Background and Etiology
The knee is the largest joint in the body. It is built for weight bearing, stability and mobility. The knee complex is composed of four bones and three osseous bone-to-bone joints. These are the patellafemoral joint, tibiofemoral joint and the tibiofibular joint. The knee joint is surrounded by eleven bursae. A bursa is a fluid filled sack that serves to reduce friction between tendons, and between tendons and bone. The four major bursae of the knee are:
- Suprapatellar bursa is located between the distal femur (leg bone) and the quadriceps tendon. It permits free movement of the quadriceps tendon over the distal femur. It allows for full flexion (bending) and extension (straightening) of the knee. It can be irritated by a direct blow or from repeated stress or motions.
- Prepatellar bursa is located at the top of the knee over the kneecap. Bursitis of the prepatella bursa is sometimes called carpet layer’s knee, housemaid’s knee or roofer’s knee. It can be caused by a direct blow to the knee or from being in a prolonged kneeling position.
- Infrapatellar bursa is located below the kneecap, under the large patella tendon. It is commonly associated with patella tendonitis or from a repetitive jumping injury called “jumper’s knee.”
- Anserine bursa is located on the medial or inside of the knee. It is in the area where the hamstring muscle attaches to the lower leg. When inflamed this bursa can produce pain in the inside of the knee when descending stairs.
- A direct blow to the infrapatellar bursa can produce inflammation and irritation.
- A fall onto the knee or infrapatellar bursa.
- Constant pressure on the infrapatellar bursa from kneeling.
- Repeated stress injury to the bursa and tendon from jumping, which can also cause tendonitis and infrapatellar bursitis.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the infrapatellar bursa or knee.
- Infrapatellar bursa can become swollen as a response to other knee conditions.
- Pain and tenderness over the location of the infrapatellar bursa
- Loss of motion of the knee
- Pain with activities that stress the infrapatellar bursa like kneeling, jumping, running or activities that cause stress on the tendons that are lubricated by the infrapatellar bursa.
- Initial treatment of infrapatellar bursitis includes avoiding activities that produce pain or stress of the infrapatellar bursa and associated tendons (jumping, running, and kneeling.)
- The use of ice to reduce inflammation and pain.
- NSAIDS (nonsteroidal anti-inflammatory drugs)
- Physical Therapy
- Drainage of the fluid in the infrapatellar bursa for severe cases. Fluid can be checked for possible infection.
- Antibiotic in the case of infections of the infrapatellar bursa
- Surgery may be indicated in extreme cases if the problem becomes chronic.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals. Physical therapy for infrapatellar bursitis must remain conservative at the onset in order to not aggravate the condition. Emphasis will be in rest, reducing the inflammation and increasing the blood circulation for healing. 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.
Common Physical Therapy interventions in the treatment of Infrapatellar Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the knee. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee to support, stabilize, and decrease the stresses place on the infrapatellar bursa and tendons of the knee joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on infrapatellar bursa and tendons in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the infrapatellar bursa.
- Home program including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Avoiding the activities that produce the pain or stress the infrapatellar bursa is the first line of treatment.
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on the infrapatellar bursa.
- NSAIDS (non steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Needle drainage to remove excessive fluid from the infrapatellar bursa
- Injection of steroids to reduce inflammation in infrapatellar bursa
- In the case of infection antibiotics may be prescribed,
- In severe recurrent conditions surgery to remove the infrapatellar bursa may be indicated.
In general, patients respond well to conservative treatment of infrapatellar bursitis. It is important that once the pain and inflammation is reduced and motion and strength are restored that the patient gradually returns back to full activities. Instruction in daily activities or sport performance is helpful to reduce the chance of a reoccurrence of the infrapatellar bursitis. In most cases full return to activity will take from 2-6 weeks depending on the severity of the condition. As a preventive measure individuals should:
- Make modifications in work or daily activities such and kneeling, squatting or wearing protective equipment to avoid prolonged pressure or unexpected blows on the infrapatellar bursa.
- Maintain strength and flexibility to reduce stress on the infrapatellar bursa and tendons of the knee.
- Avoid highly repetitive activities whenever possible.