but is painless. There is no associated effusion.
Crepitation and thickening of the tissue involving the
bursal tissue are often present in more chronic cases.
•Warmth, erythema, and pain to palpation may signify
a septic process, but aspiration is necessary to confirm
this as not all infected bursae are clinically demon-
strable.
- Most common infecting organisms include staphylo-
coccous aureus and streptococcal species. - On synovial fluid analysis, greater than 75% poly-
morphonuclear cell differential is most accurate in
confirming a septic process. Total white count and
glucose levels are less predictable (Ho and Tice,
1979). - Radiographs are usually negative aside from radiolu-
cency in the area of the bursitis. In cases involving
gouty deposits, calcific stippling can be seen.
TREATMENT
•Treatment for aseptic bursitis in this region is activity
modification, compressive wrapping, and anti-inflam-
matory medications. In more chronic situations aspi-
ration in combination with immobilization in
extension can be useful.
- Septic or more chronic aseptic processes are best
treated with surgical excision via open or arthroscopic
techniques. Cases of septic bursitis should be treated
with postoperative antibiotics sensitive to the infect-
ing organism (Kaalund, 1998).
PES ANSERINE BURSITIS
- Pes anserine bursa is the synovial tissue overlying the
attachment of sartorius, gracilis, and semitendinosis
tendons.
•Patients present with pain over this bursal region with
often some swelling in this region. - Differential diagnoses include, medial collateral liga-
ment injury, medial meniscal tear, medial compart-
mental arthritis, saphenous neuritis, and stress
fracture or avascular necrosis of the medial tibial
plateau (Larsson and Baum, 1985).
TREATMENT
•Treatment comprises activity modification, anti-
inflammatory medications, hamstring stretching, and
physiotherapy modalities. Recalcitrant cases often
respond to a corticosteroid injection.
SYNOVIAL PLICAE SYNDROME- Plicae are defined as synovial folds of tissue within
the knee. They are described as suprapatellar, infrap-
atellar, medial, or lateral based on their position
within the knee (Dandy, 1990). - Ninety percent of cadavers studied on anatomic dis-
section have the presence of at least one of the syn-
ovial plicae described. - Not all plicae are symptomatic. Differential diagnoses
include patellofemoral syndrome and meniscal/chon-
dral pathology. Medial plicae are most commonly
associated with symptoms. Its presence noted at the
time of arthroscopy in all patients ranges from 19 to
70% (Pipkin, 1971; Joyce and Harty, 1984).
•Patients often describe pain over the affected plicae in
combination with intermittent snapping or giving
way. - Clinically, this snapping can often be elicited with
manipulation of the plicae at varying degrees of flex-
ion between 45°and 60°. - Radiographic studies including X-rays and MRI are
usually negative. The latter is often obtained to rule
out other intra-articular pathology.
TREATMENT•Treatment is usually conservative with nonsteroidal
anti-inflammatory drugs (NSAIDs) and activity mod-
ification. Steroid injections have proven to be effec-
tive in more unresponsive cases.- Arthroscopic resection is limited to those not
responding to conservative treatment and has mixed
results. Associated chondral injuries or concurrent
patellofemoral maltracking have been implicated to
athroscopic failures which have been reported to be
as high as 30% (Dupont, 1997).
REFERENCES
Aglietti P, Buzzi R, Insall J: Disorders of the patellofemoral joint,
in Insall J(ed.): Surgery of the knee,3rd ed. New York, NY,
Churchill Livingstone, 930–931, 2001.
Arnoczky SP: Blood supply to the anterior cruciate ligament and
supporting structures. Orthop Clin North Am16:15–28, 1985.
Blanzina ME, Kerlan RJ, Jobe FW, et al: Jumper’s knee. Orthop
Clin North Am 4:665–678, 1973.
Bonamo JJ, Krinick RM, Sporn AA: Rupture of the patellar liga-
ment after use of its central third for anterior cruciate ligament
reconstruction. A report of two cases.J Bone Joint Surg
66–A:1294–1297, 1984.364 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE