Description, diagnosis and treatment of bursitis of the knee
Bursitis knee is inflammation of one or more periarticular bags, which is characterized by a local increase in temperature, accumulation of exudate and acute pain. Depending on the type of inflammation and the nature of fluid inside the bag bursitis can be serous, serous-fibrinous, purulent, purulent-hemorrhagic.
In the knee is localized sufficiently large number of bags (see figure).
The names of these formations are given in the table.
The Greatest role in the development of bursitis are playing bags 1, 2, 7, 8, 4, 5, 6.
Classification and main reason
The nature of inflammation bursitis can be:
- Aseptic, that is, to develop without the influence of infection (e.g. systemic diseases).
- Associated with infection (tuberculosis, brucellosis, syphilis, gonorrhea), recorded from another hearth.
- Associated with direct infection of trauma.
In addition, the bursitis are clinically relevant (acute), subacute, chronic with periods of remission and recurrence.
According to the ICD-10 (International classification of diseases) used in the encoding of pathology among the medical staff, bursitis of the knee can have a code from the rubric M70 – М71, prepatellar of them usually has a code M70.4, other codes are coded bursitis M70.5.
In ICD-10 there is no precise classification of bursitis. Other soft tissue disorders professional types, including unqualified, are codes M70.8, M70.9 ICD-10.
depending on the localization of the inflammatory process, i.e., what bag are involved in the pathological process, the bursitis can be divided into:
- Prepatellar bursitis – inflammation localization in prednaznachennyh bags (often in subcutaneous and podfartilo).
- Infrapatellar bursitis – localization of inflammation in the infrapatellar bursae (superficial tibial and/or deep).
Prepatellar and infrapatellar bursitis usually develop on the background of systemic diseases, direct trauma to the patella or its own ligaments (gap, for example).
- Bursitis duck foot.
- Baker's Cyst (in popliteal fossa, involving the calf and popliteal bags).
The main causes of this disease include trauma to the knee joint and its ligaments, arthritis and arthrose-arthritis, systemic diseases (rheumatoid arthritis, SLE, etc.), excessive load on the knee joint during training, the athletes, the nature of the work (for example, a parquet floor).
The disease is Generally diagnosed by visual inspection, palpation. The main differences between the types of bursitis by visual inspection and palpation are presented in the table below.
|Infrapatellar bursitis of the knee||the Presence of fluctuating formation in the lower part of the patella under surface, on both sides of the tendon – deep, symptoms of cylinder from both sides, the color of the skin over the tumor is not changed or modified according to the type of hyperemia, pain depends on the disease – chronic, acute, or subacute.|
|Prepatellar bursitis knee||Localized swelling in front and at the top of the kneecap, change the color of the skin or without it, positive symptom fluctuation.|
|Baker's Cyst||Soft fluctuating formation located in the popliteal fossa. The pain experienced in the back of the knee, especially when squatting. Rupture of the cyst followed by an outpouring of fluid in the subcutaneous tissue or other soft tissues of the leg.|
|Bursitis duck foot||ill-defined swelling below the joint cavity, a diffuse area of tenderness below the medial area of the joint cavity may extend to the connection point of the collateral ligament of the knee the Sartorius, semitendinosus and slender muscles. Sometimes there is pyrexia, usually a symptom of the cylinder.|
|Purulent bursitis||Significant fluctuating education, accompanied by hyperemia, local and General hyperthermia, acute soreness of the knee, the rapid development of the tumor. Possible wounded knee (injuries of different etiology) or primary infectious disease.|
Symptomsof bursitis consists of local symptoms and symptoms of General intoxication.
The severity of intoxication depends on the type of bursitis:
- Maximum severity occurs when purulent bursitis. A patient had fever up to 39 degrees or higher, chills, myalgia, excessive sweating, weakness and lack of appetite.
- systemic diseases possible low-grade fever (up to 37-37,5 degrees, rarely higher), weakness, malaise, decreased body weight, anemia, pale skin.
- In acute bursitis in the backdrop of injury, excess strain on the knee joint overall temperature increase may not be at all.
- In the chronic form the symptoms of intoxication are not expressed.
