Deep Infrapatellar Bursopathy

Deep Infrapatellar Bursopathy

Authors, Editors, Case Information Author: Michael Serra-Jovenich, DO, MMSc, CPT Affiliation: Inspira Health / Rowan-Virtua School of Osteopathic Medicine PM&R Residency Co Author(s): Tamzid Hassan, DO; Zachary Noll, OMS III; Altamash Raja, DO, RMSK, CSCS Editor: Derek Stokes, MD Clinical Vignette: 77-year-old male presented to clinic with three months of insidious onset left infrapatellar knee pain without an obvious inciting event including any report of trauma. His pain was most notably provoked when descending stairs and located primarily at the distal patellar tendon region. He otherwise denied any swelling or instability of the knee. On examination, range of motion was full without audible crepitus. Tenderness to palpation was identified at the inferior patellar pole and distal patellar tendon region. Type of Probe Used: 15-4 MHz Linear Transducer #1 - Video View Video REMOVE FROM CASE Short Axis View of the Left Quadriceps Tendon and Superior (Base) of the Patella #2 - Video View Video Medial to lateral video of the left deep infrapatellar bursa - long axis to the distal patellar tendon and tibial tubercle. An anechoic fluid collection is visualized at deep infrapatellar bursa representing a possible deep infrapatellar bursopathy. LAX unlabeled view of the distal patellar tendon/tibial tubercle Long axis view of the distal patellar tendon/tibial tubercle with the deep infrapatellar bursa in view. Doppler overlay. #4 - Video View Video Proximal to distal video of the patellar tendon from the inferior pole of the patella to the tibial tubercle - short axis to the patellar tendon. An area of hypoechogenicity representing tendinopathy versus small partial tear is briefly visualized proximally followed by an area of anechogenicity distally representing a fluid collection at deep infrapatellar bursa and possible bursopathy. LAX labeled view of the distal patellar tendon/tibial tubercle Long axis labeled view of the deep infrapatellar bursa with doppler overlay. Cortical irregularities are present. No hyperemia is visualized in the image. These findings represent a deep infrapatellar bursa fluid collection indicating possible bursopathy. SAX unlabeled view of distal patellar tendon and deep infrapatellar bursa Short axis view of the distal patellar tendon and deep infrapatellar bursa with doppler overlay. #7 - Video View Video Lateral to medial video of the inferior pole of the patella and proximal patellar tendon. An area of hypoechogenicity is visualized representing patellar tendinopathy with a possible small partial tear. SAX labeled view of distal patellar tendon and deep infrapatellar bursa Short axis labeled view of the deep infrapatellar bursa with doppler overlay. No hyperemia is visualized in the image. These findings represent deep infrapatellar bursa fluid collection indicating possible bursopathy. LAX unlabeled view of left inferior pole of the patella and proximal patellar tendon Unlabeled long axis view of the left inferior pole of the patella and proximal patellar tendon. LAX labeled view of left inferior patellar pole and proximal patellar tendon Labeled long axis view of the left inferior patellar pole and proximal patellar tendon. An area of highlighted hypoechogenicity was identified and may represent patellar tendinopathy versus a small partial thickness tear. SAX unlabeled view of left proximal patellar tendon Short axis unlabeled view of the left proximal patellar tendon. SAX labeled view of left proximal patellar tendon Short axis labeled view of the left proximal patellar tendon. An area of hypoechogenicity is highlighted and may represent patellar tendinopathy versus a small partial tendon tear. Interpretation Image Interpretation: A distended deep infrapatellar bursa suggestive of bursopathy was identified distally. No definitive hyperemia was visualized on the recorded images/videos. Additionally, a focal area of hypoechogenicity is noted at proximal patellar tendon attachment to the inferior patellar pole suggestive of a tendinopathy versus partial thickness tear. Teaching Pearl: Two infrapatellar bursae exist (superficial and deep). The superficial infrapatellar bursa is located between the skin and tibial tubercle, while the deep infrapatellar bursa is located between the insertional portion distal patellar tendon and anterior/superior portion of tibia (Chatra). Deep infrapatellar bursitis/bursopathy, an uncommon source of anterior knee pathology, can present with or without knee pain and often lack visible static effusion due to its deep anatomical location making a clinical diagnosis challenging. Localized swelling, best visualized upon terminal knee extension, can be painful or painless and typically appears adjacent to the distal patellar tendon (LaPrade). Though its etiology remains unclear, it has been associated with direct trauma, infection (septic arthritis), gout, and overuse of the extensor mechanism. However, deep infrapatellar bursitis/bursopathy has also been found in those with juvenile idiopathic arthritis, juvenile ankylosing spondylitis, Osgood-Schlatter, extra-articular villonodular synovitis, tenosynovial giant cell tumor, and insertional patellar tendinopathy. While MRI is considered the imaging modality of choice, barriers such as cost and access make ultrasound a valuable tool for detecting dynamic changes, confirming diagnoses, and guiding treatment (Jena). Sources: Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging. 2012 Jan. Volume 22, Issue 1: 27-30. PMID: 22623812. PMCID: PMC3354353. LaPrade RF. The anatomy of the deep infrapatellar bursa of the knee. Am J Sports Med. 1998 Jan-Feb. Volume 26, Issue 1: 129-32. PMID: 9474413. Jena D, Barman A, Sahoo J, Patel R, Dalai A. A Case of Chronic Deep Infrapatellar Bursitis Complicated by Patellar Tendinopathy and its Evaluation With Musculoskeletal Ultrasound. Cureus. 2022 Feb 9. Volume 14, Issue 2: e22057. PMID: 35340491. PMCID: PMC8916200.
NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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