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Bursare In Lower Extrimity
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  • 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.
  • 2. BURSAE AROUND HIP JOINT
  • 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.
  • 7. BURSAE AROUND KNEE JOINT
  • 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.
  • 14. PES ANSERINE BURSA
  • 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.
  • 18. Compiled By: Miss. Apeksha Besekar MPTh 1st yr. 22nd oct 2012.