Recent Knee Injuries
Knee bursitis can cause pain above, on or below your patella (kneecap). The knee consists of up to 11 bursae. The bursae most commonly subjected to inflammation are the prepatellar bursa, infrapatellar bursa, pes anserinus bursa and suprapatellar bursa.
The prepatellar bursa lies just above the knee cap between the skin and the knee cap. Prepatellar bursitis has historically been referred to as “housemaid’s knee”, which is derived from being a condition that was commonly associated with individuals whose work necessitated kneeling for extended periods of time. Prepatellar bursitis is common in professions such as carpet layers, gardeners, roofers and plumbers.
The infrapatellar bursa essentially consists of two bursae, one of which sits superficially between the patella tendon (below the kneecap) and the skin and the second referred to as the deep infrapatellar bursa is sandwiched between the patella tendon and tibia bone (shin). It can occur conjunctively with a condition called “Jumper’s Knee”, which involves repetitive strain and irritation to the patella tendon, often from jumping activities.
The third most common knee bursitis, pes anserinus, occurs in the lower, inside part of the knee in close proximity to the upper aspect of the shin bone (tibia). It usually affects middle-aged women and overweight individuals.
Suprapatellar bursitis occurs above the kneecap. The suprapatellar bursa extends superiorly from beneath the patella under the quadriceps muscle. It is vulnerable to injury from both acute trauma and repeated microtrauma. Acute injuries are from direct trauma to the bursa via falls directly onto the knee, as well as from overuse injuries, including running on soft or uneven surfaces, or from jobs that require crawling on the knees, such as carpet laying.
What is a Bursa?
A bursa is a thin sack filled with synovial fluid, the body’s own natural lubricating fluid. This slippery sack allows different tissues such as muscle, tendon, and skin slide over bony surfaces without catching. Your bursa essentially reduces the friction between structures.
A bursa is normally very thin, but they can become inflamed and irritated. This is what is known as bursitis.
What Causes Knee Bursitis?
There are a myriad of factors that can contribute to knee bursitis. The most common ones include:
• Direct trauma or blow to the knee.
•Frequent falls on the knee.
•Repeated pressure on the knee (eg from activities that entail prolonged periods of kneeling) or repetitive minor trauma to the knee.
•Knee Arthritis, thus bursitis can be associated with such conditions as gout, rheumatoid arthritis, and osteoarthritis.
What are the Symptoms of Knee Bursitis ?
The symptoms of knee bursitis include:
•Swelling over, above or below the kneecap.
•Limited motion of the knee.
•Redness and warmth at the site of the bursa.
•Painful movement of the knee.
Knee bursitis swelling is within the bursa, not the knee joint. People often call any swelling of the knee joint “water on the knee,” but there is an important difference between fluid accumulation within the bursa and within the knee joint.
Symptoms of knee bursitis are usually aggravated by kneeling, crouching, repetitive bending or squatting and symptoms can be relieved when sitting still.
How is Knee Bursitis Diagnosed?
Your physiotherapist will provide you with a thorough quiz of your medical history and a physical examination of your knee to determine if you have knee bursitis. If there is localised swelling and you feel tenderness over the bursa when pressure is applied, a diagnosis is confirmed.
With respect to scans, an MRI or Ultrasound are the most effective for a definitively diagnosis of knee bursitis.
What is the Treatment for Knee Bursitis?
The diagnosis is the easy part. Your physiotherapist will also undertake a biomechanical analysis to determine what the cause of your bursitis actually is. Factors may include muscle weakness, tightness, pain inhibition, leg length discrepancy, training techniques and more.
Many patients with knee bursitis start to feel better within a few weeks of the injury. Your physiotherapy treatment will aim to:
•Reduce pain and inflammation, this is achieved with the application of electrical modalities, ice, therapeutic taping and education regarding activity modification
•Normalise your knee joint range of motion.
•Strengthen your knee muscles: quadriceps and hamstrings.
•Strengthen your lower limb: calves, hip and pelvis muscles.
•Normalise your muscle lengths.
•Improve your proprioception, agility and balance.
