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Effusion associated with deep infrapatellar bursitis can be appreciated by displacing the patella buy celebrex 200 mg free shipping arthritis in fingers from golf. Based on the patient’s clinical presentation cheap celebrex 100 mg fast delivery arthritis diet for cats, additional testing may be indicated purchase generic celebrex on line arthritis for dogs, including complete blood cell count, sedimentation rate, and antinuclear antibody testing magnetic resonance imaging or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other knee bursitis, calcific tendinitis, tendinopathy, triceps tendinitis, or other 938 knee pathology (Fig. Rarely, the inflamed bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences. Radiograph demonstrating high-energy tibial plateau fractures include primary fracture lines that involve both tibial condyles, severe impaction and comminution of one or both articular surfaces, and fracture extension into the shaft. A,B: Magnetic resonance images of the knee showing abnormal mass in the infrapatellar region consistent with deep infrapatellar bursitis. A linear high frequency ultrasound transducer is placed over the previously identified patella in a longitudinal orientation (Fig. A survey scan is taken which demonstrates the hyperechoic margin of the skin and subcutaneous tissues, the superficial infrapatellar bursa, the patellar tendon, and the deep infrapatellar bursa beneath it (Fig. After the skin and subcutaneous tissues, the patellar tendon, and the deep infrapatellar bursa are identified, the bursa is evaluated for enlargement, inflammation, crystals, rice bodies, hemorrhage, and infection (Figs. The patella and patellar tendon are then evaluated for abnormalities including infections, anatomic abnormalities, and fracture (Fig. Color Doppler may help identify neovascularization and hyperemia associated with patellar tendinopathy. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the deep infrapatellar bursa. Longitudinal ultrasound image of the knee joint demonstrating the deep infrapatellar bursa lying beneath the patellar tendon. Longitudinal ultrasound image of the knee joint demonstrating deep infrapatellar bursitis. Longitudinal ultrasound image demonstrating bursitis of the deep infrapatellar bursa. The osteophyte just distal to the bursa may be serving as the nidus for the inflammatory process. Longitudinal ultrasound image demonstrating a moderately large deep infrapatellar bursitis. The use of ultrasound guidance can simplify needle placement when injecting or aspirating the deep infrapatellar bursa. The pes anserine bursa lies between the combined tendinous insertion of the sartorius, gracilis, and semitendinosus muscles and the medial tibia (Fig. The bursa is subject to the development of inflammation after overuse, misuse, or direct trauma (Fig. The medial collateral ligament often also is involved if the medial knee has been subjected to trauma. The medial collateral ligament is a broad, flat, band-like ligament that runs from the medial condyle of the femur to the medial aspect of the shaft of the tibia, where it attaches just above the groove of the semimembranosus muscle (Fig. The medial collateral ligament is crossed at its lower part by the tendons of the sartorius, gracilis, and semitendinosus muscles. Axial (A) and sagittal (B) fat-suppressed proton density-weighted images demonstrating an inflamed pes anserine bursa (arrows) along the medial tendons. The medial collateral ligament is a broad, flat, band-like ligament that runs from the medial condyle of the femur to the medial aspect of the shaft of the tibia, where it attaches just above the groove of the semimembranosus muscle. The pes anserine bursa lies beneath the pes anserine tendon, which is the insertional tendon of the sartorius, gracilis, and semitendinosus muscles to the medial side of the tibia (Fig. The bursa serves to cushion and facilitate sliding of pes anserine tendon over the tibia. The bursa is subject to inflammation from a variety of causes with acute trauma to the knee and repetitive microtrauma being the most common. Acute injuries to the bursa can occur from direct blunt trauma to the medial knee as well as from overuse injuries including running on hills or sudden increases in the distance that one runs. