to handle stress as effectively, this can put more stress on a bursa leading to bursitis.
Other conditions such as gout, tendonitis, arthritis (osteoarthritis, rheumatoid arthritis and psoriatic arthritis), diabetes and thyroid problems can also raise your risk of developing bursitis.
More rarely, bursitis can be caused by an infection (even a superficial cut getting infected).

Diagnosis of knee bursitis is based on a full case history – reviewing your symptoms and medical history followed by a physical assessment.

Occasionally you may need to be referred for further diagnostic tests. These may include:

• Aspiration – this involves a needle being used to take some fluid from the bursa to test it for signs of infection or gout.
• Imaging – X-Rays are used to rule out any other underlying problems that can be causing your pain. MRIs and Ultrasounds allow the whole joint to be examined and can examine the bursas themselves.
• Blood tests – these can be done to rule out or confirm any other conditions.

The treatment of the bursitis depends on whether or not it involves infection.

Aseptic bursitis (without infection)

This bursitis may go away with self-care such as:

• R.I.C.E. protocol – this stands for resting your knee, application of ice (always wrap the ice in another material such as a towel), compression, and elevation above heart level as often as possible.
• Anti-inflammatories and pain medications (e.g. ibuprofen and aspirin) – please seek medical advice from your pharmacist or GP if necessary.

If it persists you may be referred by your GP to see a rheumatologist, orthopedic surgeon or physical therapist for specialised treatment which can include:

• Injection of a steroid into the area to reduce swelling and pain.
• Specialised splints or braces to limit movement of the affected joint (to support the affected area until the pain eases).
• Soft tissue manual therapy to allow the muscles surrounding the bursa to reduce in tension.
• An exercise program personalised to you to treat any underlying muscular weakness that can be contributing to the pain.
• Postural and gait analysis.
• Education to avoid further overuse injuries to the knee.

Septic bursitis

• Aspiration of the fluid in the bursa with a needle.
• Antibiotics.
• If the above fails, you may be referred for surgical drainage and removal of the bursa (bursectomy).

Especially with aseptic bursitis, it can usually be treated at home and should go away within a few weeks. It can limit motion in the interim but if treated adequately, it doesn’t cause any long-lasting effects or deformities.

Yes! It may not always be possible to stop it from happening but there is a lot you can do to prevent it from occurring by:

• Maintaining a healthy weight – this takes excess load and pressure off your knee joint.
• Taking regular breaks when putting pressure on the joint, such as kneeling.
• If kneeling cushion underneath with a pillow or knee pads.
• Stretching regularly to reduce stiffness and improve flexibility.
• Warming up and cooling down after exercise so your muscles are more likely to work effectively.
• Cleaning any cuts on or around your knees to prevent an infection.

Hamstring stretch: Lie on your back with the unaffected leg flat on the floor. Raise the affected leg straight up. Put a resistance band around the arch of the affected foot and with straight arms hold onto each end. Lower the leg towards the floor against the resistance with 20% force for 10 seconds. Then bring your leg back up for 2 seconds. Repeat 8-10 times.

Quadriceps stretch: Lie on your side with the affected leg on top and the unaffected knee bent in front of you to protect your back. Bend your upper knee so that you can grasp your ankle with your upper arm. Gently pull your leg towards your buttocks until you feel a slight stretch in the front of your thigh. Keep your knee as low to the floor as possible. Hold for 30-60 seconds
You may also use a towel or a belt around your ankle to pull your leg if reaching behind is difficult.

Adductor stretch (for pes anserine bursitis): Sitting on the floor, while keeping your feet together bend your knees towards you. Let your knees fall out to the side. You should feel a stretch in the groin area. To increase the stretch you can place your elbows on your knees and lightly push down. Hold for 30-60 seconds.

*It is recommended to get to go ahead from your GP or physical therapist before carrying out any of these exercises.

Call you GP or 111 if:

• Your pain doesn’t get better/gets worse with treatment.
• Your symptoms haven’t improved in 2 weeks.
• You have a high temperature/fever or night sweats.
• You have trouble moving your knee.
• Swelling, redness and warmth around the knee.
• A severe/sharp pain in the knee.

These can be signs of an infection or indicates the need for further investigations or referral.