•Improve your technique and function eg walking, running, squatting, hopping and landing.
•Minimise your chance of re-aggravation.
Anti-inflammatories or NSAIDs are also used in combination with physiotherapy to help alleviate the pain and swelling. If the bursa becomes infected or if your symptoms persist for a prolonged period your doctor may recommend that the bursa be aspirated. Alternatively, your doctor may also recommend an injection of a glucocorticoid steroid that is mixed with a local anesthetic. If infection occurs, you may require antibiotics.
Knee Bursa Surgery
In particularly stubborn cases, surgical removal of the bursa may be recommended.
Risks of surgery include infection, persistent instability and pain, stiffness, and difficulty returning to your previous level of activity. The good news is that more than 90% of patients have no complications post-surgery.
Post-operative knee rehabilitation is one of the most important, yet too often neglected, aspects of knee surgery. The most successful and quickest outcomes result from the guidance and supervision of an experienced physiotherapist.
How Can You Prevent Knee Bursitis?
Knee bursitis is best prevented by maintaining flexible thigh muscles and reducing the amount of time you are in a kneeling position. Ice after excessive kneeling is recommended to avoid an inflammatory response, which is the first stage of bursitis.
Pacing yourself during activities which entail repeated bending or squatting is also paramount. Ensuring that you take regular rest breaks between periods of bending or kneeling and alternating them with other less aggravating activities is key. Essentially, an appropriate balance between rest and activity is recommended. Weight-management can play a role in the pressure exerted on lower limb joints, and thus should be something considered as a long-term preventative measure.
For more advice, please consult your physiotherapist.
Sinding Larsen Johansson syndrome is an inflammation of the bone at the bottom of the patella (kneecap), where the tendon from the shin bone (tibia) attaches. It is an overuse knee injury rather than a traumatic injury.
What Causes Sinding Larsen Johansson Syndrome?
In the skeletally immature or adolescent athlete, Sinding-Larsen-Johansson syndrome most likely results from a traction injury of the knee extensor mechanism at the junction of the patellar ligament and the inferior pole of the patella. This juvenile traction osteochondrosis is similar to Osgood Schlatter syndrome.Strong repetitive quadriceps contractions are thought to cause a traction force on the inferior pole, disrupting the immature bone. There is a higher incidence in active children during the adolescent growth spurt.
As a child grows, bones go through different stages of development.
The patella pole is initially cartilaginous (cartilaginous stage).
It then enters the apophyseal stage when the secondary ossification center (apophysis) appears.
The unity of the proximal tibial epiphysis with the tibial apophysis marks the epiphyseal stage.
Lastly, when the growth plates fuse, the bony stage has been reached.
Children are most susceptible to Sinding-Larsen-Johansson syndrome when their bones are in the (2nd) apophyseal stage. During this phase the apophysis is unable to withstand high tensile forces. When presented with strong, repetitive muscle contractions, micro-fractures occur at the immature area.
A potential cause for Sinding-Larsen-Johansson syndrome may be the lack of growth of the quadriceps in comparison to the femur. During a growth spurt in a child, the lengthening of the muscle is unable to keep up with the lengthening of the rapidly lengthening femur, resulting in increased tensile force on the patella.
Sinding-Larsen-Johansson Syndrome is more likely in active children who participate in sports that involve running, twisting, and jumping, such as basketball, football, volleyball, soccer, tennis, figure skating, and gymnastics.
What the Symptoms of Sinding Larsen Johansson Syndrome?
Localised pain, swelling or tenderness is felt at the front of your knee – at the base of your patella (kneecap), where the patella tendon inserts into the patella.
Patients are typically active boys aged 10 to 13 years but can also affect active girls a couple of years younger. Symptoms are usually:
• Worse with exercise, stair climbing, squatting, kneeling, jumping and running.
• Cause you to limp after exercise (as the condition progresses).
• May be unilateral or bilateral.
• Is relieved by rest
What is the Symptom Progression?
While a mild case of Sinding Larsen Johansson syndrome can resolve within a few weeks, severe cases must be professionally managed to avoid growth plate damage. The pain and swelling symptoms can potentially last for years. Longstanding Sinding-Larsen-Johansson syndrome can result in an avulsion fracture of the patella tendon, which can severely affect your ability to walk or run.
