So this weekend as the cold temperatures finally broke, I decided to hit the pavement for a run and enjoy the beautiful weather. The only problem is I actually hit the pavement. Two miles from home, I tripped over a grate, and pitched forward. Failing to get my hands up in time, I landed square on my knee cap. Technically it would be the medial base of my patella, which slammed the apex into the patellar tendon and underlying bursa with tremendous force. It was excruciating. Over the following few days, I have had pain on quads contraction, swelling around and below the patella, and low back pain due to the gait change. Given my current condition, I thought I would take this time to do some bursitis treatment and review.
A Bursa is a fluid filled sac that is often found in the body that buffers surfaces that might otherwise cause too much friction, thus damaging the body as one structure passes over the other. They are usually found in joints, where a tendonous attachment has to pass over a bony prominence. The knee has many bursa, due to its complexity, as does the hip at the greater trochanter and ishial tuberosities, and the Achilles at the point of attachment to the heel etc. Almost anywhere you find a bony prominence and tendons you will find a bursa. To visualize how it works it is something like this.
In a clinical setting, bursitis can often be confused with tendinitis, and they are actually pretty similar. Tendinitis is the inflammation of the tendon sheath, which is a similar structure to the bursa. But rather than being just under the tendon, a tendon sheath wraps around the whole structure to provide a similar function.
Both tendinitis and bursitis can be caused by over use, which means that the ‘sac’ has become inflamed. Bursitis however is often characterized by an impact to the overlying structure, the trauma of which causes swelling and inflammation. In some cases antibiotics or anti-inflamitories might be used, depending on the severity of the case.
In clinical evaluation, clients will have pain on movement, the muscles around the area may be splinted, and heat and tenderness might be but are not necessarily present. In cases such as the knee, the bursa can sometimes be seen as it puffs out around the patella. However, if the bursa is under many layers of muscle, such as at the greater trochanter, it might not be, so it is often misdiagnosed. Taking a good subjective client history can help to determine what you are really dealing with, as it can inform you to activities that would point one way or the other. Did your client recently fall? Is he/she an athlete that uses a repeated motion?
Following that up with your objective ROM, and muscle testing, will further confirm your analysis. Active resisted testing of the suspect structure is extremely helpful. Tendinitis usually has a pain response that is constant on active resisted exercises such as “speed tests”, and while bursitis also reports pain on active resisted, the pain increases with contraction as the structure continues to contract over the bursa. It’s necessary to be clear that the pain is where the bursa is located, not in the joint or referral. It’s also relevant to use a pain scale to chart the pain increasing with contraction.
Once you have assessed that you do have a case of bursitis, rather than joint pain or tendinitis, treatment through massage is extremely helpful. For the purposes of this treatment we will look at bursitis of the knee in sub-acute and then add on a few chronic suggestions.
Like all other orthopedic treatments, bursitis of the knee begins with your assessment of the primary injury and also the compensatory ones. In this case the low back is irritated by the antalgic gait (a form of stride shortening due to pain). We are going to work general to specific, starting on the opposite side of the injury. That means I am starting on the back in prone position or the low back first (depending on your time constraints) and on the low back side that is not in pain. In order to perform this safely without aggravating the bursa further while the client lies face down, you would pillow the affected knee so that it does not make hard contact with the table. I usually use a pillow under the hips with multiple leg bolsters. After treating the low back with massage, trigger point and whatever else was in your general treatment plan, you would move next to the posterior aspect of the unaffected leg, which has likely been overworked to compensate for the leg with the bursitis. Next you would move to the posterior aspect of the, affected leg, paying special attention to the structures that cross the knee. Hamstrings, gastrox, and ITB are all suspect to have pain and dysfunction because they, like the patellar tendon, cross the knee and are either getting too much movement, or too little, while the body protects that bursa.
At this point you would have your client move carefully to the supine position, once again pillowing them for comfort. Next you would want to treat the front of the unaffected leg in the same way you normally would. For the affected leg, you will want to work toward the bursa using general massage techniques. Be careful not to apply too much pressure to structures that could compress the bursa, such as quads (and ITB by torquing the knee). Gentle stroking techniques and techniques such as cupping can be used up and around the knee to encourage fluid movement. The tissue will warm quickly and the increased circulation should aid in lymph movement provided you are gentle.
I would then recommend moving on to other techniques while applying ice. Rather than put the ice directly across the tendon, which will cause muscle contraction, I will have prepared an ice ring made from a towel that will sit over the knee cap, making minimal contact with the muscle and maximum contact with the bursa. (Here is where the treatment would diverge if the bursitis was chronic and not inflamed, but sticky with scar tissue).
While the bursa and surrounding tissue ice for a few minutes, I will shift my focus from gentle stroking, to trying to lengthen the structures that cross the knee, without compressing the bursa. I might choose gentle fascia work of those structures, being careful to move towards the patella, or deeper sentimental work. The goal here is to ease compression of the bursa in order to lessen the irritation. Because the client is favoring the leg, it’s likely not moving as much, which in turn will cause a contraction of the tissue. It is then our job to act as an external muscle pump and mimic the body’s normal functions, to ease the tension.
I would finish by removing the ice ring, and once again moving to gentle stroking techniques towards the knee to re-warm the tissue and flush it. Always moving from general to specific to general again.
In my clinic we also tape supportively with fascia movement tape, so we would do a taping that looks something like this to help with drainage.
NOTE:If the client was in chronic and the bursa was adhered, instead of ice I would use gentle fascia work around the patella as well as patellar mobilizations to access the tissue under the patella, stretching and more aggressive lengthening techniques, but the essential treatment would be the same.
The treatment for bursitis is very easy, provided you understand the underlying pathology and have a plan to organize your treatment properly. Clients often get diagnosed by chiropractors and practitioners who are not familiar with soft tissue problems. so do not take anything for granted in your interviews. Good luck!
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