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur (Fig. Gout and other crystal arthropathies may also precipitate acute pes anserine bursitis as may bacterial, tubercular, or fungal infections. The patient may find any activity that involves flexion or external rotation of the knee such as getting in and out of cars increasingly difficult. Physical examination of the patient suffering from pes anserine bursitis will reveal point tenderness over the medial knee just below the medial knee joint (Fig. If there is significant inflammation, rubor and calor may be present and the entire area may feel boggy or edematous to palpation. At times, significant effusion may be present which can be quite distressing to the patient. Active resisted flexion and passive external rotation of the affected knee will often reproduce the patient’s pain. If calcification or gouty tophi of the bursa and surrounding tendons are present, the examiner may appreciate crepitus with active extension of the knee and the patient may complain of a catching sensation when moving the affected knee, especially on awaking. Occasionally, the pes anserine bursa may become infected, with systemic symptoms, including fever and malaise, as well as local symptoms, with rubor, color, and dolor being present. Patients suffering from pes anserine bursitis will suffer from point tenderness of the insertion of the pes anserine tendon. Plain radiographs are indicated in all patients who present with knee pain to rule out occult bony pathology (Fig. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing magnetic resonance imaging or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other knee bursitis, calcific tendinitis, tendinopathy, triceps tendinitis, or other knee pathology (Fig. Rarely, the inflamed bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences. Radiograph demonstrating a depressed tibial plateau fracture after an automobile–pedestrian bumper injury. Magnetic resonance image of the knee showing abnormal mass over the proximal medial tibia consistent with pes anserine bursitis. A high frequency linear ultrasound transducer is placed over the medial knee joint space in the oblique longitudinal plane with the superior portion of the ultrasound transducer turned about 20 degrees toward the patella (Fig. A survey scan is taken which demonstrates the characteristic appearance of the medial joint space with the hyperechoic medial margins of the femur and the tibia with the thick hyperechoic filaments of the medial collateral ligament overlying the triangular-shaped medial meniscus (Fig. The medial meniscus is visualized as a triangular-shaped hyperechoic structure resting between the bony medial margins of the femur and tibia (Fig. After the structures of the medial joint space and proximal tibia are identified, the ultrasound transducer is slowly moved inferiorly while slowly rotating the superior border of the transducer clockwise when imaging the right medial knee and counterclockwise when imaging the medial left knee until the pes anserine tendon is visualized as it is passing over the medial collateral ligament (Figs. When the pes anserine tendon and pes anserine bursa are identified, the pes anserine bursa is identified, the bursa is evaluated for enlargement, inflammation, crystals, rice bodies, hemorrhage, and infection (Fig. Correct longitudinal position for ultrasound transducer for evaluation of the medial joint space. After the structures of the medial joint space and proximal tibia are identified, the ultrasound transducer is slowly moved inferiorly while slowly rotating the superior border of the transducer clockwise when 946 imaging the right medial knee and counterclockwise when imaging the medial left knee until the pes anserine tendon is visualized as it is passing over the medial collateral ligament. The pes anserine tendon passes over the medial collateral ligament to attach to the medial tibia. Ultrasound image of the knee joint demonstrating the pes anserine bursa lying beneath the pes anserine tendon.