The Status of "locales" includes the aggregate of the following symptoms:
- swelling in the region of localization of a particular bag (or multiple bags), quite clearly demarcated, moderately soft consistency with symptom fluctuations.
- Local hyperemia (redness of the skin in the bag, joint), a symptom may be absent.
- Local hyperthermia, when comparing the skin temperature on the affected area and the healthy joint there is a difference, the affected area is hotter.
- dysfunction of the joint, pain with movements, flexion, extension (depending on the localization of the inflammatory process), limitation of movement.
Primary bursitis of the knee treated relatively simply. The situation is complicated, if it is secondary, due to the basic flowing of the disease. When the area of inflammation of the bag or capsule gets pyogenic microflora through minor injuries, scratches, cracks, serous inflammation becomes purulent. Infection can also occur from foci of infection localized elsewhere (erysipelas, furuncles, sore throat, flu). Suppurative bursitis can lead to necrosis of the wall of the bag and adjacent tissues, and then develop subcutaneous and intermuscular cellulitis. If pus breaks through into the cavity of the joint, it provokes purulent arthritis, and from the zone of destruction make their way out fistulas.
Long flowing traumatic bursitis of the knee causes a thickening of connective tissue formation in the synovial cavity of the projections or strands of granulation tissue, which makes it a multi. The consequence of this irreversible process is proliferating bursitis.
Prepatellar bursitis of the knee usually starts after a strong blow to the knee area and education in Bursa blood bag. Inflammatory reaction in the joint provokes the flattening of the bursal walls, their gradual depletion, high sensitivity to thermal factors (cooling) and small injuries. Especially prepatellar bursitis is often diagnosed in patients who are forced into professional work force to lean the knees against hard surfaces.
With the penetration of skin bacteria in the joint is red, swollen, the patient can hardly perform flexion and extension of the joint, expressed acute pain of the joint. Large size prepatellar bags due to the increase in the number of inflamed fluid. When it infected the knee much swollen.
From clinical signs noted high temperature, fever, leukocytosis, and General deterioration. In the acute phase of the disease requires urgent surgical treatment: opening and drainage of the knee prepatellar bags. If there is a suspicion of infection, perform puncture.
Bursitis "goose foot"
Serinovy bursitis, or as it is called, bursitis "goose paws", hits the bag, located in the medial part of the tibia, the area of attachment of the Sartorius, semitendinosus, thin muscle to the tibia. It usually develops on the background of deforming osteoarthritis, but there are a number of diseases and conditions that contribute to the development of this pathology:
- obesity, diabetes, arthritis, meniscus tear
- professional running, pronation of the foot;
- improper distribution of body weight when walking.
Serinovy bursitis is extremely rare, since the area of the bags are fully protected from injuries. Tissue damage in the zone of the bag "goose paws" always develops inflammation that is more severe. Due to the complications of bursitis "goose foot" tendonitis of the tendons of the muscles attached to the tibia, it is more difficult to treat.
Visual inspection and palpation does not always give an accurate picture of bursitis "goose paws". The most accurate clinical indicator during the initial diagnosis is pain that occurs when you press on a certain point. To clarify a need for further studies that visualize the structure of the knee joint.
Methods of diagnosis
To clarify the diagnosis, in addition to the inspection, visualization, palpation of the attending physician (usually the surgeon, traumatologist) appointed:
- ultrasound of the knee joint and surrounding bursae;
- radiography of joint in two projections;
- in case of indications will be performed puncture, collection of exudate for analysis in Cytology (cellular, chemical composition),the microflora and crop on sensitivity to antibiotics;
- arthroscopy, biopsy is carried out under strict indications, mainly for diagnosis;
- laboratory studies – KLA, OAM, a standard set of indicators of biochemistry, specific tests – antinuclear antibody, rheumatoid factor, serological tests to identify infectious agent.
The Differential diagnosis of bursitis of the knee is carried out with tendinitis, enthesopathy, arthritis of various etiologies, osteoarthritis.
Bursitis differs from tendinitis of the site: tendonitis is an inflammation of ligaments and tendons. Besides injuries, tendonitis occurs due to the weakness of tendo-ligamentous complex or irregular formation of the tendons. The same bursitis is characterized by inflammation of the bursae. When bursitis pain worse with flexion-extension of elbow tendonitis increases when decreasing the muscles associated with the affected tendon, during flexion-extension of the knee joint. Pain when tendonitis in the hip or gives the muscle system.
