Bursitis is an inflammation in one of the small fluid-filled sacs (bursae) often found near joints in the body. It can be very painful and limit mobility. The inflammation can result when too much pressure is put on one of these sacs (a bursa). The bursa, Latin for the bag is made of connective tissue and filled with synovial fluid. Like tiny pillows, they cushion parts of the body like elbows, which are often exposed to friction and pressure. There are over one hundred bursae in the human body, and many of them are near joints.

 Prevalence and outlook:


Each year, at least 1 in 10,000 people develop bursitis in the knees or elbows alone. One-third of these inflammations are caused by bacterial infection. Middle-aged men are affected the most. That is probably because they more commonly have jobs that are associated with a greater risk of bursitis. If the area is rested, the inflammation usually goes away within 2 or 3 weeks. Sometimes it remains permanent, though, for example, because the person continues doing the activity that caused it in the first place.

Causes and risk factors:

1: Injury by a heavy blow, for example during a fall.
2: Irritation by too much friction or pressure.
3: German-like bacteria can enter the bursa too causing inflammation.
4: Sometimes inflammatory diseases such as rheumatoid arthritis and gout spread to the bursa as well, causing bursitis.
5: Some jobs are associated with a high risk of bursitis. Tile installers are typical examples. Their work often involves kneeling on the hard floor.
6: Other high-risk occupations include carpenters, cleaners, roofers, and gardeners
7: Working for a long time on the computer and doing some type of sports like volleyball may also make bursitis more likely.

Symptoms:

If a bursa becomes inflamed, more fluid will build up inside it than usual. It is then referred to as effusion. This leads to swelling that is seen and felt from the outside, especially if the inflamed bursa is right under the skin. The swollen area hurts when it is resting but is especially painful when it is moved or when pressure is put on it from the outside. It sometimes looks red and warm too. You may also develop a fever and generally feel unwell.
Diagnosis:
Inflamed bursae that are right under the skin can easily be diagnosed. They are swollen and painful and are sensitive to pressure. Reddened, warm skin is also a sign of inflammation. It is important to find out whether the inflammation is caused by bacteria. If it is accompanied by fever and/or a wound close to the inflamed area, it is likely to be a bacterial infection. For confirmation, a doctor takes some fluid from the bursa using a hollow needle (cannula) and has it tested in the laboratory. Blood tests can detect further signs of inflammation or show whether the inflammation is being caused by a disease such as gout.
Imaging techniques like ultrasound and X-rays are taken to rule out the other possible causes of the symptoms, such as bone or joint injuries. They can also help to check whether bursitis may have already damaged nearby tissue.

Management:

1: Pharmacological management: The treatment primarily depends on the cause of the disease and secondarily on the pathological changes in the bursa. The primary goal of treatment is to control inflammation.
2: Conservatively, the R.I.C.E. regimen (rest, ice, compression, elevation) in the first 72 hours after the injury or when the first sign of inflammation appears.
3: Medications include non-steroidal anti-inflammatory drugs (NSAIDs), and topical medications- sprays, creams, gel, and patches can provide pain relief when those are directly applied to the skin over the knee.
4: Also, for cases of septic prepatellar bursitis, antibiotics are used to treat the infection.
5: Surgical Management; When conservative treatments have failed for chronic/ post-traumatic knee bursitis, outpatient arthroscopic bursectomy under local anaesthesia is an effective procedure.


Physical therapy management; The Rest, Ice, Compression, and Elevation method is a commonly used treatment for prepatellar bursitis. The ‘rest phase’ consists of a short period of immobilization. This period should be limited to the first days after the trauma. Resting will reduce the metabolic demands of the injured tissue and will avoid increased blood flow. The use of ice will cause a decrease in the temperature of the tissues in question, inducing vasoconstriction and a limitation of bleeding. Also, the pain will decrease because cold will cause increasing threshold levels in the free nerve endings and at synapses. Don’t place the ice too long on your knee (maximum 20 minutes at a time with an interval of 30-60 minutes). The compression will decrease the intramuscular blood flow to the affected area and will also reduce the swelling. Lastly, there is the elevation. This ensures that the hydrostatic pressure will decrease and it will also reduce the accumulation of interstitial fluid. This part of the Rice-Principle also decreases the pressure in local blood vessels and helps to limit the bleeding. However, the effectiveness of this RICE method has not been proven in any randomized clinical trial
Once the initial inflammation has reduced a program of stretching and light strengthening will be initiated to restore full motion and improve strength to reduce stress on the tendons and knee joint. Therapeutic exercises to strengthen and stretch the muscles of the knee. This includes static contraction of the quadriceps. This should be an exercise that the patient can do at home 1 to 3 times a day. The objective of the rehabilitation is that the patient can resume their everyday activities. 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 for 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.


Also, the stretching of the quadriceps is a good exercise for the patient, it reduces the friction between the skin and the Patella's tendon. There is less friction when the patella tendon is more flexible. The physiotherapist can also help the patient by using electrotherapy modalities and patient education on the use of knee pads for kneeling activities.

 
References.
Colby and Kissner : The Comprehensive Model of Therapeutic Exercises by Elizabeth Bryan, 2018