Sephadex® is a trade name for a series of cross-linked dex- Agar gel is a semisolid substance prepared from seaweed trans used in chromatography generic 200mg celebrex fast delivery arthritis knee foot pain. It involves the elec- another and their reaction at the point of contact in the gel cheap celebrex 100mg with mastercard arthritis relief walking workout. Since serum proteins Affnity chromatography is a method to isolate antigen or vary in their charge cheap 100 mg celebrex otc arthritis diet nightshade, binding to or elution from the column antibody based upon antigen–antibody binding. Antibody is possible by gradually increasing or decreasing the salt molecules fxed to a solid support such as plastic or agarose concentration (with or without changes in pH). This affects beads in a column, constituting the solid phase, may cap- the type of proteins binding to the resin. Double immunodiffusion is a precipitation reaction in gel Dialysis is a method to separate a solution of molecules that media in which both antibody and antigen diffuse radially differ in molecular weight by employing a semipermeable mem- from wells toward each other, thereby forming a concentration brane. Chromatography refers to a group of methods employed for the separation of proteins. A fxed serum from the frst tube is added to one volume of saline quantity (one volume) of physiologic saline is added to each in the second tube. After thoroughly mixing the contents of a row of serological tubes, except for the frst tube in the with the transfer pipette, one volume of the second tube is transferred to the third, and the procedure is repeated down the row. This same volume is then discarded from the fnal tube after the contents have been thoroughly mixed. Thus, Antigen to be the serum dilution in each tube is double that in the preced- isolated (i. The frst tube is undiluted; the second contains a 1:2 dilution; the third a 1:4; the fourth 1:8, etc. Serial dilution is the successive dilution of antiserum in a row of serological tubes containing physiologic saline solu- tion as diluent to yield the greatest concentration of antibody in the frst tube and the least amount in the last tube which contains the highest dilution. For example, a double quan- tity of antiserum is placed in the frst tube, half of which is Gel transferred to the second tube containing an equal volume of matrix Antibody coated diluent. After thorough mixing with a serological pipette, an bead equivalent amount is transferred to the successive tube, etc. The ratio the diameter of the ring is used to quantify the antigen con- of antibody to antigen is graded sequentially from one tube centration by comparison with antigen standards. The optimal proportion of antigen and antibody addition of antigen to a tube containing gel into which specifc is present in the tube that shows the most rapid focculation antibody has been incorporated. After washing, the site of interaction between equivalent quantities of antigen the precipitate can be analyzed for protein content through and antibody. Heidelberger and Kendall used the technique exten- molecules has increased the sensitivity of immunoassays sively, employing pneumococcus polysaccharide antigen 30,000-fold. They permit the detection and quantifcation of and precipitating antibody in which nitrogen determinations picogram quantities of an antigen or receptor. They may be used to identify a tumor site or the nique in which antibody is incorporated into agar gel and anti- presence and topography of molecules in a cell membrane. Isotopic labeling (radionuclide labeling) refers to the introduction of a radioactive isotope into a molecule by either external labeling through tagging molecules with 125I or other appropriate isotope or by internal labeling in which 14C or 3H-labeled amino acids are added to tissue culture, which allows the cells to incorporate the isotope. Once labeled, mol- Antigen and antibody ecules can be easily traced and their fate monitored by mea- movement suring radioactivity. Immunological Methods and Molecular Techniques 819 Reverse Mancini technique: See reverse radioimmuno- diffusion. If offers an advantage over equilibrium dialysis in that large, nondializable protein antigens may be used. This assay is based on the principle that certain proteins are soluble in 50% saturated ammo- nium sulfate, whereas antigen–antibody complexes are not. Spontaneous precipitation will occur if a precipitating-type antibody is used, until a point of antigen excess is reached Trace labeling: See isotopic labeling. This is in contrast to the stoichiometry of the antibody–antigen reaction and double diffusion in which both antigen and antibody diffuse inhibits the release or exchange of bound antigen. After incuba- sion proceeds, an excess of antigen develops in