management

Last edited 05/2019

  • 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: