Bursitis of the Knee

Knee Joint Overview

The knee (tibiofemoral) joint is one of the most complex joints in the body as it allows your leg to flex and extend as well as rotate horizontally. The knee provides both strength and flexibility and allows the freedom for you to make quick movements and changes in directions.

It is not the bone that provides stability within the knee joint, rather the soft tissue (tendons, ligaments, muscles, menisci) that holds the femur (thigh bone), the tibia (shinbone), the fibula (the slender bone in the lower leg) and the patella (kneecap) together at the joint. In amongst the bones, tendons, and ligaments rest the bursa sacs that function as cushions to reduce friction and allow your soft tissue to slide easily and comfortably within your knee. The bursae are lined with synovial cells that secret fluid that is rich in protein and collagen and act as the lubricant between areas in your body where friction (rubbing) is greatest.

These fluid-filled sacs form in areas where 2 surfaces in your body, most often where a bone and tendon or a bone and muscle, rub together during movement. When pressure or friction is too great, excess fluid can build up in the bursa sac causing inflammation. When a bursa becomes inflamed, moving your knee becomes very painful and movement can be difficult. Any actions that put pressure on the inflamed bursa can increase irritation and cause further inflammation and pain.

Your bursae play an important role in leading a healthy, active life. When the bursae are not irritated and working properly, your joints move smoothly and painlessly. However, when a bursa becomes swollen and inflamed, the condition is known as bursitis. As you know, when you suffer from bursitis you will experience pain during physical activity.

There are 4 major bursa in your knee including the prepatellar bursa, suprapatellar bursa, infrapatellar bursa, and pes anserine bursa; the prepatellar and pes anserine bursae are most often affected by bursitis.

Pes Anserine Bursitis

Pes anserine bursitis (often coupled with tendonitis) is a painful, inflammatory condition affecting the pes anserine bursa (and pes anserine tendon) between your shinbone (tibia) and the hamstring tendons at the inside of your knee; typically caused by stress to the area.

Specifically, the pes anserinus is the area where the tendons of 3 muscles (sartorius, gracilis, and semitendinosus) come together. The three tendons merge together in the skin of the bone on the inside surface of the shinbone. These three muscles are the dominant knee flexors that function to allow movement of the leg towards the body, influence rotation of the tibia and the external rotation of the hip, protecting the knee against rotary stress.

The pes anserine bursa lies beneath these tendons close to the shinbone, providing cushioning between the tendons and the tibia. The term, pes anserinus means "goose's foot" in Latin - owing to the webbed-foot pattern the three tendons make when they meet.

Inflammation of the pes anserine bursae or tendons usually develops due to overuse, trauma, or degradation. The most common cause of pes anserine bursitis is hamstring tightness due to a lack of warming up and stretching properly before activity, particularly long distance running or excessive climbing.

Causes of pes anserine bursitis include:

• Poor sport technique or improper warm-up
• Repetitive knee bending
• Carrying excess load due to obesity overstressing the knee joint
• Arthritis or osteoarthritis
• Biomechanical issues, such as foot rolling, out-turned knees, or limping
• A medial meniscus tear
• Overuse or traumatic injury during athletics

Prepatellar Bursitis

Prepatellar bursitis is also a painful condition affecting the knee, however, the affected area is at the front of the patella (kneecap). The prepatellar bursa is usually very thin and serves as a cushion between the patella and your skin.

The patella is a bone that protects the front on the knee and glides up and down as you bend and straighten your leg. The tendon associated with the prepatellar bursa is the patellar tendon which connects the bottom of the patella to the top of the tibia (shinbone). The quadriceps muscles work to straighten the knee by pulling at the patellar tendon by way of the patella.

The prepatellar bursa is commonly affected due to repetitive pressure on the kneecap during frequent kneeling. Prepatellar bursitis is also known as Clergyman’s knee, Carpet Layer’s knee, or Housemaid’s knee due to the nature of their work requiring kneeling for long periods of time. This prolonged pressure can begin to irritate the bursa, eventually leading to injury. Once injured, fluid and/or blood is allowed to enter into the bursa and you will begin to experience inflammation overtime. When this happens, the bursa sac walls may thicken and form scar tissue or calcium may collect in the bursa.