the area of the tion for a specifed time and temperature, the unbound cells precipitate causing it to dissolve only to form once again at are washed out, and the bound cells are collected following a greater distance from the site of origin. The harvested cells are antigen and antibody have reached equivalence in the agar, a washed, counted, and used for various other assays. The precipitation ring encloses an area proportional to the concentration of antigen measured Antigen capture assay is a method to identify minute quan- 48 to 72 h following diffusion. The antigen concentration is of high titer are linked to an insoluble solid support and the determined from the diameter of the precipitation ring. This specimen containing the antigen to be evaluated is passed method can detect as little as 1 to 3 μg/ml of antigen. As diffusion takes place, precipitation rings with 1 U of streptolysin O that prevents the lysis of erythro- that are produced are directly proportional to the antibody cytes determines the Todd units, the reciprocal of endpoint concentration. Horse serum may be used as a source of agglutination, indirect immunofuorescence, indirect immu- nonhemolytic complement for the reaction. Conglutination is the strong agglutination of antigen– A blocking test is an assay in which the interaction between antibody–complement complexes by conglutinin, a factor an antigen and its homologous antibody is inhibited by the pre- present in normal sera of cows and other ruminants. Conglutination is a sensitive technique for detecting used to prevent the reaction of an antibody with its intended complement-fxing antibodies. An example would be blood group substance soluble molecules the conglutinin solid phase assay is a test that quantifes equivalent to erythrocyte surface isoantigen epitopes found in C3bi-containing complexes that may activate complement by the body fuids. Capture assays are methods to measure antigens or anti- A consumption test is an assay in which antigen or anti- bodies in which antibodies bound to plastic capture antigens body disappears from the reaction mixture as a result of its or antigens bound to plastic capture antibodies. By gens or antiimmunoglobulins may be used to measure anti- quantifying the amount of unreacted antigen or antibody body binding to a plate-bound antigen. Antigen binding to an remaining in the reaction system and comparing it with the antibody bound to a plate can be assayed with an antibody quantity of that reagent that was originally present, the result that binds to a different antigenic determinant or epitope on can be ascertained. Cold ethanol fractionation is a technique used to fraction- A control is a specimen of known content used together with ate serum proteins by precipitation with cold ethanol. This method has been largely the substance under analysis and a negative control known replaced by more modern and sophisticated techniques. Cold target inhibition refers to the introduction of unla- Coprecipitation refers to the addition of an antibody spe- beled target cells to inhibit radioisotope release from labeled cifc for either the antigen portion or the antibody portion of target cells through the action of antibody or cell-mediated immune complexes to effect their precipitation. The procedure may be employed to quantify low concentra- Competitive binding assays are serological tests in which tions of radiolabeled antigen that are combined with excess unknowns are detected and quantifed by their ability to antibody. After soluble complexes have formed, antiimmu- inhibit binding of a labeled known ligand to a specifc anti- noglobulin or protein A is added to induce coprecipitation. The kinetoplast of this Known or unknown sources of antibody or antigen are then organism is an altered mitochondrion that is rich in double- used as competitive inhibitors. This is a used in immunofuorescence assays to detect the presence of test for antibody. This is accomplished Cytotoxicity assays are techniques to quantify the action by adding sensitized erythrocytes and conglutinin, which is of immunological effector cells in inducing cytolysis of Immunological Methods and Molecular Techniques 821 target cells. The cell death induced is either programmed Immunoassay is a test that measures antigen or antibody.

