Physical Therapist's Guide to Knee Bursitis
Knee bursitis, commonly known as "housemaid's knee" and "clergyman's knee," involves swelling of 1 or more of the bursae at the front of the knee. Knee bursitis is one of the most common bursitis conditions; it can be painful when moving the knee, when kneeling, or even when at rest. The condition can also be painless, with only visible swelling present. Knee bursitis can have many causes. The most common is trauma, whether from a direct hit, or the result of activities that require crawling or kneeling on hard surfaces for long periods of time, such as laying carpet or tile, or scrubbing floors. Knee bursitis is most commonly seen in athletes; up to 10% of runners develop knee bursitis. However, its occurrence is not related to any particular age or ethnic group, and can also be caused by infection or autoimmune conditions. Physical therapists treat individuals with knee bursitis to reduce their pain, swelling, stiffness, and any associated weakness in the knee or leg.
What is Knee Bursitis?
Knee bursitis (also called prepatellar or infrapatellar bursitis) occurs when 1 or more of the many bursae (fluid-filled sacs) becomes damaged, irritated, or inflamed. Normally, a bursa acts as a cushion or friction-reducer between 2 body parts, such as between bone and skin, or bone and ligament or tendon. Bursae on the front of the knee serve as cushions between the knee cap and skin, and between the patellar tendon and tibia bone. Prolonged pressure or traumatic blows can injure a bursa, and repetitive motions can cause irritating friction on it, leading to the development of bursitis. In fact, "itis" means "inflammation." When the bursa is injured, it can swell and become painful.
Knee bursitis can be caused by:
- Repetitive motions, including certain sports, such as running
- Prolonged kneeling, as when cleaning floors, installing flooring, or praying in a kneeling position
- Prolonged crawling, such as when laying carpet or flooring, or scrubbing floors
- Direct trauma, such as being hit or falling on the knee
- Knee surgery or knee joint replacement
- Autoimmune conditions
How Does it Feel?
With knee bursitis, you may experience:
- Swelling on the front of the knee
- Redness on the front of the knee
- Pain when you push with your fingers on the front of the knee
- Pain when kneeling
- Stiffness in the knee joint, or difficulty straightening or bending the knee
How Is It Diagnosed?
If you see your physical therapist first, your therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist also will ask you detailed questions about your injury, such as:
- How and when did you notice the swelling and/or pain?
- Have you been performing any repetitive activity?
- Did you receive a direct hit to the knee, fall on it, or kneel for a long period of time?
Your physical therapist also will perform special tests to help determine the likelihood that you have knee bursitis. Your physical therapist will gently press on the front of the knee to see if it is painful to the touch, and may use additional tests to determine if other parts of your knee are injured. Your therapist also will observe how you can move your knee, and test your strength and flexibility.
Your physical therapist will test and screen for other, more serious conditions that could cause knee pain or swelling. To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests to confirm the diagnosis and to rule out other damage to the knee, such as a fracture or infection.
How Can a Physical Therapist Help?
Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but results can be achieved in 2 to 8 weeks or less, when a proper swelling management, stretching, and strengthening program is implemented.
During the first 24 to 48 hours following your diagnosis, your physical therapist may advise you to:
- Apply light compression to the area by wrapping the knee a specific way using a compressive wrap.
- Rest the area by avoiding any activity that causes pressure or pain in the knee.
- Apply ice packs to the area for 15 to 20 minutes every 2 hours.
- Consult with a physician for further services, such as medication or diagnostic tests.
Your physical therapist will work with you to:
Reduce Pain and Swelling. If repetitive activities have caused the knee bursitis, your physical therapist will help you understand how to avoid or modify the activities to allow healing to begin. Your physical therapist may use different types of treatments and electrothermal modalities (machines that use heat, light, or sound to reduce swelling and pain) to control and reduce your pain and swelling.
Improve Motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with "passive" motions that the therapist performs for you to gently move your knee joint, and progress to active exercises and stretches that you do yourself.
Improve Flexibility. Your physical therapist will determine if any of your leg muscles are tight, start helping you to stretch them, and teaching you how to stretch them on your own.
Improve Strength. If your physical therapist finds any weak or injured leg muscles, your therapist will choose and teach you the correct exercises and equipment to steadily restore your strength and agility.
Improve Endurance. Restoring your leg's muscular endurance is important after an injury. Your physical therapist will develop a program of activities to help you regain the endurance that you had before the injury, so you can return to doing the things you like to do.
Improve Balance. Regaining your sense of balance is important after an injury. Your physical therapist will teach you exercises to improve your balance skills.
Restore Agility. Speed and accuracy of leg movement is important in athletics. Your physical therapist will help you regain these skills in preparation for a return to sports activities.
Learn a Home Program. Your physical therapist will teach you strengthening and stretching exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.
Return to Activities. Your physical therapist will discuss your activity goals with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.
