In this article we describe the most common causes of pes anserine bursitis and the most effective ways to treat it.
Pes Anserine is a term used to refer to the insertion of three muscles at the proximal end of the Tibia. These muscles include The Sartorius, Gracilis, and Semitendinosus. Their job in the body is to allow the flexion of the knee; however, they may also play a role in the internal rotation of the Tibia and protect the knee from Valgus and rotatory stress. (1) It is considered an important part of the knee for the reconstructive surgery of tendons or the steroid injection treatment of Anserine Bursitis. The pes anserine tendons are used frequently in the form of autographs for surgeries involving knee ligamentous reconstruction. (2)
This article explores the causes and implications of inflammation of the pes anserine bursa and what treatment regimens are found to be successful for it.
What is Pes Anserine Bursitis?
Bursa, are sac-like cavitation structures found in the body, lined with synovial tissues. Their job is to provide a cushioning effect to the surrounding structures to avoid frictional injuries. Bursitis is a term used to describe an inflammatory process in the Bursa. When these structures are inflamed, the individual may present with tenderness, swelling, and redness.
Pes Anserine Bursitis, specifically, is the inflammation of the Pes Anserine Bursa. The pain experienced in individuals with this condition is often located at the medial knee and upper tibial area. This may also be referred to as the pes anserine pain syndrome, which is mainly characterized by medial knee pain. This pain may or may not be associated with the inflammation of the Bursa.
What is the Cause of Pes Anserine Bursitis?
The common factors that promote the onset of Pes Anserine Bursitis include direct trauma to the Bursa, obesity, overuse of the structures, tight hamstrings, and mechanical derangement. It may also be associated with medial knee osteoarthritis. This is, in fact, an early and common finding in individuals with Pen Anserine Bursitis.
Individuals who indulge in increased physical activities and regular sports may be at an increased risk. The sports that increase the individual risk for Pes Anserine Bursitis include Running, Basketball, and racquet sports, as they may lead to overuse and acceleration of the inflammatory activity. (3)
As mentioned earlier, obesity is a common risk factor for Pes Anserine Bursitis. In addition, studies have shown obese and overweight individuals to have a higher risk for diabetes mellitus. Therefore, since individuals with diabetes are at an increased risk for Pes Anserine Bursitis, obesity indirectly plays a causative role.
People with Knee osteoarthritis already have an increased inflammatory activity around their knee joint. This inflammation does not only end up promoting the Pes Anserine Bursa on its own but may also lead to other knee complications and structural deformities, which may eventually lead to the inflammation of these Bursa. (4)
As mentioned earlier, Medical derangement is another factor responsible for promoting the onset of Pes Anserine Bursitis. The medical derangement affecting the Medial Knee joint is proposed to cause increased inflammatory activity in the surrounding hard and soft tissues. These medical derangements may include medial meniscus protrusion and medial collateral ligament (MCL) displacement.
What are the Symptoms of Pes Anserine Bursitis?
Individuals with Pes Anserine Bursitis commonly complain of pain on the inside of the knee, also referred to as the medial aspect. This pain is usually reported to be triggered by sitting down, stepping on stairs, or crossing the legs. As individuals cross their legs, the three muscles, known as the semitendinosus, Gracilis, and Sartorius, work in connection with each other, which is why this motion most commonly triggers pain, as seen in Pes Anserine Bursitis.
Some individuals may also report muscle weakness or a reduction in the knee joint’s range of motion. Others may also report tenderness when the skin over the insertion of the Pes Anserine Tendons is pressed. This is also known as the goose’s foot and is located at the upper medial Tibia and medial knee level. Due to inflammatory activity, swelling may also be experienced by some individuals.
The doctor may confirm the presence of the reported tenderness by asking the individual to undergo knee flexion at an angle of 90 degrees. At this position, the individual may experience tenderness when the medial tendinous structure along the proximal medial tibial region is palpated.
How is Pes Anserine Bursitis Diagnosed?