Blocking antibodies may phocytes order celebrex toronto arthritis knee does feel like, macrophages quality celebrex 100mg arthritis diet rheumatoid, or mast cells that specifcally binds the Fc region of immunoglobulin purchase celebrex online arthritis diet patrick holford, often when the Fc IgE Antigen molecule Mast cell Allergen Identical Allergen intercepted IgG epitopes Blocking IgG Ab’s before reaching IgM molecule IgE on mast cells figure 7. B and T lymphocytes, natural killer cells, poly- the release of infammatory mediators and cytokines. The Fc receptors for IgG are complexes, the cell may produce leukotrienes, prostaglan- designated FcγR (Figure 7. Those for IgE are desig- dins, modulate antibody synthesis, increase consumption nated FcεR (Figure 7. IgM and IgD Fc receptors have of oxygen, activate oxygen metabolites, and become phago- yet to be defned. In When the Fc region of immunoglobulin binds to the cation humans, it binds IgG1 and IgG3. In humans, it binds IgG1 be present in increased number, often accompanied by a and IgG3. Fcϵ receptor (FcϵR): Mast cell and leukocyte high affnity receptor for the Fc region of IgE. When immune complexes bind to Fcε receptors, the cell may respond by releasing the mediators of immediate hypersensitivity, such as histamine and serotonin. It is found on mononuclear phago- action of multivalent antigen with multiple IgE molecules cytes, B lymphocytes, eosinophils, and platelets. It is a 321-amino acid single polypeptide chain that ing vasoactive amines that produce local infammation and is homologous with a sialoglycoprotein receptor. Allergic individuals also express it on monocytes, eosinophils, B and T cells, but not mast cells or Langerhans cells, eosinophils, and monocytes. Specifc antigen interaction with the C cell-bound IgE molecules leading to cross-linkage results in cell activation and degranulation. FcαR represents the high affnity receptor for IgA and is comprised of an α chain that binds IgA and FcRγ chain dimer. It is expressed in fve splice variants found on eosinophils, monocytes, and alveolar macrophages. The genetic code includes the codons and nucleotide trip- the polyimmunoglobulin receptor is an attachment site for lets correlating with amino acid residues in protein synthe- polymeric immunoglobulins located on the basolateral mem- sis. After binding, the receptor–immunoglobulin complex is endocy- Immunoglobulin genes encode heavy and light polypep- tosed and enclosed within vesicles for transport. Exocytosis tide chains of antibody molecules and are found on differ- takes place at the cell surface where the immunoglobulin is ent chromosomes (i. A similar mechanism in chromosome 2 for κ light chain, and chromosome 22 for λ the liver facilitates IgA transport into the bile. The receptor a complete immunoglobulin heavy or light polypeptide segment that is bound to the polymeric immunoglobulin is chain. Separate gene segments that are widely distributed known as the secretory component which can only be used in somatic cells and germ cells come together to form these once in the transport process. In B cells, gene rearrangement leads to the cre- ation of an antibody gene that codes for a specifc protein. Poly-Ig receptor is the abbreviation of polyimmunoglobu- Somatic gene rearrangement also occurs with the genes lin receptor. Gene rearrangement of this type permits the great versatility of the immune Polymeric immunoglobulins (Ig) are immunoglobulin system in recognizing a vast array of epitopes. Three molecules that are comprised of numerous identical H2L2 forms of gene segments join to form an immunoglobu- monomers linked by a J chain. Heavy and A genome consists of all genetic information that is light chain genes have a closely similar organizational contained in a cell or in a gamete. There are 100 to 300 Vκ genes, fve Jκ genes, and one C gene on the κ locus of chromosome 2. Several Hypothetically, gene conversion was an evolutionary event as Vλ, six Jλ, and six Cλ genes are present on the λ locus of well as an ongoing one, giving rise to new mutations; there- chromosome 22 in humans. Isotype switching refers to the mechanism whereby a cell Tonegawa received the Nobel Prize for revealing the mecha- changes from synthesizing a heavy polypeptide chain of one nism of the generation of diversity in antibody formation. Germinal center B cells express it molecules, and revealed by preparing Southern blots using selectively. IgM is the main antibody ies and can help to identify defective genes associated with produced frst in a primary humoral response to thymus-depen- inherited disease. The specifcity of the antigen-binding region is not Gene rearrangement refers to genetic shuffing that results altered. The translatable During switching, B cells may temporarily express more than sequences (known as exons) are united to produce a func- one class of immunoglobulin. IgG1 expression replaces IgM expression as a consequence of Locus accessibility is the extent to which the chromatin the frst switch. IgE expression replaces IgG1 expression as a architecture of a specifc antigen receptor gene permits it to result of the second switch. Application of a labeled secondary small sub-exons to produce a complete constant exon in the antibody after washing away unbound primary antibody per- Igh