Bursae are small fluid sacs that are situated around large joints. The fluid-filled structure is typically located in the shoulder, hip, knee, and elbows. There are around 160 bursae in the body.
These bursae work as a cushion for the joints and prevent friction between tendon and bone or skin and tendon. An overuse of the joint can result in inflammation and lead to bursitis.
The inflammation is also known to be a result of trauma, infection, and hemorrhage.
The different knee bursae are grouped depending on their location. The ones situated near the patella are the suprapatellar bursa, the superficial and deep infrapatellar bursae, and the prepatellar bursa.
The others that are not situated close to the patella are grouped under a single category. These include the gastrocnemius-semimembranosus bursa, the tibial and fibular collateral ligament bursae, iliotibial bursa, and the pes anserine bursa.
Some cases of bursitis are usually a result of an occupation or hobby. Superficial infrapatellar bursitis is therefore also known as clergyman’s knee, while prepatellar bursitis is termed as the housemaid’s knee. (1)
Prepatellar bursitis is associated with pain at the front of the knee and might limit the knee’s range of motion. Rest and self-care techniques are usually able to alleviate the discomfort.
However, sepsis of this bursa is quite common and care should be taken to identify the signs and start treatment immediately. (2)
What Causes Pre-Patellar Bursitis?
The prepatellar bursa is among the most commonly affected knee bursae. The bursa, which is situated between the patella and the skin, is a synovial-lined sac.
This is a superficial bursa and is formed from direct pressure in the first few months to years of life.
These sacs contain a minimal amount of fluid necessary to facilitate movement during muscle contraction. A trauma or overuse results in an inflamed bursa, which causes a multiplication of the synovial cells.
The resulting effect is a rise in the fluid production and collagen formation.
The causes include the following.
- Overuse/repetitive kneeling
- Direct trauma to the knee
- History of inflammatory disease
- Crystal deposition
- Infection resulting in septic bursitis
The condition could be a result of a combination of the above causes. Most frequently, overuse and trauma are indicated as the reason.
What are The Signs?
The symptoms of housemaid’s knee are usually localized to the anterior part of the knee and include the following.
- Anterior knee pain
- Swelling of the knee
- Tenderness of the patella to palpation
- Decreased knee flexion
- Lump or abscess over the knee
Septic bursa is a result of a traumatic injury that causes the direct introduction of microorganisms. A study suggests that a sign of fever or a local skin lesion are not always associated with a septic bursa. Sepsis should be considered even without the presence of fever.
Types of Prepatellar Bursitis?
Depending on the causes of bursitis, the condition can be termed as either acute or chronic.
Acute Pre-Patellar Bursitis
The acute condition is usually a cause of a direct fall on the knee. A direct blow could rupture the blood vessels causing bleeding into the sac. The walls of the bursa could react to this with inflammation.
In this condition, the bursa wall could also thicken and result in tenderness. It is common to notice the tenderness even after the swelling has reduced.
An acute bursitis could also be a result of a surface injury. This results in an infection as a skin wound over the kneecap could lead to bacteria spreading in the fluid.
Chronic Pre-Patellar Bursa
Chronic conditions are characterized by mini injuries over a period of time. This is usually noticed in people whose occupation or hobbies involve repeated kneeling.
The kneeling action results in a pressure on the kneecap. This could lead to thickening of the bursa walls resulting in inflammation. (3)
Risk factors are important to understand if you need any precautionary measures to avoid injury to the area and develop bursitis. Men are more likely to develop bursitis as compared to women.
Repeated Squatting & Kneeling
If your occupation or hobby involves repeated squatting or kneeling, you are at a high risk of developing this condition. Knee pads can work as a precautionary measure to protect the knee.
Certain sports that involve tackling or falling on the knee, such as football and volleyball, are possible risk factors for bursitis.
Obesity & Osteoarthritis
Obese women with osteoarthritis are more prone to suffer from this painful condition.
Impaired Immune System
A weak immune system resulting from diabetes, cancer, and HIV could make a person more prone to septic bursitis.
Bursitis diagnosis usually consists of a physical examination of the knee. However, as the prepatellar bursa is a common site for infection, an aspirated fluid from the location is commonly sent for inspection to check for the following factors.
- WBC Count
- Elevated protein
- Gram stain results
- Elevated lactate
To ensure that an underlying cause is not the reason for bursitis, the following factors are also checked.
- Gout – Monosodium urate crystals
- Pseudogout – Calcium pyrophosphate crystals
- Rheumatoid bursitis – Cholesterol crystals (4)
Housmaid’s Knee Treatment
Usually, the pain and inflammation associated with prepatellar bursitis can be treated at home with self-care techniques.
The following techniques can be followed at home and can help improve functionality in the knee.
The first step of treatment after noticing pain and inflammation is Protect, Rest, Ice, Compression, and Elevation. The therapy aims to reduce the pain and improves the healing process.
Use of knee pads and knee braces could help protect the knee from further damage. Compression can also be offered by certain sleeves to improve healing.
Use of NSAIDs can reduce pain and inflammation by decreasing prostaglandin synthesis.
A combination of NSAIDs with compression bandage is known to be efficient in reducing pain. The commonly used medication is Ibuprofen.
Antibiotics are suggested when sepsis is suspected. Certain antibiotics are tailored to be used for specific organisms.
