Knee Pain
Prepatellar, Infrapatellar & Suprapatellar Bursitis
A bursa is a small fluid-filled sac that reduces friction between skin, tendon and bone. Around the kneecap there are several bursae, and any one of them can become inflamed, swollen and painful — a condition known as bursitis.
What is bursitis?
Bursitis is inflammation of a bursa. When irritated the bursa fills with excess fluid, producing a soft, often visible swelling around the front of the knee. It can be caused by repeated pressure or kneeling, a direct blow, infection, or underlying inflammatory arthritis or gout.
Prepatellar bursitis
Sits directly in front of the kneecap. Classically known as "housemaid's knee" or "carpet layer's knee" — associated with prolonged kneeling. Presents as a well-defined swelling over the front of the patella.
Infrapatellar bursitis
Two bursae sit just below the kneecap — a superficial one in front of the patellar tendon ("clergyman's knee") and a deep one behind it. Common in runners, jumpers and after repetitive kneeling in a more upright posture.
Suprapatellar bursitis
Lies above the kneecap and communicates with the knee joint itself. Swelling here often reflects fluid within the knee joint (an effusion) rather than an isolated bursitis, and should prompt a search for an intra-articular cause.
Causes and associations
- Repetitive kneeling — flooring, plumbing, gardening, roofing, carpet fitting
- Direct trauma or a fall onto the front of the knee
- Overuse in running and jumping sports
- Infection (septic bursitis) — the bursa becomes hot, red and very tender, and may follow a small skin break
- Inflammatory arthritis such as rheumatoid arthritis
- Gout and pseudogout (crystal deposition)
- Suprapatellar swelling is commonly associated with meniscal tears, cartilage damage and early osteoarthritis
Symptoms
A soft, fluctuant swelling at the front of the knee, tenderness on direct pressure, discomfort with kneeling or full bending of the knee, and sometimes redness or warmth. Range of motion is usually preserved but may feel tight at the extremes. Fever, rapidly increasing pain, spreading redness or a very hot knee suggest infection and require urgent assessment.
Diagnosis
Diagnosis is usually clinical, based on history and examination. Ultrasound is very useful for confirming the bursa involved, measuring fluid and guiding aspiration if needed. MRI is reserved for atypical cases or when an intra-articular cause is suspected — particularly with suprapatellar swelling. If infection is suspected the bursa is aspirated and the fluid sent for urgent microscopy, culture and crystal analysis.
Treatment
Non-surgical treatment
- Rest, ice and elevation
- Avoiding kneeling and the aggravating activity
- Anti-inflammatory medication if suitable
- Compression with a soft neoprene support
- Ultrasound-guided aspiration of large or persistent swellings
- Corticosteroid injection into the bursa in selected non-infected cases
- Antibiotics and prompt aspiration if infection is confirmed
Surgical treatment
Rarely required. Reserved for recurrent, chronic bursitis that has failed conservative measures, or for infected bursae that do not settle with aspiration and antibiotics. Surgical bursectomy (removal of the bursa) can be performed open or endoscopically as a day-case procedure. For suprapatellar swelling driven by an intra-articular cause, treatment is directed at the underlying meniscal, cartilage or arthritic problem.
Rehabilitation
Week 0–2
Settle the inflammation
Relative rest, ice 15 minutes several times a day, compression sleeve, elevation and complete avoidance of kneeling. Gentle pain-free range of motion.
Week 2–4
Restore motion
Full range of motion work, static quadriceps activation, straight leg raises and gentle hip and calf strengthening. Continue to protect from direct pressure.
Week 4–8
Rebuild strength
Progressive quadriceps, hamstring, glute and core loading. Stationary bike, low-impact cardio and closed-chain exercises within a comfortable range.
Week 8+
Return to activity
Graded return to running, sport and occupational kneeling with padded kneepads. Ongoing quadriceps and hip strength work to protect against recurrence.
Variations in the rehabilitation protocol can occur based on Mr Rehmatullah's assessment and the underlying cause of your bursitis.
When to seek urgent help
Please seek urgent medical review if the knee becomes very hot, red, extremely tender or rapidly more swollen, if you develop a fever, or if you feel unwell — these features may indicate septic bursitis, which needs prompt aspiration and antibiotics.