Arthritis is also should be differentiated from bursitis, it is sometimes difficult because of their combination (systemic diseases). Usually arthritis can be observed morning stiffness in his movements, defiguration joint in General. Degenerative, post-traumatic disease (menisco-, chondro-, tendinopathy) generally occur without inflammatory process. They are observed more frequently with arthritis, but sometimes occur independently. In osteoarthritis the patient complains of increased pain in the evening, the feeling of crunching, creaking in the execution of motion in the affected joint, symptoms of intoxication are not typical. The age of patients with osteoarthritis, typically the middle and elderly.
So the outside changes is problematic to accurately differentiate disease diagnosis. This requires additional methods of examination: x-ray, ultrasound, MRI or computed tomography, arthroscopy. To identify the presence of inflammation in the bursitis, make a General analysis of blood, diagnosis of the vessels is carried out by the method of angiography, Doppler ultrasound (suspected thrombosis pathology, etc.).
Innovative visualization techniques
Because the knee is a complex biomechanical system with the anatomical connections, auxiliary apparatus of the mucous bursae, menisci, fat bodies, muscles, differential diagnosis of bursitis can be difficult.
Most Often bursitis is combined with synovitis, tendinosis, subluxation, deforming arthrosis of the. Therefore, to obtain an objective picture of the condition of the knee joint can be used anthropamorphic under local anesthesia. It is relatively simple: in the knee joint injected with a thin needle, medical oxygen pressure (60 – 120 ml), and after 15 minutes perform x-ray in lateral projection. Especially good in this case can be seen inversions of the synovial bags, wing folds, allowing to determine the presence of hypertrophy of the fat bodies.
The Method of magnetic resonance image – MRI can depict soft tissue and ligamentous apparatus of the joint. To view better the knee joint in the sagittal plane: so clearly visible layers subcutaneous soft tissue, adipose prepatellar pillows. The menisci are connected by a ligament of Winslow, and the body of Goff determined by their size, intensity of existence.
Ultrasonography of the knee shows the following abnormal items:
- effusion in the upper inversion of the knee joint and the heterogeneity of the liquid;
- violation of integrity of tendons and the presence of foreign bodies;
- changed the contours of the patella, the integrity, the thickness and structure of native ligament;
- hypertrophy of fat bodies;
- damage mediaparade folds, changes in the structure and the presence of diastasis of the lateral ligaments;
- modify the surfaces of the femur and tibia, the presence of bone growths and inclusions
- violation of the contours and thickness of hyaline cartilage;
- change contours, shapes, structures of the joint, the presence of fragmentation and calcination, liquid formations in the area pericapsular external and internal menisci.
Puncture of the knee joint to make the upper and nizhnemedialnuyu, upper - and inferolateral corners of the patella. Artrotsentez is done by perpendicular entry of the needle length of 1.5-2.5 cm bursitis of the cellular composition of the synovial fluid varies, and it acquires the following form:
- acute – neutrophil;
- in chronic process – lymphocytic and mononuclear;
- Allergy – eosinophilic.
A Sample of synovial fluid is taken with a syringe with a volume of 10-20 ml. In Parallel, the puncture can be a medical procedure for the removal of exudate and the introduction of intra-articular injections (corticosteroids: hydrocortisone, diprospan).
When serous bursitis prescribed painkillers, anti-inflammatory drugs used physiotherapy. Of the latter recommend the laser therapy, which relieves inflammation, stimulates regeneration and healing of tissues. Ultrasound treatment relieves pain, removes swelling, reduces inflammatory processes.
Magneto -, and electrotherapy are also used to treat bursitis. In the clinical setting to minimize pain using cryotherapy, and home treated using ice.
If the disease is infectious in nature, after the puncture do drainage, in parallel with the appointment of antibiotics (cephalosporins, protected aminopenicillins, carbapenems). To relieve the pain and inflammatory process, can be assigned to injection of diclofenac sodium (ortofena, voltaren, Ketoprofen – "Ketonal", "Ketanov"). Negative analysis for the presence of infection antibiotics are not shown, use of steroid drugs that reduce inflammation. Along with this use of ultrasound, UHF, warm and cold packs, always under the supervision of an experienced specialist.