If you notice an open wound near the knee-cap, it is essential to take medical advice to know the right antibiotic required and the duration of the dose.
Stretching the quads muscles can help reduce the friction between the skin and the patella tendon. This exercise should be carefully undertaken and should be stopped if it leads to pain or discomfort.
It is also important to note that the stretch is focused at the front of the thigh. A pressure on the knee during these exercises could aggravate the injury.
Stretch 1: Put a towel around the ankle while lying on your stomach. With the help of the towel, pull the foot towards the bottom. A light stretch should be felt in the front of the thigh. Hold the position for 30 seconds and repeat three times in a day.
Stretch 2: Stand straight with a hand placed on a chair for balance. Start bending the leg to pull your heel towards the bottom. Hold the stretch for 30 seconds and repeat three times in a day. (5)
Intrabursal corticosteroid injections are considered if the pain and inflammation do not subside with conventional treatment options.
Corticosteroids have anti-inflammatory properties and can help reduce pain and swelling. Corticosteroids such as hydrocortisone suppress migration of polymorphonuclear leukocytes and reverse the increased capillary permeability.
A doctor might suggest aspiration for treating bursitis, particularly in the case of a septic bursa.
A syringe and needle are used to drain the excess fluid from the bursa to reduce the symptoms.
Surgical intervention is usually the last resort to treat bursitis. It is considered in the following scenarios.
- Adequate drainage not achieved by aspiration
- Formation of abscess or necrosis
- Exploration to evaluate the spread of infection to adjacent structures
Endoscopic bursectomy has been studied to be an effective treatment for infectious prepatellar bursitis. (6)
A surgical removal of the bursa can be considered if the condition is affecting the mobility of a person and causing life-changing effects.
Use of some spices and essential oils are known to reduce inflammation and pain associated with bursitis.
Ginger: It can be used in the form of ginger tea or a ginger paste to benefit from its anti-inflammatory and analgesic qualities that can reduce pain and discomfort. It is also known to improve circulation to encourage the healing process.
Castor Oil: The oil contains ricinoleic acid, which reduces inflammation and pain.
A castor oil pack can be prepared by soaking a piece of wool in cold oil and applying it on the affected knee. Cover the area with a plastic wrap and apply heat with a hot water bottle.
Apple Cider Vinegar: Consumption of one tbsp. apple cider vinegar mixed with honey can reduce inflammation by restoring the alkalinity of the body.
Turmeric: Adding the spice to boiled milk can treat acute as well as chronic bursitis. However, excessive intake of the spice should be avoided if you are taking blood thinner medications.
Including the following anti-inflammatory food in your diet can reduce the symptoms of bursitis.
- Olive Oil – Extra virgin olive oil prevents COX-1 and COX-2 enzyme production to reduce inflammation.
- Garlic – Raw garlic cloves consumed on an empty stomach or rubbing garlic oil on the knee can offer relief from pain and inflammation.
- Tart Cherries – A cup of tart cherry juice consumed daily can have beneficial effects.
Other options include sweet potatoes, spinach, blueberries, and walnuts. (7)
It is important to note that a nutritional diet is essential for the proper functioning of the body. Obesity is a known risk factor for bursitis. Hence, ensure that a healthy lifestyle is followed to prevent and manage the condition.
Usually, the condition settles in a few weeks with conventional self-care techniques
Housemaid’s Knee Prevention
The condition is most commonly caused by overuse or a direct trauma. Overuse-associated bursitis can be prevented by using knee pads to protect the knee joint when kneeling on hard surfaces.
Direct traumas in day-to-day activities are difficult to prevent. However, athletes can wear protective braces to support and protect the knee during tackles or a fall on the knee.
Prepatellar bursitis is a painful condition characterized by pain and inflammation at the anterior side of the knee.
The signs of an acute condition are noticeable immediately. Stretching exercises and other self-care techniques are known to treat this condition effectively.
Chronic cases are usually a result of overuse and repetitive squatting or kneeling. Such conditions present symptoms only after a period. Modification of activities and protection in the form of braces can improve the recovery period.
Septic bursa is a serious condition and needs medical intervention. In most cases, it is associated with a fever and a skin lesion. Antibiotics and aspiration are recommended in such cases. Prepatellar bursitis in children is suggested to be associated with an infected bursa.
Diagnosis of the condition is usually based on a physical examination and medical history of the individual. It would be helpful to remember the cause of the onset of the symptoms to understand if it is acute or chronic.
Imaging techniques such as MRI are used majorly for septic bursitis or in cases where an underlying cause such as an autoimmune disorder is suspected.
Ultrasonography is used as a confirmatory procedure to differentiate it from other knee injuries.
Housemaid’s knee could result in discomfort during day-to-day activities because of the pain and swelling. However, it responds well to treatment and does not result in any lasting physical deformities.
The symptoms usually reduce within a few weeks. However, resuming strenuous activity post the healing period should be avoided. The intensity and the duration of the activity should be gradually increased to avoid aggravating the injury.
Diabetics should be extremely careful if they are suffering from knee pain. Such patients are advised to regularly check for any open wounds or lesions that could result in an infected bursa.
Identifying the signs and understanding the risk factors is imperative for proper management of the condition. Conservative treatments have shown efficacy and safety, while surgical procedures are used rarely as the last resort.