Management

• management depends on whether septic or non-septic bursitis
  
  
• conservative management - general measures for pre-patellar bursitis
  • rest, ice, and reduced activity
  • consider analgesia such as paracetamol or a nonsteroidal anti-inflammatory drug such as ibuprofen
  • avoid trauma to the knees - however if this is not possible, suggest protective knee pads

Non-septic bursitis

• medical treatment
  • consider aspiration of the prepatellar bursa (using an aseptic technique) - only indicated if non-septic bursitis
    • specialists may consider an intra-bursal corticosteroid injection if there has been failure of conservative treatment
      • requires exclusion of infection
      • may be considered if person is an athlete or has high occupational demands where repeated kneeling is required
  • routine bursal aspiration and corticosteroid injection are not recommended for the treatment of aseptic bursitis due to a lack of supporting evidence and risk of adverse effects such as infection, skin atrophy, and chronic pain (1)
    
    
• surgical treatment
  • may be indicated if chronic or recurrent
  • surgical options include:
    • arthroscopic bursectomy
    • open bursectomy

Septic bursitis

• prepatellar septic bursitis is usually successfully managed non-operatively with rest, compression, immobilisation, aspiration and antibiotics (1)
• if septic bursitis is suspected - aspirate bursal fluid using an aseptic technique:
  • treat empirically with an oral antibiotic that covers staphylococcal and streptococcal species until culture results are known
    • adult doses
      • flucloxacillin (500 mg four times a day) is the preferred antibiotic.
      • clarithromycin (500 mg twice a day) may be used if the person is allergic to penicillin
        • if patient is pregnant or breastfeeding then Erythromycin (500 mg four times a day) is the preferred macrolide
      • in mild to moderate cases of septic bursitis, oral antibiotics can be given for 2 weeks - seek specialist advice if longer periods of treatment are required (1)
  • if patient is immunocompromised people then seek urgent specialist advice
  • incision and drainage of the bursa may be indicated if there has not been significant improvement in the condition after 36-48 hours
  • regular review is required to guide management

Seeking specialist advice

• urgent same day secondary care review is indicated if:
  • patient is systemically unwell (for example with features of sepsis) or,
  • septic bursitis is severe/ infection spreading to surrounding tissue or,
  • patient is immunocompromised or has serious comorbidities, such as diabetes or rheumatoid arthritis (1) or,
  • development of an abscess - requires incision and drainage or,
  • if there is clinical suspicion of infection of the underlying knee join (septic knee joint)
    • if there is a limitation in range of movement of knee join - unlike in septic bursitis
      
      
• seek urgent specialist or orthopaedic advice if
  • if there is inadequate response/worsening of septic bursitis despite antibiotic treatment
    • may require intravenous antibiotic therapy/change in antibiotic regime/surgical intervention
      
      
• orthopaedic referral is required - urgency will depend on clinical judgement
  • if there is a history of recurrent septic bursitis
  • if there is a chronic discharging bursal sinus
  • in non-septic bursitis
    • specialist advice should be sought if conservative treatment not affective/bursitis associated with significant pain/swelling.

Reference:

• NICE CKS - Pre-patellar bursitis (Accessed 15/5/2019)
• Baumbach SF et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm.Arch Orthop Trauma Surg. 2014 Mar;134(3):359-70
• Aron DL et al. Four common types of bursitis: diagnosis and management.J Am Acad Orthop Surg. 2011 Jun;19(6):359-67
• Primary Care Rheumatology Society (PCRS). Joint and soft tissue Injection guidelines PCRS (Updated 2017)