Clergyman's Knee Syndrome: Causes, Symptoms, Diagnosis, and Treatment

What is clergyman knee syndrome?

Clergyman's knee syndrome, medically known as prepatellar bursitis, is an inflammatory condition affecting the bursa located directly in front of the kneecap, often caused by repetitive kneeling or direct trauma.

Understanding the Anatomy

To grasp clergyman's knee, it's essential to understand the prepatellar bursa. Bursae are small, fluid-filled sacs found throughout the body, acting as cushions between bones, tendons, muscles, and skin. Their primary function is to reduce friction during movement. The prepatellar bursa is strategically positioned between the skin and the kneecap (patella), allowing the skin to glide smoothly over the bone as the knee bends and straightens.

What is Clergyman's Knee Syndrome?

Clergyman's knee syndrome is a common term for prepatellar bursitis, an inflammation of the prepatellar bursa. This condition is also sometimes referred to as "housemaid's knee" or "carpet layer's knee," reflecting its frequent occurrence in individuals whose occupations or activities involve prolonged or repetitive kneeling. When the bursa becomes inflamed, it can swell with excess fluid, leading to pain, tenderness, and restricted movement.

Causes and Risk Factors

The inflammation of the prepatellar bursa typically arises from one of several mechanisms:

• Repetitive Kneeling: This is the most common cause. Sustained or repeated pressure on the kneecap irritates the bursa. Occupations at high risk include plumbers, roofers, gardeners, carpet layers, and those who spend extended periods in prayer or other activities requiring kneeling.
• Direct Trauma: A sudden, acute blow to the front of the kneecap can also inflame the bursa. This could be from a fall, a sports injury, or a direct impact.
• Infection (Septic Bursitis): Although less common, the bursa can become infected if bacteria enter through a cut, scrape, or puncture wound near the knee. This is a more serious form of bursitis and requires immediate medical attention.
• Underlying Medical Conditions: Certain systemic inflammatory conditions, such as rheumatoid arthritis, gout, or pseudogout, can predispose individuals to bursitis, including prepatellar bursitis.

Signs and Symptoms

The symptoms of clergyman's knee typically develop gradually, though they can appear suddenly after an acute injury or infection. Key indicators include:

• Pain: Localized pain directly over the front of the kneecap. This pain often worsens with kneeling, direct pressure, or bending the knee.
• Swelling: A noticeable, often soft, lump or puffiness over the kneecap. The swelling can range from mild to significant, making the kneecap appear distended.
• Tenderness: The area over the bursa is painful to touch.
• Warmth and Redness: If the bursa is severely inflamed or, more importantly, infected (septic bursitis), the skin over the kneecap may feel warm to the touch and appear red.
• Limited Range of Motion: While often not severe, significant swelling or pain can make it difficult or uncomfortable to fully bend or straighten the knee.
• Fever and Chills: These systemic symptoms are strong indicators of a septic (infected) bursa and warrant immediate medical evaluation.

Diagnosis

Diagnosing clergyman's knee typically involves a thorough clinical assessment:

• Medical History: The healthcare professional will inquire about your occupation, activities, recent injuries, and any other medical conditions.
• Physical Examination: A physical exam will involve visual inspection of the knee for swelling, redness, and warmth. The area will be palpated to assess tenderness and the nature of the swelling. The range of motion of the knee will also be checked.
• Imaging Studies: In most straightforward cases, imaging is not necessary. However, X-rays may be ordered to rule out bone fractures or other bony abnormalities. MRI scans are rarely needed but can provide detailed images of soft tissues if there's suspicion of other knee pathologies.
• Aspiration: If infection (septic bursitis) is suspected, a small needle may be used to draw fluid from the bursa (aspiration). This fluid is then sent to a laboratory for analysis to identify bacteria and determine the appropriate antibiotic treatment.

Treatment and Management

Treatment for clergyman's knee syndrome primarily focuses on reducing inflammation, alleviating pain, and preventing recurrence.

• Conservative Management (RICE Protocol):
  • Rest: Avoid activities that aggravate the knee, especially kneeling.
  • Ice: Apply ice packs to the affected area for 15-20 minutes several times a day to reduce swelling and pain.
  • Compression: A compression bandage or sleeve can help reduce swelling, but ensure it's not too tight.
  • Elevation: Elevate the leg above heart level when resting to help drain fluid.
• Medications:
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter NSAIDs like ibuprofen or naproxen can help manage pain and inflammation.
  • Antibiotics: If the bursitis is septic (infected), antibiotics are crucial and will be prescribed based on the identified bacteria.
• Aspiration: Draining the excess fluid from the bursa with a needle can provide immediate relief from pressure and swelling. This is often done in conjunction with corticosteroid injections.
• Corticosteroid Injections: For persistent inflammation that doesn't respond to conservative measures, a corticosteroid injection directly into the bursa can significantly reduce inflammation.
• Surgery (Bursectomy): Surgical removal of the prepatellar bursa (bursectomy) is a rare option, typically reserved for chronic, recurrent cases that have failed all other non-surgical treatments, or in cases of persistent septic bursitis that do not respond to antibiotics and aspiration.

Rehabilitation and Exercise Considerations

Once acute pain and swelling subside, a structured rehabilitation program can help restore knee function and prevent recurrence.

• Gentle Range of Motion: Begin with light, pain-free knee flexion and extension exercises to maintain mobility.
• Strengthening Exercises: Focus on strengthening the muscles around the knee, including the quadriceps, hamstrings, and glutes. Examples include straight leg raises, hamstring curls, and glute bridges. These should be performed without putting direct pressure on the kneecap.
• Flexibility: Regular stretching of the quadriceps and hamstrings can help maintain overall knee health.
• Proprioception/Balance: Exercises that improve balance and coordination can enhance knee stability.
• Gradual Return to Activity: Slowly reintroduce activities that previously aggravated the condition, always using protective measures.

Important Note: During recovery, avoid any exercises or activities that involve direct kneeling or put pressure on the prepatellar bursa until fully healed.

Prevention

Preventing clergyman's knee largely involves modifying activities and using protective measures:

• Use Knee Pads: For occupations or hobbies that require frequent or prolonged kneeling, always wear protective knee pads.
• Take Frequent Breaks: Avoid staying in a kneeling position for extended periods. Stand up, stretch, and change positions regularly.
• Proper Technique: When kneeling, try to distribute weight evenly and avoid direct, sustained pressure on the kneecap.
• Maintain Overall Knee Health: Regular exercise, maintaining a healthy weight, and ensuring good flexibility and strength in the leg muscles can contribute to overall knee resilience.

When to See a Doctor

While many cases of clergyman's knee can be managed with self-care, it's important to seek medical attention if you experience:

• Severe pain or rapid swelling.
• Signs of infection, such as fever, chills, spreading redness, or pus draining from the area.
• Inability to bend or straighten your knee fully.
• Symptoms that worsen or do not improve after a few days of conservative treatment.

Conclusion

Clergyman's knee syndrome, or prepatellar bursitis, is a common and often painful condition resulting from inflammation of the bursa in front of the kneecap. While it can be debilitating, it is highly manageable with conservative treatments such as rest, ice, and anti-inflammatory medications. Proactive measures, particularly the use of knee pads and avoiding prolonged kneeling, are crucial for prevention. Understanding the underlying anatomy and biomechanics empowers individuals to take effective steps towards recovery and long-term knee health.