prepatellar bursitis and pes anserine bursitis

[PinchandBurn]

one of my patinets is in her 60s. I've seen her twice now. Tried NSAIDs,no relief. She has a lot of pain amplification behavior, however on exam looks like she has a pre patellar bursitis and a pes ansersine bursitis.

Xray of the knee just shows degenerative changes. Radiologist comments that there is no overlying sof tissue issues.

On exam, literally the pes anserine and pre patellar bursas look enlarged. Both are TTP.

She is affebrile, vitals are WNL.

Quesiton I have is whether I should drain these bursas that are inflammed. OR should I drain and the inject steroids.

My concern is infection. THere is no rubor or calor. I was thinking of just aspirating both bursas and putting a pressure dressing. IF pain goes away then good. I was also going to send the drainage over for analysis. Would I just send for WBCs? If increased send to ortho? Watcha think?

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[Gauss]

Could be joint effusion. Would be a good ultrasound exam. Those Bursas typically produce very minuscule amounts of fluid to drain, and labs aren't very enlightening. Usual labs are: cell count, gram, culture, crystals. Unless it's an athlete itching to get back to play, I don't rush to drain them especially since they recur or get infected like you said.

 

[lobelsteve]

2cc bupi, 1cc steroid directly into bursa.

Skip the US and you will not get fluid, nor do you need fluid.

Alternatively, just put some triple cream on it and turf to PT for US, exercise, hybresis.

 

[PMR 4 MSK]

I've drained an injected plenty of prepatellar bursitis. No infx. Never injected a pes anserine bursitis, but I've injected painful pes.

 

[SSdoc33]

unless it looks like a water balloon, you are not gonna get fluid, especially from the pes. these often look swollen in overweight women. then again, so do a lot of body parts in overweight women.

 

[deleted185747]

If it looks like its infected- drain it and send for cell count with diff, micro for crystals, gram stain. If neutrophils are greater than 55,000 than its a septic joint and an orthopedic emergency.

If it looks like a large effusion is present in the joint then draining it will relieve the pain by decreasing the capsular stretch and correcting the biomechanics. After drainage leave the needle in place and use it to inject steroid+LA.

If no effusion and no s/s infection then my approach would be to inject the PES with 1% lidocaine as a diagnostic block. Wait 10 minutes. If all the pain is gone you are done - treat what you found. Tx is PT and/or reinjection with steroid into the same location.