Pes Anserine Bursitis Diagnosis is mainly based on clinical assessment. While lab work is usually not needed, the health professional may take the help of imaging tools for a more accurate diagnosis. These imaging tools should always be conducted with a detailed medical history and thorough physical examination. When an individual presents with acute pain, the doctor may advise an x-ray to ensure they have no fractures or foreign body intrusions. On the other hand, ultrasound may be a better imaging tool when the healthcare professional wants to differentiate between inflamed Bursa and cellulitis. This may allow a live analysis of the range of motion and rule out the presence of any tendinous injuries. Some individuals may also be recommended to undergo a Magnetic Resonance Imaging; however, this is rare. This may be used to diagnose prepatellar Bursitis, which may present as an oval fluid-filled lesion between the knee joint and soft tissues. (5)
The Recommended Treatment Options for Pre Anserine Bursitis
The causes of Pre Anserine Bursitis should be investigated in detail first to develop the most appropriate treatment plan for the patient. If the cause is a medical condition like Gout, it should be treated first via systemic drug therapies. If the cause of infection is seen in septic bursitis, antibiotic therapy may be considered most appropriate. This is followed by a general management approach for all forms of Bursitis, including Resting, Icing, Modifications of Activates, and taking anti-inflammatory medications. (6)
Overall, the treatment modalities may be divided into two forms known as conservative management and surgical management. While most acute cases of Pre Anserine Bursitis can be treated using conservative methods, some severe cases may require a surgical intervention. The chronic cases of Pre Anserine Bursitis may not be simply managed by over-the-counter medication and may require corticosteroid injections. These patients are also recommended to come for frequent follow-up visits to the doctors, which will help them keep track of their progress and help them decide what interventions may be more appropriate for them at the particular stage. (7)
Medical Treatment
The initial steps for starting a medical treatment of pes anserine bursitis include the recommendation of an over-the-counter Non-steroidal anti-inflammatory drug (NSAID). However, in the cases where it is not found to be effective for pain relief and uncomfortable symptoms of the individual, other modalities like steroid injections may be found effective. The injection of either steroid alone or in combination with a local anaesthetic into the bursal space is considered the second-line treatment for this condition. (8)
Physical Therapy
Physical therapy, which is also referred to as physiotherapy, is among the most common recommended techniques for Pes Anserine Syndrome. The physiotherapist may ask the individual to rest and avoid activities that put excessive stress on their knee joints. This may include climbing stairs. They may recognize the inflammatory phase of the individual, during which regular icing is recommended. The recommended way for this is to apply ice for 15 minutes every 5 hours in order to control the inflammatory activity. They may also recommend an elastic bandage wrapped around the knee joint to reduce the swelling. (9)
The physiotherapist may recommend muscle conditions and strengthening exercises, including hamstring muscles stretch, standing calf stretch, quadriceps stretch, quadriceps isometrics, hamstrings isometrics, and calf stretch. This may be associated with other close kinetic chain exercises like squats, leg presses, and knee dips. This may also help in preventing other risk factors for Pes Anserine Bursitis, one of which is Collateral Knee instability. (10)
Surgical Treatment
Surgical management may be recommended where conservative treatment options may fail to work. For example, the most commonly conducted surgical intervention for pes anserine bursitis includes a simple incision and drainage. This is conducted on the distended Bursa to relieve the excess pressure and relieve the uncomfortable symptoms. If there is a chronic infection that antibiotics cannot treat, the doctor may also remove the Bursa. After the Bursa is removed during the surgical procedure, the individual is recommended to take a rest and undergo the steps mentioned in the physical therapy above. (11) Another surgical technique that may be effective for chronic Bursitis that is not treated with antibiotics is the use of surgical decompression.
Prolotherapy:
In recent years, Prolotherapy has built its reputation within the medical community for its clinically proven ability to treat Pes Anserine Bursitis.
Published research has proven its pain-relieving, anti-inflammatory and regenerative benefits.
Prolotherapy involves injecting a natural regenerative solution with tiny needles. This has been shown to stimulate the production of collagen cells, the small cells needed to repair the damage and help Pes Anserine Bursitis.
As prolotherapy is helping to treat the root cause of Pes Anserine Bursitis, it is deemed to be a permanent fix, preventing the symptoms from returning.
Other Conditions That Pes Anserine Bursitis May Be Confused With
Patients who present with pain in the pes anserine bursa may often be considered to have a number of clinical conditions. While Pes Anserine Bursitis is often the most common cause of this pain, this may not always be the cause, and hence it is imperative that the health experts also consider other causes. These may include the presence of any infections like Osteomyelitis and Septic Bursitis. In addition, Gout is another condition that may be considered as the symptoms caused by gouty changes are similar to those caused by Pes Anserine Bursitis.
