Clergyman's Knee (Prepatellar Bursitis): Causes, Symptoms, and Management

Why is it called clergyman's knee?

Clergyman's knee is an informal, historical term for prepatellar bursitis, a common inflammatory condition affecting the bursa located just in front of the kneecap (patella), so named due to its frequent occurrence in individuals whose professions, such as clergymen, involved prolonged kneeling.

What is Clergyman's Knee?

Clergyman's knee is the colloquial name for prepatellar bursitis, an inflammation of the prepatellar bursa. A bursa is a small, fluid-filled sac that acts as a cushion between bones, tendons, muscles, and skin, reducing friction during movement. The prepatellar bursa is strategically positioned over the kneecap, separating the skin from the patella itself. When this bursa becomes inflamed, it fills with excess fluid, leading to pain, swelling, and tenderness in the front of the knee.

The Historical Naming: Why "Clergyman's Knee"?

The term "clergyman's knee" emerged from the historical observation that individuals in professions requiring extensive kneeling were particularly susceptible to this condition. Clergymen, who traditionally spent significant time kneeling for prayer, services, and other duties, frequently developed this inflammation. The constant pressure and friction on the prepatellar bursa from kneeling directly on hard surfaces were identified as primary culprits.

This naming convention is not unique to clergymen. Other similar occupational terms highlight the repetitive stress associated with specific jobs:

• Housemaid's Knee: Also refers to prepatellar bursitis, common among housemaids who spent much time kneeling to scrub floors.
• Roofer's Knee: Another term for the same condition, affecting roofers who kneel on hard, uneven surfaces.
• Miner's Elbow: A historical term for olecranon bursitis, affecting the bursa at the tip of the elbow due to repetitive leaning or pressure.

These terms underscore the direct link between sustained occupational postures and the development of specific musculoskeletal conditions. While less common in formal medical literature today, they persist in common parlance, reflecting a clear understanding of the biomechanical stressors involved.

Anatomy and Biomechanics of the Condition

To understand prepatellar bursitis, it's crucial to grasp the anatomy and biomechanics of the affected area:

• The Patella (Kneecap): A sesamoid bone embedded within the quadriceps tendon, which enhances the leverage of the quadriceps muscles as they extend the knee.
• The Prepatellar Bursa: This superficial bursa lies between the skin and the anterior surface of the patella. Its primary function is to allow the skin to glide smoothly over the kneecap during knee flexion and extension, minimizing friction.
• Mechanism of Injury: When excessive or prolonged pressure is applied to the front of the knee, or when there is repetitive friction, the walls of the prepatellar bursa can become irritated and inflamed. This irritation causes the synovial lining of the bursa to produce more fluid than normal, leading to distension and swelling. The increased fluid volume puts pressure on surrounding tissues, resulting in pain and tenderness.

Common Causes Beyond Clerical Duties

While historically linked to specific occupations, prepatellar bursitis can affect anyone. Common causes include:

• Prolonged Kneeling: As the name suggests, any activity involving extended periods of kneeling on hard surfaces without adequate protection (e.g., floor layers, plumbers, gardeners, athletes in sports like wrestling or volleyball).
• Direct Trauma: A sudden impact or fall directly onto the kneecap can irritate or rupture the bursa.
• Repetitive Friction: Activities that cause repeated rubbing or shearing forces over the kneecap.
• Infection (Septic Bursitis): A cut, scrape, or puncture wound over the kneecap can allow bacteria to enter the bursa, leading to a painful and potentially serious infection. This often presents with redness, warmth, fever, and more severe pain.
• Underlying Medical Conditions: Certain systemic inflammatory conditions, such as rheumatoid arthritis, gout, or pseudogout, can predispose individuals to bursitis.

Symptoms and Diagnosis

The symptoms of prepatellar bursitis typically include:

• Swelling: A noticeable lump or swelling over the front of the kneecap, which may feel soft and fluctuant.
• Pain: Localized pain over the kneecap, often worse with kneeling, direct pressure, or knee flexion.
• Tenderness: The area over the bursa is painful to touch.
• Warmth: The affected area may feel warm to the touch.
• Redness: In cases of septic (infected) bursitis, the skin over the bursa may appear red.
• Limited Range of Motion: While often mild, severe swelling can sometimes restrict full knee flexion.

Diagnosis is usually clinical, based on a physical examination and the patient's history. Imaging studies like X-rays (to rule out bone injury) or ultrasound (to visualize fluid accumulation) may be used. If infection is suspected, fluid may be aspirated from the bursa for laboratory analysis.

Management and Prevention

Management of prepatellar bursitis focuses on reducing inflammation and pain:

• Rest and Activity Modification: Avoiding activities that aggravate the knee, especially kneeling.
• Ice Application: Applying ice packs to the affected area to reduce swelling and pain.
• Compression: Using a compression bandage can help reduce swelling.
• Elevation: Elevating the leg can assist in reducing fluid accumulation.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter medications like ibuprofen or naproxen can help manage pain and inflammation.
• Physical Therapy: Exercises to maintain knee mobility and strength, ensuring proper biomechanics.
• Bursa Aspiration: In cases of significant fluid accumulation, a healthcare professional may drain the fluid from the bursa.
• Corticosteroid Injections: Injecting corticosteroids into the bursa can powerfully reduce inflammation, though this is not typically done for septic bursitis.
• Antibiotics: If the bursitis is septic, a course of antibiotics is necessary.
• Surgery (Bursectomy): In rare, chronic, or recurrent cases that do not respond to conservative treatment, surgical removal of the bursa may be considered.

Prevention strategies are key, especially for those in high-risk occupations or activities:

• Use Knee Pads: Always use protective knee pads when kneeling for extended periods.
• Take Breaks: Regularly change positions and take breaks from kneeling.
• Proper Technique: Avoid direct, sustained pressure on the kneecap.
• Address Underlying Conditions: Manage systemic inflammatory diseases effectively.

When to Seek Professional Help

Consult a healthcare professional if you experience:

• Persistent or worsening pain and swelling that doesn't improve with rest and home care.
• Significant redness, warmth, or a fever, which could indicate an infection.
• Inability to bend or straighten your knee fully.
• Any signs of a skin break or puncture wound over the bursa.

Early diagnosis and appropriate management are crucial to prevent chronic issues and potential complications, especially in cases of septic bursitis.