locus. Immunoglobulin genes it synthesizes from IgM to IgG, IgE, or IgA without alter- manifest this phenomenon. The genetic switch hypothesis is a concept that predicts a Immunoglobulin-synthesizing cells produce only a sin- switch in the gene governing heavy chain synthesis by plasma gle class of heavy chain and one type of light chain at a cells during immune response ontogeny. Immunoglobulin Synthesis, Properties, Structure, and Function 281 D1 D2 Deletion: L1 V1 L2 V2 Ln Vn Dn J Cµ L1 V1 L2 V2 Ln Vn Dn J Cµ Inversion: C1 J2 J1 C2 V14 C1 C2 J1 J2 V14 Sister chromatid exchange: duplicated sister chromatids Daughter cells V1 V2 J2 J3 V1 J2 J3 V1 V2 J2 J3 V1 V2 V2 J2 J3 figure 7. The synthe- one or the other of the light polypeptide chain isotopes, κ or sis of a functional μ heavy chain from the IgH locus on λ. It is the productive rearrangement of light-chain genes such one chromosome blocks V(D)J recombination and μ chain as the rearrangement of the κ gene which occurs when both κ synthesis from the other IgH allele. The two coding regions in the V gene segment are developing T or B lymphocytes is modifed by somatic separated by a 100- to 400-bp intron. The second 3′ cod- ing region is part of an exon that codes for the terminal 4 signal Junctional diversity occurs when gene segments join peptide residues and 95 to 100 variable region residues. A J imprecisely, and the amino acid sequence may vary and gene segment encodes the rest of the variable region. A D gene affect variable region expression, which can alter codons at segment is involved in the encoding of immunoglobulin heavy gene segment junctions (Figure 7. An intron A variable (V) region is that part of an immunoglobulin lies between them. Immunoglobulin Synthesis, Properties, Structure, and Function 283 Structure of Heavy Chain Gene from IgM-Producing Cell µ Chain gene Leader V D J Cµ µ µ µ4 Tm peptide Tail sequence figure 7. V region subgroups are individual chain V region sub- A haplotype consists of those phenotypic characteristics divisions based on signifcant homology in amino acid encoded by closely linked genes on one chromosome inherited sequence. According to Mendelian genetics, 25% of siblings will domain that is encoded by the corresponding variable (V) share both haplotypes. Bystander B cells are nonantigen-specifc B cells in the area of B cells specifc for antigen.

Rarely buy 100mg celebrex arthritis medication pulled off market, the inflamed bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences (Fig purchase celebrex 200mg rheumatoid arthritis medication uk. T1-weighted magnetic resonance image showing a 16 mm × 12 mm well-defined lucency with central calcific densities 200mg celebrex with mastercard arthritis diet sheet, suggesting chronic osteomyelitis with sequestrum. A linear high frequency ultrasound transducer is placed over the previously identified patella in a longitudinal orientation (Fig. A survey scan is taken which demonstrates the hyperechoic margin of the skin and subcutaneous tissues, the prepatellar bursa and the patella beneath it (Fig. After the skin and subcutaneous tissues and the prepatellar bursa are identified, the bursa is evaluated for enlargement, inflammation, crystals, rice bodies, hemorrhage, and infection (Figs. The patella is then evaluated for abnormalities including infections, anatomic abnormalities, and 924 fracture (Fig. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the prepatellar bursa. Ultrasound image of the knee joint demonstrating an enlarged prepatellar bursa lying above the patella. Transverse image anterior to the patella demonstrates fluid in the prepatellar bursa consistent with prepatellar bursitis. Other pathologic processes may mimic prepatellar bursitis and judicious use of medical imaging including ultrasound, magnetic resonance imaging, plain radiography and computerized tomography may help clarify the diagnosis (Figs. Given that bursitis is usually the result of either trauma or abnormal function of the affected joint, one should assume that additional pathology other than the bursitis being treated is present. Palpable fluctuant mass of the anterolateral knee (A) is demonstrated to be a multiseptated hypoechoic structure on transverse ultrasound image (B) consistent with ganglion. Plain lateral radiograph of the knee showing prepatellar soft tissue swelling but no obvious bony lesion. A,B & C: Lipoma arborescens is typically seen in adults in the fifth through seventh decades, although the reported range of occurrence is 9 to 66 years of age. The superficial infrapatellar bursa lies between the anterior subcutaneous tissues of the knee and the anterior surface of the patellar tendon (Fig. The bursa serves to cushion and facilitate sliding of the skin and subcutaneous tissues of the anterior inferior portion of the knee