When there is an acute disease with infection prepatellar bags, doing surgery polutrusy insert into the cavity of the bag. Usually after the inflammatory process is stopped, the wound heals quickly. But if the walls of the bag are thickened to such an extent that do not provide slip, and the movements are accompanied by sharp pain, perform a complete resection of the bags.
After surgery, the wound is sutured in several layers, set the lock for 3-5 days. At the end of this period he removed, perform physical therapy and later the patient in their own home performs a set of movements recommended. Need to be careful during rehabilitation, when formed healthy bag with normal walls. Usually this period is a calendar month.
Full recovery occurs not earlier than in 2-3 months. In the conservative treatment of this term significantly decreases. But in any situation only a doctor can determine the extent of possible loads on the joint, and to recommend a valid mode of physical activity.
Therapy non-steroidal anti-inflammatory drugs (NSAIDs)
For the relief and treatment of diseases caused by inflammation in the joints, apply a non-steroidal drug, which are divided into several subclasses. Their activity initially associated with the termination of inflammation or a decrease in its intensity.
NSAIDs fall into several classes (tab. 2).
|Arylcarbamoyl acid||Arylalkenes acid||Anacova acid|
salicylate of sodium
|Anthranilic (fenamate): |
To include a non-acidic derivative Poquoson, tiaramide, bufexamac, aerosol, nabumeton, flurprofen, flurizan, tinoridine, colchicine. The combined drugs-known artrotec comprising a mixture of diclofenac and misoprostol.
Because most NPVS have a low pH level, they actively binds with plasma proteins accumulate in the area of inflammation due to increased vascular permeability. Analgesic and anti-inflammatory effect due to suppression of cyclooxygenase (COX), which participates in the synthesis of prostaglandins (PG). Locking GHG generation is in parallel with the change in the function of neutrophils, lymphocytes and vascular effects (reduction of erythema and edema), analgesic properties.
For therapy, use of NSAIDs, which largely inhibit the process of formation of COX-2, which is the cause of the synthesis of GHG in the process of creation of proinflammatory reactions. COX-1 is responsible for formation of PG, perform a role in normal metabolic processes in the body. Therefore, effective treatment of bursitis of the knee is performed by therapy NSAIDs, which inhibit equally COX-1 and COX-2 because there are drugs that 10-30 times stronger blocking COX-1.
The Choice of NSAIDs to date is empirical, the doctor usually writes the destination based on their own experience, evaluating a patient's condition and previous response to drugs. First, use the least toxic NSAIDs, increasing the dose until the most effective and making the combination with analgesics, corticosteroid blockade to potentiate the effect of NSAIDs.
Alternative methods of treatment
Alternative methods of treatment of bursitis of the knee joint has been extended through the application of acupuncture, which relieves pain, reduces edema, normalizes energy balance. Moksoterapiya increases the local circulation due to the warming of acupuncture points. Can be treated way contact (directionaldirect moxibustion) or contactless moxibustion, when heating is carried out at a distance of 1-2 cm from the point of impact.
It is Permissible to add small doses of homeopathic remedies in the area of inflammation of bags: reduced swelling, relieved the pain. Ditto phytotherapy. To increase the flow of lymph from the site of the damage will allow vacuum therapy, it minimizes swelling, reduced inflammation.
Multi-factor assessment of bursitis showed that to differentiate diseases of the knee different etiologies are possible if you have a large practical experience based on data from imaging studies of articulation. Sometimes for accurate diagnosis and treatment of bursitis should visit a health facility, ask the advice of an experienced physician. Showing pictures and images sore spot, no need to search the forums for answers to questions that it is better to ask a specialist directly.
Treatment of bursitis should be aimed at maximum use of methods of physiotherapy in the early stages of the disease, avoid complications, chronicity and transition of inflammation to other anatomical structures of the knee joint. Especially careful should be the employees, whose professional activity is associated with increased loads at the knee: at the slightest complications should not self-medicate, and should consult a specialist. Early diagnosis of bursitis will prevent the transfer of disease into a chronic form, to cure acute pathology, process of rehabilitation with timely treatment is much shorter.
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