If you are experiencing a significant amount of swelling or pain, it is possible that you have a broken or chipped patella. In this case, your doctor may recommend an x-ray to examine this further.

Causes of prepatellar bursitis include:

• Repetitive pressure during frequent kneeling
• Carrying excess load due to obesity which overstresses the knee joint
• Arthritis or osteoarthritis
• Overuse injury during athletics
• A direct blow during athletics or when falling on the knee
• Aggravation during exercise requiring stair climbing, running, jumping, or hiking

Symptoms of Knee Bursitis

Pain

If you suffer from bursitis in your pes anserine bursa you will feel pain over your tibia, approximately 2-3 inches below the patella (kneecap). The pain often radiates to the back and inside of the thigh.

Bursitis in the prepatellar bursa results in pain on the middle part of the knee and over the patella. The pain may radiate up your inner knee and thigh and/or down to your midcalf. Those who suffer from prepateller bursitis complain of increased pain when crossing their legs or when rising after sitting for several hours. Due to the location of the bursa, pain will make kneeling difficult.

Bursitis pain amplifies during exercise or when you are climbing stairs, but can also increase by simply bending and straightening your knee. Pain usually starts gradually and develops over a few days or even months.

Tenderness, Warmth, Swelling and Redness

You will experience tenderness near the inflamed bursa; 2-3 inches below the kneecap with pes anserine bursitis, just below and over top of the kneecap with prepatellar bursitis, and underneath the kneecap if the infrapatellar bursa is affected.

Swelling is usually evident over and around the bursa that is inflamed, most notably with prepatellar bursitis which often appears as an abscess on the kneecap. This swelling may appear immediately following trauma, over a couple of hours, or up to 7-10 days after the incident.

You may also notice warmth and visible redness on your skin in the area as inflammation in the bursa and along the tendons becomes more severe.

Difficulties Sleeping

Patients suffering from knee bursitis may also have interrupted sleep patterns. Simply bending your knee or rolling over during sleep can cause pressure on the inflamed bursa, increasing your pain. The pain can range from mild to very sharp depending on the amount of inflammation in your knee. Many knee bursitis sufferers recommend placing a pillow between your knees/thighs while you sleep to reduce pain throughout the night.

Limited Range of Motion and Weakness

When you have bursitis in your knee, the pain is often limiting as you stop performing motions that make the pain worse. If bursitis is left untreated the inflammation can increase, causing more pain, limiting movement even more and eventually weakness in the leg muscles and tendons can set in. As you lose strength in your quadriceps, your legs may begin to give out during daily activities.

It is important to treat bursitis in the early stages to reduce the symptoms, minimize damage and maintain motion and strength in your knee. Eliminate any squatting, repetitive knee bending, crossing your legs, kneeling or any other activities that add pressure on your bursa. By treating your knee bursitis in the early stages with cold therapy, ultrasound therapy and Blood Flow Stimulation Therapy, you are more likely to prevent long-term damage and chronic conditions from setting in.

Treating Bursitis in Your Knee

Relieving the symptoms of bursitis initially focuses on taking the pressure of the bursa. This can be done with proper cushioning and equipment during activities and sports. If your bursitis is caused by an infection (septic bursitis), the doctor will probably drain the bursa sac with a needle and perscribe antibiotics to treat the infection.

For bursitis that is not caused by infection, the preliminary treatment starts with non-invasive treatments such as ultrasound thereapy, cold therapy and Blood Flow Stimulation Therapy. Surgery to remove the inflamed bursa is normally not required for bursitis, however if you fail to see improvement with the conservative treatments, your physician may recommend surgery to remove the bursa completely. Although this removes the problem of an inflamed bursa, you are left with less cushioning in your joint which can lead to a host of other joint conditions.