Speed Recovery Time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you safely heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.
If Surgery Is Necessary?
Surgery is not commonly required for knee bursitis. But if surgery is needed, you will follow a recovery program over several weeks, guided by your physical therapist. Your physical therapist will help you minimize swelling and pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.
Can this Injury or Condition be Prevented?
Your physical therapist can recommend a home program to help prevent knee bursitis. It may include strength and flexibility exercises for the leg muscles.
To help prevent a recurrence of the injury, your physical therapist may advise you to:
- Avoid kneeling for prolonged periods of time.
- Use knee pads or a cushion when you do have to kneel, including during sports or other physically-challenging activities to protect your knee.
- Avoid hard hits or prolonged pressure to the front of the knee.
- Follow a consistent flexibility and strengthening exercise program, especially for the knee and leg muscles, to maintain good physical conditioning, even in a sport's off-season.
- Always warm up before starting a sport or heavy physical activity.
- Gradually increase any athletic activity, rather than suddenly increasing the activity amount or intensity
Real Life Experiences
Ed is a 30-year-old tile installer. He often spends 3 to 4 hours a day on his knees, laying tile in homes and businesses. He is also an avid runner, and recently increased his weekly mileage from 8 to 12 miles. Ed recently noticed some swelling, in a round shape, on the front of his right knee, after a long day at work. It hurt when he pushed on the area with his fingers, and he felt pain when he knelt on that knee. He decided to call his physical therapist.
Ed’s physical therapist took a complete health history, and then asked Ed if he had recently fallen or been hit on his knee. Ed said no, but told her how many hours a day he kneeled at work, and that he had recently increased his running distance.
Ed’s physical therapist gently felt the swollen area and measured it. She tested the motion of the knee, and the strength and flexibility of the muscles of the leg. She concluded that Ed had knee (prepatellar) bursitis, an inflamed bursa on the knee that was irritated from the prolonged pressure of kneeling on it and running extended distances. She also found that Ed had some muscle weakness and loss of motion in the right knee area.
Ed's physical therapist asked him about his goals. He replied that he wanted to get rid of the swelling and pain, be able to kneel at work without difficulty for 6 hours a day, and be able to participate in an organized long-distance run the next month. He also wanted to learn how to prevent the swelling and pain from happening again.
Ed’s physical therapist began his treatment by gently massaging the knee in a specific way to help reduce the swelling. She applied a short course of ultrasound therapy to the swollen area. Next, she applied ice and electrical stimulation to the knee to help halt and reverse the inflammation process. She discussed with Ed the importance of "relative rest" for the knee area, meaning he should avoid kneeling or bumping it against any hard objects, until the swelling had resolved. Before Ed left the office, she applied some therapeutic tape to the knee, and an elastic compressive bandage that provided general compression to the entire knee area. She instructed him to wear it day and night, except when showering.
When Ed returned for his next treatment a couple of days later, the swelling was greatly reduced. His physical therapist noted that his knee movement was better as well. She taught Ed strengthening exercises for the muscle weakness in his leg; he continued to do these exercises each time he returned for treatment. He used stretch bands at first, but as he got stronger, cuff weights were added. At each session, the cuff weights were increased, so they became more challenging for Ed. The physical therapist also taught Ed some simple stretches to do at home. She continued to apply the ultrasound, electrical stimulation, and ice for 1 week until all the swelling was gone. Ed continued to use the compressive bandage most of the day at work. At his physical therapist's suggestion, Ed replaced the old knee pads he used at work with new ones that provided much better cushioning. He was able to steadily increase the number of hours per day that he could kneel and lay tile.
Two and a half weeks after the swelling started, Ed’s knee looked almost normal, and his pain was infrequent. His physical therapist instructed him to stop using the compressive bandage. Ed had been able to return to running about 11 miles per week. His physical therapist said that she would see him 1 more time the following week to check on his progress, and then would discharge him from clinical care.
On the day of his big race the following month, Ed was happy to tell his race friends that, thanks to his physical therapist's guidance, he was now able to kneel as much as needed at work—and he was able to enjoy the race without worrying about any pain or swelling in his knee!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat knee bursitis. However, you may want to consider:
- A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.
- A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider. The following articles provide some of the best scientific evidence related to physical therapy treatment of knee bursitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Kamper L, Haage P. Images in clincial medicine: infrapatellar bursitis [erratum in: N Engl J Med. 2009;360(17):1797]. N Engl J Med.2008;359(22):2366. Free Article.
Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists [erratum in: Phys Ther. 2007;87(9):1258]. Phys Ther. 2007;87(8):986–994. Free Article.
McFarland EG, Mamanee P, Queale WS, Cosgarea AJ Olecranon and prepatellar bursitis: treating acute, chronic, and inflamed. Phys Sportsmed. 2000;28(3):40–52. Article Summary in PubMed.
Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.
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