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Bursitis of the knee

The knee involves several structures. The anserine bursa, which is along the medial aspect just below the tibial plateau. It is commonly found in patients who also have osteoarthritis. Occasionally rheumatoid arthritis. Patients complain of pain in the specific area, just below the medial aspect of the knee, below the tibial plateau. It may radiate up into the thigh because this is where the muscles course that overlie that bursa.

In examination, you usually find point tenderness over that area if you have the patient try to adduct, which is bring their knees together, they may have pain in that specific area. Again, because these muscles that overlie - I think it’s the sartorius - that overlie that bursa, when they contract they squeeze the bursa and that’s uncomfortable. The main thing is that when you are evaluating a patient with knee pain, you want to differentiate whether it is bursa or is it articular. Usually just a careful examination looking for tender areas will help. If there is no synovitis in the knee joint, and if you have good range of motion without any other findings, that would indicate that it’s a periarticular problem. Also the prepatellar bursa is right on top of the kneecap and the infrapatellar bursa is right behind the patellar tendon just above the insertion.

These can also be inflamed. The prepatellar bursa is quite easy to recognize. This was a gentleman who, I think he had chest pain and they thought myocardial infarction and it ended up being nothing, but he got dizzy after doing a test and he fell and just fell right to his knees. He developed these large swellings on both knees. But you can see the knee joint itself has not much going on there. Obviously, when I directly examined him, there was no true synovitis of the knee joint, the range of motion was normal, but he had these tremendous swellings above the knees. Someone had already - before I saw the patient - had stuck a needle in the knee joint and got nothing, or like an ml of fluid. When I came by he wouldn’t let me tap the prepatellar bursa but he was kind enough to let me take the picture. I was concerned - he also had a fever - whether or not it was septic.

Injection. If it is just traumatic non-septic, injection therapy works very well particularly for anserine bursitis, prepatellar bursitis. Infrapatellar you are a little less ready to do that because of the fact that it is right next to the patellar tendon and there is a potential. So you might try and reserve that for an otherwise unresponsive patient. Antiinflammatory drugs are also very useful, but the main thing you want to do is differentiate this from knee arthritis.

Plantar Fasciitis. That’s why we have a field of podiatry because these problems are very very common. One of the areas, the plantar fascia, can be involved with plantar fasciitis as it inserts into the calcaneus and also the Achilles tendon as it inserts into the back of the calcaneus. These are very common problems. If there is any sense that it is chronic inflammatory in nature and there are other systems involved, really think of a spondyloarthropathy because these areas are very commonly involved with things like ankylosing spondylitis and the like. But I do see patients occasionally and that’s all they have. They just have Achilles tendonitis or plantar fasciitis. Sometimes you can even get bursal inflammation although it’s very difficult to differentiate from direct tendon involvement. But plantar fasciitis, again the most common situation I see is someone who walks a lot. Mail carriers. They start out with a 50 pound bag of mail and it’s hard on their feet. They just walk around and deliver mail all day. But anybody who is on their feet a lot, walking, carrying extra weight, and the pain is usually in the sort of medial aspect of the bottom of the calcaneus. It’s not dead center.

When you examine you can put a stress on the plantar fascia either by pushing on the forefoot up, or just putting your thumb right into this area of the insertion.

Treatment generally involves antiinflammatory drugs which often work quite well. Sometimes just modifying the shoes a little bit, getting some inserts. You can buy them in a drug store or sporting goods store. Sometimes a podiatrist can design an orthotics - or an orthopedic surgeon can design orthotics - that would help to relieve the strain of this plantar fascia. Corticosteroid injections can be useful. I don’t like to do them repeatedly, again because this structure has a tremendous amount of stress.