History

Prepatellar Bursitis and Quadriceps Contusion with Hematoma: Differences in Assessment and Treatment

Christopher Wuttke

University of Bridgeport College of Chiropractic Bridgeport, CT

•  Bursitis: Inflammation or irritation of the bursa.

•  Prepatellar bursitis is also known as “housemaid’s knee” or “nun’s knee.”

•  Causes include: injury, such as a fall or impact, prolonged pressure from kneeling or leaning, strain or overuse from repetitive motion, joint stress from abnormal gait.3

References 1.  Todd D. Bursitis: An overview of clinical manifestations, diagnosis, and management. UpToDate. 2016. 2.  Souza T. Differential Diagnosis and Management for Chiropractors. Jones & Bartlett Learning; 2014. 3.  Todd D. Patient education: Bursitis (Beyond the Basics). UpToDate. 2015. 4.  Bickley L, Szilagyi P. Bates' Guide to Physical Examination and History Taking. Philadelphia: Lippincott Williams & Wilkins; 2003. 5.  Delos D, Maak T, Rodeo S. Muscle Injuries in Athletes. Sports Health: A Multidisciplinary Approach. 2013;5(4):346-352. 6.  Trojian T. Muscle Contusion (Thigh). 2017. DOI: http://dx.doi.org/10.1016/j.csm.2012.12.009. 7.  Stainsby B, Piper S, Gringmuth R. Management approaches to acute muscular strain and hematoma in National level soccer players: a

report of two cases. The Journal of the Canadian Chiropractic Association. 2017. 8.  Yochum A, Reckelhoff K, Kaeser M, Kettner N. Ultrasonography and Radiography to Identify Early Post Traumatic Myositis Ossificans

in an 18-Year-Old Male: A Case Report. Journal of Chiropractic Medicine. 2014;13(2):134-138.

•  An extensive history and examination is very important for a differential diagnosis. •  The protocol for treating a bursitis and a contusion (hematoma) have different treatment procedures and contraindications. •  No definitive data on treatment comparing these conditions therefore more research is needed.

Conclusion

•  Muscle lesions are one of the most common categories of sports injuries in athletes. Over 90% are muscle strains or contusions.5

•  Average return to play without proper treatment is 45 days. Thigh contusions can cause prolonged disability if not treated correctly and efficiently.6

•  Hematomas are intramuscular (in the epimysium) or intermuscular (ruptured fascia). Intermuscular hematomas may appear dramatic (bruising and swelling) and intramuscular hematomas are considered more serious.7

•  Myositis Ossificans (MO) (aka Posttraumatic Calcific Metaplasia): Uncommon condition but, when present, seen in the quadriceps muscles. It represents degeneration and necrosis of damaged muscle tissue resulting in bone formation. It can develop approximately two weeks post contusion.8

Orthopedic Examination

Physical Exam

History

Physical Exam Findings

Bursitis Treatment Options

•  R.I.C.E. (Rest, Ice, Compression, Elevation) •  Appropriate corrective exercises and stretches2

•  IASTM - Instrument-Assisted Soft Tissue Mobilization Ø  Increase blood flow, reduce swelling/draining of the injured area

and improve ROM11

•  Anti-inflammatories or NSAIDs if needed Ø  For infectious or more serious injury further testing is required12

•  Signs and Symptoms: Ø  Pain with palpation of

extra-articular tissues of patella. Ø  Swelling over the patella. Ø  Warmth or heat (inflammation).4

Tests to rule out any other possible pathologies or conditions that exhibit similar signs and symptoms:10

Quadriceps Contusion with Hematoma Prepatellar Bursitis

Ultrasound Image of MO15

Knee bursae 2 •  A bursa is a fluid-filled sac lined by a synovial membrane forming clefts between mobile structures in the musculoskeletal system. The prepatellar bursa is a superficial bursa that serves as a cushion between the skin and the bone.1

Gait and Pain Levels 9

•  R.I.C.E. •  Kineseotaping, Laser Therapy, Mobilization

Ø  Reduces swelling, promoting healing13

•  NSAIDS to prevent MO formation9

•  Absolute Contraindication for IASTM14

Ø  Aggressive manual therapy and IASTM have been seen to delay recovery.7

Effusion: Patella Ballottement Test Fluctuation Test Plica: Mediopatella Plica Test Hughston Plica Test

Hematoma Treatment Options

•  In acute phases, pain with motion is present. Limited ROM may be present. Antalgic gait can be observed.4

Palpation of the Knee4

•  Inspect for deformity, swelling, or ecchymosis (rounded, oval or irregular flat nodule).4

•  Palpation of the quadriceps (at the distal end) will locate area of muscle damage.

•  Strength testing (Resisted Knee Extension and Hip Flexion) will show the severity.

•  Measurement of knee flexion has been used as a prognostic indicator in quadriceps contusions and its effect on gait.9

Contusion Ecchymosis 9

•  For a definitive diagnosis and if injury does not subside after two weeks a MRI or diagnostic ultrasound is required.8

Meniscal Instability: Thessaly’s Test, Apley’s Compression Test Patellafemoral Dysfunction: Patella Grinding Test, Clarke’s Patellar Scrape Ligamentous Instability: Drawer’s Sign, Slocum Test

IASTM13

9.  Kary J. Diagnosis and management of quadriceps strains and contusions. Current Reviews in Musculoskeletal Medicine. 2010;3(1-4):26-31. DOI: 10.1007/s12178-010-9064-5.

10.  Cipriano J. Photographic manual of regional orthopaedic and neurological tests. Philadelphia: Lippincott Williams & Wilkins Health; 2010.

11.  Kim J, Sung D, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. Journal of Exercise Rehabilitation. 2017;13(1):12-22. DOI: https://doi.org/10.12965/jer.1732824.412.

12.  Kimpton K, Laurencin C, Panagis J, Ward M. Bursitis and Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2017;.

13.  Conforti M. The Treatment of Muscle Hematomas. Muscle Injuries in Sport Medicine. 2013. DOI: 10.5772/56903. 14.  Hammer W. The effect of mechanical load on degenerated soft tissue. Journal of Bodywork and Movement Therapies. 2008;12(3):

246-256. DOI: https://doi.org/10.1016/j.jbmt.2008.03.007. 15.  Myositis Ossificans – Carles Pedret (carlespedret), Sports Medicine and Sports Orthopedics. TheUltrasoundSite. 2017.

Apley’s Compression Test (Left) Thessaly’s Test (Right)10

Mediopatella Plica Test (Top) Fluctuation Test (Bottom)10