Knee Bursitis

Bursitis is an inflammation of the small fluid-filled sac or bursae near the joints in the body. The inflammation occurs when too much pressure is put on one of these sacs. It can be very painful and also limit mobility. The bursa is made of connective tissue and filled with synovial fluid, they cushion various parts of the body like the elbow, which are often exposed to friction and pressure. Knee bursitis most commonly occurs over the kneecap or on the inner side of the knee below the knee joint.

If a bursa becomes inflamed, more fluid builds up inside it than usual. Knee bursitis symptoms may vary, depending on the site of the bursa affected and the cause of inflammation. These involve:

• Swelling seen and felt from outside, especially if the inflamed bursa is exactly under the skin,
• Painful when moved or when pressure is applied from outside,
• Pain even at rest,
• The affected portion of the knee might feel warm,
• Tenderness present,
• Red and warm,
• The patient may develop a fever and feel unwell.

Pathology:

Bursitis is the inflammation of a bursa. Bursae are saclike structures present between the skin and the bone or between tendons, ligaments, and bone and are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures. Bursitis occurs when the synovial lining becomes thickened, producing excessive fluid, leading to localized swelling and pain.

The initial inflammation is a natural response from the body, this process allows cells and nutrients to gather around the injury to start the healing process. The various causes of knee bursitis can be:

• Heavy blow during a fall,
• Direct impact on the bursa,
• Excessive friction or pressure,
• Frequent or prolonged kneeling also known as housemaid's knee,
• Overuse or strenuous activity,
• Bacteria can enter the bursa, causing inflammation,
• Inflammatory diseases such as osteoarthritis, rheumatoid arthritis, and gout,
• Some jobs in which they work often involve kneeling on the hard floor,
• Occupations include carpenters, cleaners, roofers, gardeners,
• Working for a prolonged period on the computer,
• Sports like runners, volleyball, wrestling, football, etc,
• Obesity.

Physical examination:

The examiner compares the condition of both knees, particularly if only one is painful, then gently the areas of the knee are palpated to detect the warmth, swelling, and the source of pain. The examiner inspects the skin over the tender area for redness or other signs of infection. The patient is then asked to move the legs and knees to determine the knee's range of motion and whether it hurts to bend or flex it.

X-ray:

X-ray helps to reveal any problem with bone or arthritis.

Magnetic resonance imaging (MRI):

Magnetic resonance imaging (MRI) uses radio waves and a strong magnetic field to produce detailed images of structures in the body. This imaging helps to visualize soft tissues, such as bursae.

Ultrasound:

Ultrasound uses sound waves to produce images in real-time, ultrasound can help the examiner to better visualize swelling in the affected bursa.

Laboratory tests:

Laboratory tests are done to find out if any inflammation is caused by bacteria. If the patient also suffers from fever or a wound close to the inflamed area, then it can be a bacterial infection. For confirmation, the examiner takes some fluid from the bursa using a cannula and gets it tested in the laboratory.

Blood tests:

Blood tests are done to detect the signs of inflammation or show whether the inflammation is being caused by a disease such as gout.

Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium aspirin, ibuprofen, antibiotics, topical medications like sprays, creams, gel, and patches.

Note: Medication should not be taken without the doctor's prescription.

Corticosteroid injection:

A corticosteroid drug is injected into an affected bursa to reduce inflammation. The inflammation usually subsides rapidly, but the patient might feel pain and swelling due to the injection for a couple of days.

Aspiration:

Bursa is aspirated to reduce excess fluid and treat inflammation. A needle is inserted into the affected bursa and the fluid is drawn into the syringe. Aspiration can cause short-term pain and swelling, and the patient might need to wear a knee immobilizer for a short period after the injection to reduce the chance of recurrent swelling.

Surgery:

In case the severe chronic or recurrent bursitis does not respond to other treatments, then surgery such as arthroscopic bursectomy under local anesthesia is recommended to remove the bursa.

Rest:

Activity that has caused knee bursitis, should be discontinued, and also avoid movements that worsen the pain. Rest reduces the metabolic demands of the injured tissue and avoids increased blood flow.

Ice:

An ice pack should be applied to the knee for 20 minutes several times a day until the pain goes away and the knee no longer feels warm to the touch. Ice causes a decrease in the temperature of the tissues and causes vasoconstriction and limitation of the bleeding. It also decreases the pain because cold causes an increase in the threshold levels in the free nerve endings and at synapses.

Compression:

A compressive wrap or knee sleeve is used to reduce swelling. Compression decreases the intramuscular blood flow to the affected area and also reduces the swelling

Elevation:

The affected knee is elevated and kept on pillows to help reduce swelling in the knee. Elevation ensures a decrease in the hydrostatic pressure and also reduces the accumulation of interstitial fluid. It is a part of Rice-principle, r-rice, i- ice, c-compression, and e-elevation.

Transcutaneous electrical nerve stimulation (TENS):

Transcutaneous electrical nerve stimulation (TENS) or EMS (electrical muscle stimulation) is very effective for treating knee pain.

Ultrasound therapy:

Ultrasound therapy is used to treat the painful knee. Its deep micro-massage effect and tissue thermal effectiveness are found to be effective to reduce pain and swelling.

Low-level laser therapy (LLLT):

Low-level laser therapy is the application of red light over the injured area to stimulate cellular repair. LLLT has a powerful anti-inflammatory effect and also a healing effect on inflamed bursae and surrounding soft tissues. 

KT Tape:

KT tape helps to relieve pressure off of the inflamed bursae and also increases the circulation to the area. As a result, the pain reduces and also reduces the healing time.

Manual therapy:

Manual therapy involves soft tissue massage and joint mobilization by a physiotherapist to regain mobility and range of motion of the knee.

Stretching Exercises:

Once the initial inflammation is reduced stretching is given, the initial focus should be on pain-free movement, and stretching exercises generally start with gentle stretching to improve flexibility. It also promotes healing of the affected area and reduces the friction between the skin and the patella tendon. When the patella tendon is more flexible less friction is produced. Stretching exercises like a seated hamstring stretch, calf stretch, posterior knee capsule stretch, etc are recommended.

Strengthening Exercises:

Light strengthening exercises are initiated to restore full motion and improve strength to reduce stress on the tendons and knee joints. Static contraction of the quadriceps is done 1 to 3 times a day so that the patient can resume everyday activities. To check if the exercise is working, fingers are placed on the inner side of the quadriceps to feel the muscle tighten during the contraction of the muscle. The patient is asked to hold his/ her contraction for 5 seconds but should be pain-free, and can be repeated 10 times as hard as possible. Light strengthening exercises like straight-leg raises in supine and side-lying, ankle-toe movements, etc are recommended. 

The physiotherapist advises the patient to use knee pads for kneeling activities, to avoid activities that worsen the knee pain, avoid excessive repetitious bending of the knees like excessive squatting. And also take rest before the patient feels pain.