Pes Anserine Bursitis Clinical Presentation
- Author: P Mark Glencross, MD, MPH, FACOEM, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD more...
Pes anserine bursitis can result from acute trauma to the medial knee, athletic overuse, or chronic mechanical and degenerative processes. This condition should not be overlooked when the diagnosis of osteoarthritis of the knee is made, because the 2 are commonly associated. Typical findings in patients with pes anserine bursitis may include the following:
Pain and tenderness over the inner knee – This may occur with arising from a seated position, at night, or with ascending (or, possibly, descending) stairs, though not usually with walking on level surfaces; although patients sometimes point to an area directly over the pes anserine bursa, they may often point to a diffuse region over the medial aspect of the knee; many of these patients also have plical irritation or medial joint compartment pathology (eg, medial meniscal tears or medial compartment arthritis)
Chronic refractory pain in the area during aggravating activities in individuals with arthritis of the knee or in obese females
A history of athletic activity - Generally, susceptible persons are those who are involved in any sport that requires side-to-side movement or cutting; the incidence of pes anserine bursitis is higher among runners and in individuals who play basketball, soccer, and racket sports, in part because of the popularity of these activities
Pes anserine bursitis also has been reported in swimmers; accordingly, the condition occasionally is called breaststroker’s knee, although this term usually refers to medial collateral ligament (MCL) strains. Coexisting MCL pathology may be present among athletes or other individuals with pes anserine bursitis.
The hallmark physical finding in pes anserine bursitis is pain over the proximal medial tibia at the insertion of the conjoined tendons of the pes anserinus, approximately 5-7 cm below the anteromedial joint margin of the knee. At its worst, pes anserine bursal pain is only mild to moderate. Intense pain could suggest a proximal tibial stress fracture.
The pes anserine bursa can be palpated at a point slightly distal to the tibial tubercle and about 3-4 cm medial to it (about 2 fingerbreadths). However, the bursa may not be palpable unless effusion and thickening are present. Palpable crepitus consistent with bursitis occasionally is noted. Pain in this area indicates an underlying inflammation of the pes anserine bursa or a bursitis.
Palpation of this area of the knee is important in a patient who complains of medial knee pain because the examiner needs to determine whether the pain is from joint-line pathology or pes anserine bursal pathology (or both). The 2 may coexist, because pes anserine bursitis can accompany primary knee pathology. Some researchers report pain along the medial joint line, mimicking a meniscal tear. As many as 30% of asymptomatic people may report tenderness when the area of the pes anserine bursa is pressed, so it is important to palpate the contralateral normal knee to verify that the pain on the affected side is more or reproduces their symptoms.
Concurrently with the physical examination, the hamstring-popliteal angle should be assessed to determine the patient’s underlying amount of hamstring tightness. This assessment is made by having the patient’s hip flex to 90° and then passively extending the leg. The angle formed between a perpendicular line to the femoral shaft and the tibial shaft is the hamstring-popliteal angle.
With the sports-related variant or pes anserine bursitis, symptoms may be reproduced by means of resisted internal rotation and resisted flexion of the knee. With the chronic variant in older adults, flexion or extension of the knee usually does not elicit pain. Valgus stress may reproduce the symptoms in athletic individuals, making it hard to distinguish pes anserine bursitis from MCL injuries using this technique alone. Typically, painful tenderness in association with MCL injuries is superior and posterior to the pes anserine bursa.
Noticeable bursal swelling is less frequent among elderly patients with concurrent arthritis. Bursitis is found more frequently on the right side than on the left, and approximately one third of patients have bilateral involvement. If swelling can be traced more proximally along the pes anserine tendons, a formal tendinitis may be present, and a snapping of the pes anserine tendons can occur. Two case reports of large cystic swellings of the bursa that resolved with conservative management have been documented.
An exostosis of the tibia has been described in athletes and may contribute to chronic symptoms.
Wood LR, Peat G, Thomas E, et al. The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults. Osteoarthritis Cartilage. 2008 Jun. 16(6):647-53. [Medline].
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996 May 15. 53(7):2317-24. [Medline].
Moschowitz E. Bursitis of sartorius bursa, an undescribed malady simulating chronic arthritis. JAMA. 1937. 109:1362.