over the tibia. The superficial infrapatellar bursa is held in place by patellar tendon which is an extension of the common tendon of the quadriceps tendon. Both the quadriceps tendon and its expansions as well as the patellar tendon and the superficial infrapatellar bursa are subject to the development of inflammation caused by overuse, misuse, or direct trauma (Fig. The quadriceps tendon is made up of fibers from the four muscles that comprise the quadriceps muscle: the vastus lateralis, the vastus intermedius, the vastus medialis, and the rectus femoris. The tendons of these muscles converge and unite to form a single, exceedingly strong tendon (Fig. The patella functions as a sesamoid bone within the quadriceps tendon, with fibers of the tendon expanding around the patella and forming the medial and lateral patella retinacula, which help strengthen the knee joint. These fibers are called expansions and are subject to strain; the tendon proper is subject to the development of tendinitis. The superficial infrapatellar, deep infrapatellar, and prepatellar bursae also may concurrently become inflamed with dysfunction of the quadriceps tendon. Longitudinal ultrasound images demonstrate diffuse thickening of 928 the proximal (A) and distal (B) patellar tendon (solid arrows) with areas of hypoechogenicity (open arrow). C: T2- weighted sagittal magnetic resonance image of patellar tendon, showing degenerative interstitial tears (arrows) at the proximal and distal attachments. Introduction to diagnostic musculoskeletal ultrasound: part 2: examination of the lower limb. The quadriceps tendon is made up of fibers from the four muscles that comprise the quadriceps muscle: the vastus lateralis, the vastus intermedius, the vastus medialis, and the rectus femoris. The tendons of these muscles converge and unite to form a single, exceedingly strong tendon. The superficial infrapatellar bursa lies between the anterior subcutaneous tissues of the knee and the anterior surface of the patellar tendon (Fig. The bursa serves to cushion and facilitate sliding of the skin and subcutaneous tissues of the anterior inferior knee over the tibia. The bursa is subject to inflammation from a variety of causes with acute trauma to the knee and repetitive microtrauma being the most common. Acute injuries to the bursa can occur from direct blunt trauma to the anterior knee from falls onto the knee as well as from overuse injuries including running on uneven or soft surfaces or jobs that require crawling on the knees like carpet laying and scrubbing floors. Abnormalities of the patella may also predispose patients to the development of superficial infrapatellar bursitis (Fig. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur. Gout and other crystal arthropathies may also precipitate acute superficial infrapatellar bursitis as may lose bodies and bacterial, tubercular, or fungal infections (Fig. Anteroposterior (A) and axial (B) radiographs demonstrate the typical appearance of a bipartite patella. Note the position of the accessory ossification center at the superolateral margin of the patella. C: A tripartite patella was an incidental finding on this overpenetrated anteroposterior fi lm, which was obtained to exclude the possibility of gouty arthritis. Axial fat-suppressed proton density (A), coronal T1-weighted (B), sagittal proton density (C), and sagittal fast spin echo, T2-weighted (D) images demonstrate the well-circumscribed loose body anterior to the transverse ligament. Physical examination of the patient suffering from superficial infrapatellar bursitis will reveal point tenderness over the anterior knee. If there is significant inflammation, rubor and calor may be present and the entire area may feel boggy or edematous to palpation. At times, massive effusion may be present which can be quite distressing to the patient (Fig. Active resisted extension and passive flexion of the affected knee will often reproduce the patient’s pain. If calcification or gouty tophi of the bursa and surrounding tendons are present, the examiner may appreciate crepitus with active extension of the knee and the patient may complain of a catching sensation when moving the affected knee, especially on awaking. Occasionally, the superficial infrapatellar bursa may become infected, with systemic symptoms, including fever and malaise, as well as local symptoms, with rubor, color, and dolor being present. Superficial infrapatellar bursitis is associated with significant effusions over the anterior inferior knee. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other knee bursitis, calcific tendinitis, tendinopathy, triceps tendinitis, or other knee pathology. Rarely, the inflamed bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences.

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