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Definition/ Description 

Prepatellar bursitis is also dubbed housemaid"s knee or carpenter"s knee. A bursa is a fluid-filled sac which ensures tright here is much less friction in between body components. The prepatellar bursa is situated superficially between the skin and the patella. The inflammation of a bursa is dubbed bursitis. This inflammation can take create by either an contagious nature (30%) or a non-infectious nature (70%). A direct loss on the patella, an acute trauma, repeated blows or friction on the knee might cause prepatellar bursitis. Other causes incorporate infections or low-grade inflammatory problems, such as gout, syphilis, tuberculosis or rheumatoid arthritis.

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<1> Prepatellar bursitis regularly occurs in particular tasks which entails a place wright here they work-related on their knees for a prolonged period of time such as miners, gardeners, carpet layers and also mechanics.<1>

Clinically Relevant Anatomy

The patella is a triangular-shaped bone in front of the knee. It moves up and down in the groove of the femur as soon as you bfinish and also straighten your knee. The patellar tendon is a thick framework that connects the bottom of the patella through the tibia. The top part of the patella is linked to the quadriceps, which permits the knee expansion and also moves the patella upwards. Bursae approximately the knee have the right to be divided into two groups- those about the patella (suprapatellar bursa, the superficial and deep infrapatellar bursae & prepatellar bursa) and also those that happen in other places (pes anserinus bursa and also the iliotibial bursa) <2> <1>

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Epidemiology

Prepatellar bursitis affects males more regularly than womales and it have the right to emerge at all eras. 80% of the human being through prepatellar bursitis are guys aged in between 40 – 60 years. 1/3 of the prepatellar bursitis are septic and 2/3 are non-septic. <3> An infectious prepatellar bursitis emerges even more frequently via kids than grown-ups. Prepatellar bursitis occurs often, with at leastern an annual incidence of 10/100 000. The incidence of prepatellar bursa is probably underapproximated bereason a lot of of the case are non-septic and just patients with the many severe cases of prepatellar bursitis requires admission in the hospital. <4>

Etiology

Direct trauma/blow to the anterior kneeFrequent drops on the kneeCo-existing inflammatory disease- rheumatoid arthritis, gout and so on.

Characteristics/Clinical Presentation

PainDifferential warmth around the kneePainful and restricted ROM at the kneeIf bursitis is brought about by an infection, pain is connected through fever and chills.

Differential Diagnosis

Prepatellar bursitis is often confused with other reasons of knee pain including: <6>

Pes Anserinus bursitisPatellar tendon ruptureChondromalacia patellaePatellofeethical pain

Diagnostic Procedures

<7>Bursitis can be diagnosed through a thorough history (about the onset of symptoms, the pattern of knee pain and also swelling and also how the symptoms influence their lifestyle)<8> and also a physical examination, however, X-ray, MRI and also CT-shave the right to can be done to preeminence out the possibility of a fracture or soft tproblem injury. If it is unparticular whether or not the bursa is infected, an arthrocentesis can be done. It is typically done for 3 reasons: vital indevelopment is needed to make a diagnose, to relieve the press in the joint and will certainly help alleviate the pain and excess liquid additionally requirements to be rerelocated before a therapeutic injection is provided. <9>

Outcome Measures

Physical Examination

Physical examination entails checking for:

Differential warmth roughly the kneeErythemaTendernessSwellingPainRange of motion

When tright here is a restricted selection of movement or swells, a doctor might recommfinish using a needle and syringe to rerelocate the liquid from the joint. This fluid have the right to be sfinish to labs for experimentation whether or not the bursa is infected. Usual tests for infection are gram stain, white blood cell count (an elevated number of white blood cells in the synovial liquid indicates infection) and glucose levels tests (as soon as the levels are considerably reduced than normal it may indicate an infection). Gram stain is supplied to recognize if there are specific troublesome bacteria current. Not all bacteria’s deserve to be identified. Even when the test comes earlier negative, septic bursitis cannot be totally ruled out. <9>

Medical Management

The therapy for prepatellar bursitis counts primarily on the reason of the bursitis and secondarily on the pathological alters in the bursa.

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<12> The primary goal of treatment is to control the inflammation.

Medications including non-steroidal anti-inflammatory drugs, topical medications- creams, sprays, gels and also patches have the right to provide pain relief as soon as those are straight used to the skin over the knee. To alleviate the gastrointestinal side effects that have the right to be resulted in by oral medications, topical medications might be a great option. Also, for cases of septic prepatellar bursitis, antibiotics are used to treat the infection.Corticosteroid injections

Surgical Management

When conservative therapies have actually failed for chronic/post-traumatic prepatellar bursitis, outpatient arthroscopic bursectomy under neighborhood anaesthesia is an efficient procedure. Arthroscopic or endoscopic excision of the bursa has actually more freshly been reported to have satismanufacturing facility outcomes through much less trauma than open up excision.<13><14>

