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Bursitis

Multiple bursas are present throughout the knee -- the prepatellar bursa, the infrapatellar bursa bursitis, bersitis, bersitus, bursitus. Bursas are fluid filled sacs, they are there to minimize friction, they can get inflamed, they can get septic, more commonly, the reason for sepsis is usually that there has been intervention, either with a needle or a puncture wound from an abrasion. Patient’s usually present with swelling, erythema, tenderness to palpation, you can treat these with aspirations if you are a little aggressive but you have to be concerned , it’s a prime media for infection.

Compressive bandages and anti-inflammatories are usually all they need. At the hip, we see greater trochanteric bursitis, this is common in the middle age groups, the runners, the athletes, especially with hills, especially when they are doing uneven surfaces. Their symptoms are usually pain over the top of the greater trochanter, when their hip does a lot of flexion extension.

People that pronate cause a lot of rotation at the knee and the hip, and that’s a concern, you need to check feet, especially in runners, look at their feet. Treatment, anti-inflammatories, aspiration, injections, physical therapy, a lot of this stuff resolves. As sports doctors, we see a lot of overuse injuries. Overuse injuries can occur in any of the soft tissues, or even hard tissues of the body. About 30 to 50% of all sports practices are related to overuse injuries from repetitive trauma. The injury just overwhelms the soft tissue and failure occurs, so we see all types of athletes whether they are recreational or professional and it happens at all levels. Muscle and tendon injuries, it’s age dependent. Adolescents, their weakest structure in the muscular tendinous extent tends to be at the growth plate. As we become young adults, it’s the ligaments and the soft tissues, muscles and tendons. In older adults it tends to be the bone, and we see more fractures and bone injuries. Tears can happen within the substance of the tendon, where the tendon attaches to the bone, where the ligaments attach to the bone.

Most common mechanism of injury is excessive amount of stretch. It is usually failure of the musculotendinous junction or the muscle tendon units, it can be an intrasubstance degeneration. Normal physiology, there is a crimp or a wavy pattern to the tendon. Once you exceed approximately 4% of strain on t hat tendon, you lose this wavy pattern, this wavy pattern, the hydrogen binding of the collagen molecules. As your strain increases up to 10%, you can start getting failure of the fibers themselves. Here is an EM of a tendon, you see the crimp pattern, as strain increases, you start getting failure. Failure is initially microscopic and then becomes macroscopic.

Symptoms. Patient’s usually present with pain, swelling, pseudoparalysis, lack of motion, it could be acute, sharp or inability to actively move the joint. The picture on the right, it’s sort of hard to see but you start noticing some swelling just above the knee on the new leg, but it’s hard to determine it. Here, same patient, knee is bent, this is the thigh, here is the patella sitting in the wrong spot, palpating you see a defect directly in the level of the patellar tendon. Radiographs, this can make your diagnosis here, that’s too much of an extent from the patella down to the insertion site. Physical findings, you usually notice tenderness, you can have a palpable defect, there is usually a loss of motion, there is moderate amount of swelling, muscles have very good blood supply and bleed rapidly, ecchymosis is related to that. Plain radiographs are helpful, especially with avulsion type of injuries, or as you see in the patellar tendon x-ray that complete disruption where the patella is riding high.