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

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Prepatellar Bursitis and Quadriceps Contusion with Hematoma: Differences in Assessment and Treatment Prepatellar Bursitis and Quadriceps Contusion with Hematoma: Differences in Assessment and Treatment Christopher Wuttke University of Bridgeport College of Chiropractic Bridgeport, CT Prepatellar Bursitis Quadriceps Contusion with Hematoma History History • A bursa is a fluid-filled sac lined by a Knee bursae 2 • Muscle lesions are one of the most common categories of sports synovial membrane forming clefts injuries in athletes. Over 90% are muscle strains or contusions.5 between mobile structures in the musculoskeletal system. The prepatellar • Average return to play without proper treatment is 45 days. Thigh bursa is a superficial bursa that serves as contusions can cause prolonged disability if not treated correctly and a cushion between the skin and the bone. efficiently.6 1 • Hematomas are intramuscular (in the epimysium) or intermuscular • Bursitis: Inflammation or irritation of the bursa. (ruptured fascia). Intermuscular hematomas may appear dramatic (bruising and swelling) and intramuscular hematomas are considered • Prepatellar bursitis is also known as “housemaid’s knee” or “nun’s more serious.7 knee.” • Myositis Ossificans (MO) (aka Posttraumatic Calcific Metaplasia): • Causes include: injury, such as a fall or impact, prolonged pressure Uncommon condition but, when present, seen in the quadriceps from kneeling or leaning, strain or overuse from repetitive motion, muscles. It represents degeneration and necrosis of damaged muscle joint stress from abnormal gait.3 tissue resulting in bone formation. It can develop approximately two weeks post contusion.8 Physical Exam Findings Physical Exam • Signs and Symptoms: • Inspect for deformity, swelling, or Ø Pain with palpation of ecchymosis (rounded, oval or irregular flat extra-articular tissues of patella. nodule).4 Ø Swelling over the patella. • Palpation of the quadriceps (at the distal end) Contusion Ecchymosis 9 Ø Warmth or heat (inflammation).4 will locate area of muscle damage. • Strength testing (Resisted Knee Extension • In acute phases, pain with motion is and Hip Flexion) will show the severity. present. Limited ROM may be Palpation of the Knee4 • Measurement of knee flexion has been used present. Antalgic gait can be as a prognostic indicator in quadriceps observed.4 contusions and its effect on gait.9 Gait and Pain Levels 9 Orthopedic Examination Tests to rule out any other possible pathologies or conditions that exhibit similar signs and symptoms:10 Meniscal Instability: Effusion: Thessaly’s Test, Apley’s Compression Test Patella Ballottement Test Fluctuation Test Mediopatella Plica Test (Top) Patellafemoral Dysfunction: 10 Fluctuation Test (Bottom) Patella Grinding Test, Clarke’s Patellar Scrape Plica: Mediopatella Plica Test Ligamentous Instability: Apley’s Compression Test (Left) Hughston Plica Test Drawer’s Sign, Slocum Test Thessaly’s Test (Right)10 Bursitis Treatment Options Hematoma Treatment Options • R.I.C.E. • R.I.C.E. (Rest, Ice, Compression, Elevation) • Kineseotaping, Laser Therapy, Mobilization • Appropriate corrective exercises and stretches2 Ø Reduces swelling, promoting healing13 • IASTM - Instrument-Assisted Soft Tissue Mobilization IASTM13 • NSAIDS to prevent MO formation9 Ø Increase blood flow, reduce swelling/draining of the injured area • Absolute Contraindication for IASTM14 and improve ROM11 Ø Aggressive manual therapy and IASTM Ultrasound Image of MO15 • Anti-inflammatories or NSAIDs if needed have been seen to delay recovery.7 Ø For infectious or more serious injury further testing is required12 • For a definitive diagnosis and if injury does not subside after two weeks a MRI or diagnostic ultrasound is required.8 Conclusion • 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. 9. Kary J. Diagnosis and management of quadriceps strains and contusions. Current Reviews in Musculoskeletal Medicine. References 2010;3(1-4):26-31. DOI: 10.1007/s12178-010-9064-5. 1. Todd D. Bursitis: An overview of clinical manifestations, diagnosis, and management. UpToDate. 2016. 10. Cipriano J. Photographic manual of regional orthopaedic and neurological tests. Philadelphia: Lippincott Williams & Wilkins 2. Souza T. Differential Diagnosis and Management for Chiropractors. Jones & Bartlett Learning; 2014. Health; 2010. 3. Todd D. Patient education: Bursitis (Beyond the Basics). UpToDate. 2015. 11. Kim J, Sung D, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms 4. Bickley L, Szilagyi P. Bates' Guide to Physical Examination and History Taking. Philadelphia: Lippincott Williams & Wilkins; 2003. and practical application. Journal of Exercise Rehabilitation. 2017;13(1):12-22. DOI: https://doi.org/10.12965/jer.1732824.412. 5. Delos D, Maak T, Rodeo S. Muscle Injuries in Athletes. Sports Health: A Multidisciplinary Approach. 2013;5(4):346-352. 12. Kimpton K, Laurencin C, Panagis J, Ward M. Bursitis and Tendinitis. National Institute of Arthritis and Musculoskeletal and Skin 6. Trojian T. Muscle Contusion (Thigh). 2017. DOI: http://dx.doi.org/10.1016/j.csm.2012.12.009. Diseases. 2017;. 7. Stainsby B, Piper S, Gringmuth R. Management approaches to acute muscular strain and hematoma in National level soccer players: a 13. Conforti M. The Treatment of Muscle Hematomas. Muscle Injuries in Sport Medicine. 2013. DOI: 10.5772/56903. report of two cases. The Journal of the Canadian Chiropractic Association. 2017. 14. Hammer W. The effect of mechanical load on degenerated soft tissue. Journal of Bodywork and Movement Therapies. 2008;12(3): 8. Yochum A, Reckelhoff K, Kaeser M, Kettner N. Ultrasonography and Radiography to Identify Early Post Traumatic Myositis Ossificans 246-256. DOI: https://doi.org/10.1016/j.jbmt.2008.03.007. in an 18-Year-Old Male: A Case Report. Journal of Chiropractic Medicine. 2014;13(2):134-138. 15. Myositis Ossificans – Carles Pedret (carlespedret), Sports Medicine and Sports Orthopedics. TheUltrasoundSite. 2017. .
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