Operative Technique

The patients are placed in a supine position and the tourniquet will certainly be routinely used on the thigh and not inflated till vital. The skin will be ready in an aseptic manner over the entirety reduced extremity. A solution will certainly be infiltrated at the portal website and also into the cavity, respectively a 1% xylocaine solution through a 1:100,000 epinephrine. For monitoring a 2.7-mm, 30-level endoscope will be supplied and also a 2.7-motorised shaver to remove thickened synovium. Two or three 2mm portals will certainly be made; an anterior medial portal and also anterior lateral portal are routinely provided and also if crucial a remarkable lateral portal. To make a 2mm incision for each portal, a no. 11 scalpel will be supplied. After this, the trochar will be placed right into the cavity and also the other tools will certainly follow. The bursa cavity and synovial thickening are straight visible by the endoscopy. The motorized shaver inserts with the other portal and full synovectomy consisting of the bursa will be perdeveloped till all the pathological lesions are removed. When all the steps are completed, the portals will be closed through adhesive tape without any kind of suture. The anterior knee area is dressed with loosely unfolded gauze, padding and bandage are used. <1>

Physical Therapy Management

The Rest, Ice, Compression and also Elevation method<15> (level of proof 2a) is frequently offered therapy for prepatellar bursitis. The ‘rest-phase’ consists of a brief period of immobilization. This period need to be restricted to the initially days after the trauma. Resting will mitigate the metabolic needs of the injured tissue and will prevent increased blood circulation. The usage of ice will reason a decrease of the temperature of the tconcerns in question, inducing vasoconstriction and also a limitation of the bleeding. Also, the pain will decrease because cold will certainly cause raising threshold levels in the complimentary nerve endings and also at synapses. Don’t location the ice too lengthy on your knee (maximum 20 minutes at a time through an interval of 30-60 minutes). The compression will decrease the intramuscular blood flow to the impacted location and will likewise reduce the swelling. At ultimately there is the elevation. This ensures that the hydrostatic push will certainly decrease and also it will likewise mitigate the accumulation of interstitial liquid. This part of the Rice-principle also decreases the press in regional blood vessels and also helps to limit the bleeding. However before, the effectiveness of this RICE-strategy has not been prrange in any kind of randomized clinical trial. <16>

Once the initial inflammation has decreased a regime of stretching and light strengthening will be initiated to regain full motion and enhance toughness to minimize anxiety on the tendons and knee joint. Therapeutic exercises to strengthen and also stretch the muscles of the knee. This contains static contractivity of the quadriceps<17>. This should be an exercise that the patient can execute at home 1 to 3 times a day. The objective of the rehabilitation is that the patient deserve to resume their day-to-day activities. To see if the exercise is functioning you need to put your fingers on the inner side of the quadriceps, you will certainly feel the muscle tighten throughout the contractivity of the muscle. The patient hregarding organize his contractivity for 5 seconds; the exercise have the right to be recurring 10 times as tough as possible. It is crucial not to foracquire this exercise must be pain-complimentary.

Also, the extending of the quadriceps is an excellent exercise for the patient, it reduces the friction between the skin and also the patella tendon. Tright here is much less friction once the patella tendon is even more flexible. The physiotherapist have the right to likewise assist the patient by making use of electrotherapy modalities and also patient education on the usage of knee pads for kneeling tasks.

Prevention

In order to proccasion prepatellar bursitis you should protect against injury or an overload of your muscles. It is extremely crucial to perform an appropriate warm-up and cool dvery own, while playing sporting activities. For instance, if you play volleyball, it is advisable to wear knee pads. This will certainly prevent falling on the kneecap. Also when you spent the majority of time on your knees is it advisable to wear knee pads. Anvarious other vital point to stop prepatellar bursitis is to examine if the adaptability of the knee and also the toughness and also endurance of the leg muscles continues to be optimal. <2>

Key Research

Yu-Chih H, et al. Endoscopic treatment of prepatellar bursitis. Int Orthop 2011; 35(3): 355–358.(2)Hurkmans E.J., et al. KNGF-tip for Physical Therapy in patients via rheumatoid arthritis. 2008; 118 (5): 13-16.(1)

Resources

• http://www.drlox.com/knee-pain-v2/knee-bursitis/• http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/knee/prepatellar-bursitis• http://www.arthritis-health.com/types/bursitis/knee-prepatellar-bursitis

Clinical Bottom Line

The prepatellar bursa is located under the skin and also occurs in a lot of world. When a bursa is inflamed, it"s referred to as bursitis. The inflammation can be of an infectious nature or a non-transmittable nature. Many kind of various aetiologies have actually been proposed as the cause of prepatellar bursitis. Chronic inflammation of prepatellar bursa after recurring minor trauma is called ‘housemaid’s knee’. It have the right to be checked out in those who have to kneel very frequently, such as carpet layers and housemaids. Also a fall straight on the patella, an acute trauma, may reason patellar bursitis. Treatment for prepatellar bursitis relies mostly on the cause of bursitis and also secondarily on the pathological adjust in the bursa. A surgical procedure is in the majority of situations not forced, however if necessary, the surgical steps involved are (1) aspiration and irrigation with a perfect drug, (2) incision and drainage in cases of acute suppurative bursitis, and (3) excision of chronically infected and also thickened bursa. <1>