Another possible cause of this pain may be the compression of the Saphenous Nerve, which may exhibit significant Medial Knee Discomfort. Inflammation of other surrounding Bursa may also be considered, which include the semimembranosus Bursa or the tibial collateral ligament bursa. (12) If the individual has a previous history of trauma, the cause of their medial knee pain may be a medial meniscus tear or a tibial stress fracture.
Frequently Asked Questions
How Do You Treat Pes Anserine Bursitis?
Pes Anserine bursitis is usually treated using numerous interventions, including medications like NSAIDs, recommendation of rest, application of cold packs, insertion of wedge insoles, and Kinesiology tape. The healthcare provider may recommend these as these can lead to a significant reduction in anterior knee pain. However, no matter what management tool is used, this should be accompanied by physical therapy, which may allow the individual to gain strength through stretching exercises and increase their range of motion. In the cases where over-the-counter medications like ibuprofen fail to be effective for the patient, they may be recommended to take steroid injections, therapies like PRP, and surgical procedures. Even though the need for surgery in the cases of pes anserine bursitis is rare, some individuals with severe cases may require it.
What Does Pes Bursitis Feel Like?
In order to make sense of their symptoms, a large number of people are often curious about what PEs Bursitis feels like. The common symptoms reported by individual who has been diagnosed with Pes Anserine bursitis include gradual development of pain on the inside of their knees. This pain may also be felt below the knee joint on the shinbone. The pain also increases during activities such as climbing stairs or running.
How Long Does It Take For Pes Anserine Bursitis To Heal?
The healing time for Pes Anserine Bursitis may vary from individual to individual based on their health status, their lifestyle, the severity of the condition, and what caused it in the first place. However, the majority of the cases of Pes Anserine Bursitis take between six to eight weeks to heal.
What Aggravates Pes Anserine Bursitis?
Activities which man aggravate Pes Anserine Bursitis include climbing stairs, running, squatting, and other physical acts which involve repetitive movements. It may also be aggravated by incorrect sports training or starting heavy exercise before the adequate warm-up.
How Do You Stretch Pes Anserine?
Pes Anserine may be stretched by undergoing stretching exercises like Heel Slide, Quad set, and straight-leg raises to the front.
Is Walking Good For Bursitis?
Walking for limited periods while wearing comfortable and well-fitting shoes may be considered safe for Bursitis.
References
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- Candal-Couto, J. J., & Deehan, D. J. (2003). The accessory bands of Gracilis and Semitendinosus: an anatomical study. The Knee, 10(4), 325–328. https://doi.org/10.1016/s0968-0160(02)00154-0
- Sapp, G. H., & Herman, D. C. (2018). Pay Attention to the Pes Anserine in Knee Osteoarthritis. Current sports medicine reports, 17(2), 41. https://doi.org/10.1249/JSR.0000000000000449
- Pompan D. C. (2016). Pes Anserine Bursitis: An Underdiagnosed Cause of Knee Pain in Overweight Women. American family physician, 93(3), 170.
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- Chatra P. S. (2012). Bursae around the knee joints. The Indian journal of radiology & imaging, 22(1), 27–30. https://doi.org/10.4103/0971-3026.95400
- Aaron, D. L., Patel, A., Kayiaros, S., & Calfee, R. (2011). Four common types of bursitis: diagnosis and management. The Journal of the American Academy of Orthopaedic Surgeons, 19(6), 359–367. https://doi.org/10.5435/00124635-201106000-00006
- Baumbach, S. F., Lobo, C. M., Badyine, I., Mutschler, W., & Kanz, K. G. (2014). Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Archives of orthopaedic and trauma surgery, 134(3), 359–370. https://doi.org/10.1007/s00402-013-1882-7
- Williams, C. H., Jamal, Z., & Sternard, B. T. (2022). Bursitis. In StatPearls. StatPearls Publishing.
- Alvarez-Nemegyei J. (2007). Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 13(2), 63–65. https://doi.org/10.1097/01.rhu.0000262082.84624.37
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- Zhao, H., Maheshwari, A. V., Kumar, D., & Malawer, M. M. (2011). Giant cell tumor of the pes anserine bursa (extra-articular pigmented villonodular bursitis): a case report and review of the literature. Case reports in medicine, 2011, 491470. https://doi.org/10.1155/2011/491470