Grover RP, Rakhra KS. Pes anserine bursitis - an extra-articular manifestation of gout. Bull NYU Hosp Jt Dis. 2010. 68(1):46-50. [Medline].
Rainey CE, Taysom DA, Rosenthal MD. Snapping pes anserine syndrome. J Orthop Sports Phys Ther. 2014 Jan. 44(1):41. [Medline].
Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007 Apr. 13(2):63-5. [Medline].
Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. 1997 Nov. 24(11):2162-5. [Medline].
Uysal F, Akbal A, Gokmen F, Adam G, Resorlu M. Prevalence of pes anserine bursitis in symptomatic osteoarthritis patients: an ultrasonographic prospective study. Clin Rheumatol. 2015 Mar. 34 (3):529-33. [Medline].
Kim IJ, Kim DH, Song YW, et al. The prevalence of periarticular lesions detected on magnetic resonance imaging in middle-aged and elderly persons: a cross-sectional study. BMC Musculoskelet Disord. 2016 Apr 26. 17 (1):186. [Medline]. [Full Text].
Hall R, Barber Foss K, Hewett TE, Myer GD. Sport specialization's association with an increased risk of developing anterior knee pain in adolescent female athletes. J Sport Rehabil. 2015 Feb. 24 (1):31-5. [Medline].
Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005 Jul. 34(7):395-8. [Medline].
Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010 May-Jun. 50(3):313-27. [Medline].
Alvarez-Nemegyei J, Canoso JJ. Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis. J Clin Rheumatol. 2004 Aug. 10(4):205-6. [Medline].
Unlu Z, Ozmen B, Tarhan S, et al. Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus. J Rheumatol. 2003 Feb. 30(2):352-4. [Medline].
Kang I, Han SW. Anserine bursitis in patients with osteoarthritis of the knee. South Med J. 2000 Feb. 93(2):207-9. [Medline].
Klontzas ME, Akoumianakis ID, Vagios I, Karantanas AH. MR imaging findings of medial tibial crest friction. Eur J Radiol. 2013 Nov. 82(11):e703-6. [Medline].
Maheshwari AV, Muro-Cacho CA, Pitcher JD Jr. Pigmented villonodular bursitis/diffuse giant cell tumor of the pes anserine bursa: a report of two cases and review of literature. Knee. 2007 Oct. 14(5):402-7. [Medline].
Hepp P, Engel T, Marquass B, et al. Infiltration of the pes anserinus complex by an extraarticular diffuse-type giant cell tumor (D-TGCT). Arch Orthop Trauma Surg. 2008 Feb. 128(2):155-8. [Medline].
Zhao H, Maheshwari AV, Kumar D, Malawer MM. Giant cell tumor of the pes anserine bursa (extra-articular pigmented villonodular bursitis): a case report and review of the literature. Case Report Med. 2011. 2011:491470. [Medline]. [Full Text].
Hemler DE, Ward WK, Karstetter KW, et al. Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 1991 Apr. 72(5):336-7. [Medline].
Voorneveld C, Arenson AM, Fam AG. Anserine bursal distention: diagnosis by ultrasonography and computed tomography. Arthritis Rheum. 1989 Oct. 32(10):1335-8. [Medline].
Yoon HS, Kim SE, Suh YR, et al. Correlation between ultrasonographic findings and the response to corticosteroid injection in pes anserinus tendinobursitis syndrome in knee osteoarthritis patients. J Korean Med Sci. 2005 Feb. 20(1):109-12. [Medline].
Uson J, Aguado P, Bernad M, et al. Pes anserinus tendino-bursitis: what are we talking about?. Scand J Rheumatol. 2000. 29(3):184-6. [Medline].
Zeiss J, Coombs RJ, Booth RL Jr, et al. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr. 1993 Jan-Feb. 17(1):137-40. [Medline].
Marra MD, Crema MD, Chung M, et al. MRI features of cystic lesions around the knee. Knee. 2008 Dec. 15(6):423-38. [Medline].
Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accuracy of ultrasound-guided versus unguided pes anserinus bursa injections. PM R. 2010 Aug. 2(8):732-9. [Medline].