1. BURSAE IN LOWER
EXTREMITY
A bursa is a sac of synovial fluid, rich in
protein and collagen that acts as a cushion
to protect soft tissues, such as tendons,
ligaments and muscles, from friction and
excess pressure.
3. Bursae in the hip include the greater
trochanteric bursa, the iliopsoas bursa,
gluteus medius bursa, ischio gluteal
bursa and ischial tuberosity bursa
located in the back of joint.
Soft Tissue Landmarks:
1. Inguinal Region (femoral triangle)
Iliopsoas bursa – Lies over the anterior
surface of the articular capsule, lateral
to the femoral artery and beneath the
deep surface of the iliopsoas muscle. It
is the largest and most constant bursa
and communicates with the hip joint in
15% of cases.
2. Greater Trochanter
Trochanteric Bursa – Comprises three
bursae (gluteus maximus is the principal
one).
4. PALPATION
In supine:
1. Start at the symphysis pubis (bony palpation).
2. Work laterally along the inguinal ligament, feeling
for
a. the normal femoral pulse
b. Inguinal adenopathy (superficial nodes along ligament,
deep nodes in the femoral sheath)
c. Tenderness over the iliopsoas suggesting a bursitis.
Palpate over the Iliac crests feeling for bony tenderness or
entheseal tenderness
4. Stop halfway and drop your hands down to the lateral
aspect of the femur and feel the greater trochanter and
the trochanteric bursal region.
5. In sidelying:
Better palpation of the trochanteric
bursa
Can palpate the ischial tuberosity
and ischial bursa.
In prone:
Can palpate the ischium/ischial
bursa in this position.
6. Diagnostic cues in hip pain:
Trochanteric bursitis: Increase in pain while
sitting with affected leg crossed. Walking and
going up stairs will tend to exacerbate the
condition as will trying to perform squats. The
area will suddenly go weak also.
Ischiogluteal bursitis: Pain at sitting, legs not
crossed. It can cause dull pain in this area that
is most noticeable ascending stairs. Pain often
appears after sitting on hard surfaces for a
while.
8. 4 bursae Communicate With the
Synovial Cavity of the Knee
Joint:
1. Suprapatellar (anteriorly)
2. Popliteus (posterolaterally)
3. Anserine (medially)
4. Gastrocnemius (med head)
(posteromedially)
9. IN STANDING
INSPECTION:
1. Cutaneous Structures: Look for Erythema,
scarring, bruising, and swelling in the following
areas:
a. Peripatellar grooves
b. Suprapatellar bursa
c. Prepatellar bursa
d. Infrapatellar tendon
e. Anserine bursa
f. Popliteal fossa.
10. IN SUPINE:
INSPECTION
1. Cutaneous Structures: Again looking for
scarring, erythema, bruising, and swelling as
described above
a. Peripatellar grooves
b. Suprapatellar bursa
c. Prepatellar bursa
d. Infrapatellar tendon
e. Anserine bursa.
11. PALPATION
KNEE IN EXTENSION:
Temperature: Feel the knee for warmth. A normal joint should be
about 1 degree cooler than the surrounding tissues.
Anterior Palpation: a. Quadriceps muscle for tenderness.
b. Move down to palpate the insertion of the quadriceps tendon into the
superior pole of the patella.
c. Palpate over the patella feeling for a pre-patellar bursitis and
pain/tenderness of the patella itself.
IN 90 DEGREES OF FLEXION
Medial Palpation
Start at the soft-tissue (medial tibia) depression and move upwards .
Palpate upwards until you reach the pes anserinus located just below
the medial tibial plateau. This is the insertion of the Sartorius,
Gracilis, and Semitendinosus tendons. The pes anserine bursa can
become inflamed and result in medial knee pain.
12. Bursae Associated
with Anterior Aspect
of Knee Joint:
1. (Suprapatellar
Bursa)
2. Prepatellar Bursa
3. Superficial
Infrapatellar Bursa
4. Deep Infrapatellar
Bursa
13. Prepatellar Bursitis: Also known as
housemaid’s knee. Common in coal miners and
military personnel.
Superficial Infrapatellar
Bursitis (Clergyman’s
Knee) common in roof
tilers and carpet layerers.
15. BURSAE IN FOOT
The main bursae in the foot that
become affected by bursitis include
the metatarsal bursa, the
metatarsophalangeal bursa, and the
calcaneal bursa.
The metatarsal bursa is located at
the base of the toes on the bottom of
the foot. This bursa can be irritated
when one metatarsal bone takes more
load than the others.
Those suffering from conditions like
hammertoe often develop bursitis as
a secondary condition.
Intermetatarsal bursitis occurs when
the tiny bursae between the toes
(metatarsals) become compressed.
16. The metatarsophalangeal bursa is
located on the inner part of the foot near
the big toe. This bursa is a common spot
for bursitis to develop as it is where a
bunion (enlarged metatarsal bone)
causes excess rubbing.
At the bottom of the heel lies
the calcaneal bursa. Bursitis is common
in this bursa due to the thinning of the
fat pad in the heel over time.
17. The retrocalcaneal bursa as its
name implies is directed at the
posterior aspect of the
calcaneum.
There are actually two bursa
posterior to the calcaneus and
either one can be implicated-
-The Subcutaneous bursa , which
sits just under the skin and
superficial to the Achillis
tendon
-However ,the other one is the
Subtendinous Bursa that sits
between the Achillis tendon and
calcaneus is also called as
retrocalcaneal bursa.