The most important factor in healing bursitis (and tendonitis) is resting your knee to reduce the pressure on the bursa. This can be difficult when you have to carry on with daily activities, but resting and elevating your knee whenever you can is recommended. During your recovery you will probably have to modify or avoid the activities that stress your bursa until your pain and inflammation settle. Scar tissue can often develop with tendinitis and/or bursitis. As your damaged tissues heal this dead, fibrotic tissue is naturally produced instead of forming brand new healthy tissue. This scar tissue adheres to your muscle fibers, tendons, ligaments, and nerves causing pain and preventing them from moving properly (this limits your range of motion, flexibility and strength). However, the more diligent you are with your treatment and rehabilitation, the faster you will see successful results.

Treatments should involve decreasing swelling, relieving pain and stress on the knee, correcting any biomechanical dysfunction that may be causing a shift in your gait, and then restoring strength and mobility to your knee. It is important to follow any instructions you receive from your physician. If you are performing an activity that could cause further trauma to the bursa, it is recommended that you protect the area with padding and/or proper equipment to prevent further irritation or damage.

To decrease inflammation and relieve pain caused by pes anserine or patellar bursitis rest your knee and limit activity to reduce pressure on the inflamed bursa. Then use cold therapy, ultrasound therapy and Blood Flow Stimulation Therapy (BFST) to rid yourself of bursitis.

Cold Compression Therapy

The R.I.C.E. Treatment Philosophy

This treatment philosophy is used to decrease inflammation and relieve pain for a chronic or acute bursitis within the first 48 hours of a flare-up.

• Rest and limit your activity, to decrease swelling and minimize further inflammation in the bursa.
• Ice your knee to help reduce blood flow and fluid build up.
• Compress the area if possible by adding light pressure to minimize swelling (make sure the compress is snug, but not too tight as it could cause numbness, tingling or more pain).
• Elevate your knee to relieve the pressure from swelling and allow fluid to drain from your injured area.

Applying cold to your inflamed bursa will help decrease the swelling and redness around the bursa. Cold therapy will also help to numb the pain in your knee and help to control the inflammation.

Icing the bursa as needed throughout the day, for approximately 15 - 20 minutes at a time, is recommended to reduce pain, swelling, redness and inflammation. Do not apply ice directly on your skin, rather wrap it in a cloth or towel or, better yet, use a cold gel pack that fits easily and comfortably around your knee.

The cold compression Knee Freezie Wrap™ can be used to apply cold in a safe, convenient and effective way - and the gel pack is reusable. The gel pack sits over the inflamed bursa to reduce swelling and redness. The wrap is soft and adjustable so it fits your knee joint properly, without irritating the bursa, and allows you to adjust the compression. This is important when treating an inflamed bursa because too much pressure can cause you further pain. You control how much pressure the bursa receives so you can benefit from the compression to hold the cold where you need it, without increasing your pain.

Applying cold to your tender knee is the first step in treating your bursitis. Once severe inflammation has been reduce, you can begin using ultrasound therapy and Blood Flow Stimulation Therapy to continue the healing process.

Ultrasound Therapy

Ultrasound has been used by physical therapists and chiropractors for years to treat bursitis. By applying ultrasound therapy to your sore bursa (and tendon if you suffer from patellar or pes anserine tendonitis as well) you can reduce the inflamed fluid that has built up in the bursa. In addition, ultrasound therapy will treat any other soft tissue conditions that you may be experiencing in your knee such as arthritis, a torn meniscus, an ACL tear or sprain, gout, repetitive stress injury (RSI) and more. By treating yourself with ultrasound everyday, you are able to rid yourself of bursitis pain; this is best accomplished with a personal, therapeutic ultrasound device.

Ultrasound therapy is a great therapeutic option to decrease inflammation, pain and soft tissue (muscle, connective and nerve tissue) damage experienced with bursitis and other soft tissue injuries. The treatment is easy, painless, and generally requires between 5 - 10 minutes of your time. It is based on a form of deep thermal therapy which is generated through high frequency sound waves that reach into the cells of the tissue. These sound waves help to reduce the fluid build up in the bursa, heal any tissue damaged through trauma, reduce scar tissue, as well as reduce any crystal or calcific deposits that may have gathered in the area.

The sound waves send vibrations into your bursa and surrounding tissue to raise the temperature of your soft tissue. By raising the temperature, blood flow increases to the area, delivering nutrient filled blood to heal the area and whisking away the excess fluid and damaged tissue. The waves are delivered through a hand held transducer along with MendMeShop medicinal conductive gel in a slow, circular motion on your skin over the injured area.

If not treated properly, injured tissue can heal with a weakened state which can lead to scar tissue or calcification, adding to the bursitis pain you are already experiencing. If used on an ongoing basis, ultrasound will help to break down any scar tissue that may form in your knee maintaining flexibility and range of motion in your joint.

The MendMeShop Ultrasound Therapy System is the device you need to treat your bursitis once and for all. It comes with a bottle of the MendMeShop Lavender Infusion Gel so you get two therapies in one. The medicinal ingredients of natural Bulgarian lavender, eucalyptus, peppermint and menthol help to stimulate blood flow, widen blood vessels to enhance blood flow, and act as an anti-inflammatory deep in the tissue to enhance your ultrasound therapy through a process called phonophoresis.

Blood Flow Stimulation Therapy

When your bursa is injured and inflamed, your body needs a fresh supply of blood to rid the area of inflammation and get your bursa and any other damaged tissue back to normal. Unfortunately, when you have bursitis in your knee it is painful to walk and move your leg normally. When you limit movement in your knee the blood flow is reduced, starving your tissue of the necessary oxygen and nutrients. The trick is to find a way to increase the healing flow of blood without causing pain and/or further inflaming the bursa. This is where Blood Flow Stimulation Therapy (BFST) becomes a powerful tool. BFST compliments your body’s natural healing process by promoting the flow of blood to your knee while you give it the rest it needs.

The Knee Inferno Wrap™ uses a patented process to generate the same energy that is part of the sun's spectrum of light, the same energy that is necessary to all living things for optimum health. The energy emitted from the Energy Web™ delivers waves to the bursa and surrounding tissue and stimulates blood flow to your knee. By reaching deep into your bursa and tendons, you are able to reduce the inflammation and whisk away the toxins that build up from inflammation and tissue damage.

Once you have calmed the pain and inflammation in your bursa with the use of the Freezie Wrap™ you can begin the healing process with ultrasound therapy and BFST. This 3 step process is the most effective method to treat your swollen and painful bursa, reduce the inflamed fluid in the bursa and heal any tissue damage.

Pain and Anti-inflammatory (NSAIDs - Non-steroidal anti-inflammatory drugs) can be used if required to help manage your pain. However, these aren't recommended for long term use, as they can cause gastrointestinal difficulties and increase the risk of cardiovascular disease. The use of cold therapy, ultrasound and BFST in conjunction with NSAIDs can greatly improve the effect of this medication and can help to heal quicker.

Rehabiliation Exercise

Physical Therapy is a beneficial way to restore atrophied muscles and improve strength and mobility in your knee after treating bursitis. The type of physical therapy and the duration will be dependent on the tissue damage and your symptoms. When you are treating or recovering from bursitis, it is important to ensure you do not perform any exercises that will further irritate the bursa.

Once your pain starts to diminish, a physiotherapist will set up an individualized strengthening and stretching exercise program for you to perform at home or in the gym. This will be based on your needs and abilities, and will help you return to performing your normal routines. It is extremely important to strengthen your muscles properly, as they may have weakened during the period of non-use. A trained therapist will help to ensure your rehabilitation process is effective. For best, long term results use ultrasound and BFST in conjunction with physical therapy and an exercise program.

During your recovery, you may have to modify and/or eliminate any activities that cause pain or discomfort in your knee until your pain and inflammation settle, and you gain more mobility and strength. The more diligent you are with your rehabilitation and therapies, the faster you will see successful results.