Fortunately, Sinding Larsen Johansson Syndrome is very successfully managed via physiotherapy.
How is Sinding Larsen Johansson Syndrome Diagnosed?
Sinding Larsen Johansson Syndrome is normally diagnosed clinically by your physiotherapist or doctor. Knee X-ray can show calcification or ossification at the junction between the patella and the patella ligament. MRI scan will exclude most other musculoskeletal injuries.
Treatment for Sinding Larsen Johansson Syndrome
Physiotherapy assessment and treatment is a proven benefit for Sinding-Larsen-Johansson syndrome sufferers. Left untreated most patients will fully resolve their symptoms within 3 to 18 months (Duri et al 2002). With the good management, most athletes will be able to return to their sport within 6 to 14 weeks (Iwamoto et al 2009).
Phase 1 - Knee Load Management
Immediate restriction of high impact activities such as jumping and running.
Low impact activities eg. cycling, cross-trainer, water running or swimming are usually fine.
Use an infrapatella knee strap to dissipate forces away from the site of Sinding-Larsen-Johansson syndrome. Kinesiology taping may provide both pain relief and load reduction at the site of pain and injury.
Only on rare occasions severe Sinding-Larsen-Johansson syndrome may require crutches.
Consult with your physiotherapist for the best advice specific to your knee.
Phase 2 – Anti-inflammatory Treatment
Ice & Electrotherapy
A combination of ice treatment, electrotherapy and a home tens unit will reduce pain and improve the healing rate. This usually hastens the recovery rate of sufferers. Ice is useful at home or after exercise. (Michlovitz et al 2007)
Phase 3 – Functional Training
Rest is also important in the management of Sinding-Larsen-Johansson syndrome and relief of pain. It is best to discuss your exercise workload with your physiotherapist for advice on how to best manage your return sport while respecting your injury.
Whether or not you should continue playing sport is dependent on symptoms. Patients with mild symptoms may be able to continue to play some or all sport. Others may choose to modify their program. In mild cases, it may enough to just limit your physical activity so that the post-exercise pain is only mild and lasts for maximum of 24-hrs. When symptoms become worse it may be necessary to take a short break from your aggravating sports.
Phase 4 – Therapeutic Exercises
Stretching, Massage & Foam Rollers
One of the common reasons for developing Sinding-Larsen-Johansson syndrome is excessively tight quadriceps muscles, ITB, hamstrings, hip flexors and calf muscles. (Iwamoto et al 2009). Your physiotherapist will prescribe specific stretches for you if they assess that you are tight in these muscle groups.
Massage and foam rollersare beneficial especially in the early phase when stretches create pain at the Sinding-Larsen-Johansson syndrome site.
Your muscle control around the knee will usually need to be addressed to control or maintain your symptoms during the active phase of Sinding-Larsen-Johansson syndrome. Your physiotherapist will commonly prescribe or modify exercises for your quadriceps, hamstrings, calves, foot arch and gluteal (buttock) muscles. (Franchesci et al 2007)
Foot Arch Control & Orthotics
Your foot biomechanics or arch control may be inadequate for your intensity of sport. Your physiotherapist can assist both the assessment and corrective exercises for your dynamic foot control. Active Foot Correction Exercises can be beneficial as both a preventative and corrective strategy. Occasionally, your foot biomechanics may be predisposing you to torsional stresses that can cause abnormal knee forces, which can cause knee injury. In these instances, foot orthotics may need to be prescribed. There are mixed views on how effective these are, since the foot structure is rapidly changing at this age. Ask your physiotherapist or podiatrist for advice.
Prognosis for Sinding Larsen Johansson Syndrome
Sinding-Larsen-Johansson syndrome is a self-limiting syndrome. Complete recovery can be expected with closure of the patella growth plate. Although symptoms of Sinding-Larsen-Johansson syndrome may linger for months, few patients have poor outcomes with conservative treatment, and surgical intervention is seldom necessary. Corticosteroid injections are not recommended due to case reports of subcutaneous atrophy.
For a thorough individualised assessment and professionally guided care for your Sinding-Larsen-Johansson syndrome please consult with your physiotherapist.
While your knee potentially has four plica it is the medial plica that is most likely to be symptomatic (Dupont 1997). It runs parallel to your medial patella just below your medial retinaculum and inserts into your fat pad.
What is Plica Syndrome?
Plica syndrome is essentially an inflammed plica. Your plica can catch during:
repetitive knee straightening and bending,
blunt trauma or knee twisting,
fat pad irritation,
altered knee motion,
internal knee derangements eg meniscal tears. (Schindler 2004)
This is particularly the case if you have experienced persistent pain and weakness in the quadriceps muscles. Plica syndrome often does not always occur in isolation, but concurrently with other knee conditions such as meniscal injuries, patellar tendonitis and Osgood-Schlatter’s Disease.
What are the Symptoms of Plica Syndrome?
Plica syndrome can be suspected when you have:
Anteromedial knee pain – esp medial femoral condyle.
Visible and palpably tender plica.
Audible clicking or snap during knee motion – painful arc 30 to 60 degrees. (Dupont 1997).
Positive Duvet test: pain eased by using a duvet between your knees to ease pain in bed.
Pain with activities: ascending and descending stairs, squatting, rising from a chair and/or sitting for extended periods. (Shetty et al 2007).
Quadriceps atrophy is common on chronic cases.
How is Plica Syndrome Diagnosed?
Your physiotherapist will be able to clinically diagnose plica syndrome. It is more important that you have your knee thoroughly assessed by a physiotherapist or sports doctor to exclude other knee pathologies, in particular meniscal injuries.
X-ray may be useful to rule out other associated pathologies but will not identify a plica. MRIs can identify plica inflammation. However, MRI is more useful for diagnosing other pathologies that may be related to the plica irritation. A comprehensive examination by your physiotherapist or sports physician is preferable.
Plica Syndrome Treatment
Studies show that about 60% of patients with plica syndrome will settle successfully with conservative physiotherapy treatment within 6 to 8 weeks. (Lu et al 2010).
Your physiotherapy treatment will aim to:
Reduce pain and inflammation.
Improve patellofemoral (knee cap) alignment via taping, bracing and exercises.
Normalise your muscle lengths.
Strengthen your knee: esp quadriceps (esp VMO) starting with closed-chain exercises and eventually progressing to open-chain exercises
Strengthen your hip and lower limb muscles.
Address foot biomechanics issues.
Improve your proprioception, agility and balance.
Improve your lower limb function and quality of movement eg walking, running, squatting, hopping and landing.
Minimise your chance of re-aggravating your plica syndrome. (Gerbino et al 2007).
We strongly suggest that you discuss your knee injury after a thorough examination from a knee specialist such as a sports physiotherapist, sports physician or knee surgeon.
Should your symptoms persist beyond 3 to 6 months, arthroscopic knee surgery for a plica syndrome may be considered. The most successful surgery involves lateral retinacular release to allow the patella to track more medially and thereby alleviate plica irritation as it rolls over the medial femoral condyle. Success rates exceed 85%. (Gerbino et al 2007).
How to Prevent Plica Syndrome
Since plica syndrome usually occurs concomitantly with other knee conditions, it is important to be proactive in managing your other knee injuries. This involves maintaining normal knee joint alignment, adequate strength and flexibility in the muscles around the knee joint plus the rest of the lower limb.
Ensuring that you wear adequate footwear that supports your foot biomechanics. Also, weight-management can play a role in the pressure exerted on lower limb joints, and thus should be something considered as a long-term preventative measure.
For more advice, please consult your physiotherapist.
Braces for Plica Irritation
Many patients will try a knee brace. Brace that improve patellofemoral joint alignment seem to be the most effective to ease plica-related pain.
• Patellofemoral Brace – An effective patellofemoral brace can be useful as an alternative to kneecap taping.
• ITB Roller – Excellent for stretching your tight thigh structures: ITB, quadriceps and hamstrings.
For knee pain, contact us for an assessment