Pes Anserine Bursitis Differential Diagnoses
- Author: P Mark Glencross, MD, MPH, FACOEM, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD more...
In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:
Medial meniscal tear
Other bursitis of the knee
Proximal tibia stress/fracture
Saphenous nerve compression
Medial collateral ligament (MCL) sprain can be excluded by means of physical examination or, if necessary, magnetic resonance imaging (MRI).
Medial meniscus injury presents with medial joint line tenderness, knee locking, or catching. The McMurray test is positive with valgus stress and external tibial rotation. In older patients, a degenerative medial meniscus may present with the insidious onset of medial knee pain. Medial synovial plica syndrome (medial plica) can result in point tenderness and palpable clicking over the medial femoral condyle. Parameniscal cysts and dissecting synovial cyst (from another location) can cause swelling in the area.
Medial ligament syndrome is a poorly defined syndrome described in rheumatology literature as causing pain at the site of insertion of the MCL. Valgus stress exacerbates pain, and the patient may have pain behaviors. The etiology is unknown, but, in some cases, an inflammatory arthropathy, such as ankylosing spondylitis, is present. Medial ligament syndrome is treated with rest, heat, and a small corticosteroid injection.
Medial tibial condyle bone marrow edema associated with soft tissue edema surrounding the MCL on MRI has been reported to result in a painful syndrome of medial tibial crest friction, possibly related to the angle of the crest. This is not to be confused with medial tibial stress syndrome, "shin splints," which is pain in the mid-to-distal tibia.
Osteonecrosis (death of subchondral bone due to an unknown cause) of the femur may present with sudden, severe medial compartment knee pain that is constant (day and night). Bone scanning shows increased uptake in the femoral condyle.
Tumors in the region can include villonodular synovitis, osteochondromatosis, and synovial sarcoma.[18, 19, 20] Synovial hemangioma, meniscal cyst, xanthomas, and ganglion cyst also may occur here.
Of the more than 150 bursae in the body, at least 12 of them are found in each knee, including the suprapatellar, prepatellar, deep infrapatellar, adventitious cutaneous, gastrocnemius, semimembranosus, sartorius, anserine, and MCL bursae, as well as 3 lateral knee bursae located adjacent to the fibular collateral ligament and the popliteus tendon (laterally). Knee pain may be the consequence of inflammation of any of these bursae.
The MCL bursa is located at the anterior border of the MCL. It may be palpable during knee flexion as a small, tender, rounded nodule moving into the leading edge of the MCL. Pain can be elicited by palpating the bursa or by briskly extending the knee from a position of 90° flexion. Pes anserine tendonitis may exist exclusively or in conjunction with bursitis. So-called snapping tendinitis of the semitendinosus tendon is usually thought of as distinct from pes anserine bursitis, but some authorities classify it as the same inflammatory disorder.
Semimembranosus tendinitis can occur with running or cutting activities. This condition is characterized by swelling over the posteromedial aspect of the knee and by tenderness with resisted flexion or valgus strain. An insertional enthesopathy of the semimembranosus has also been described.
Stress fractures of the proximal medial tibia may produce pain in the area of the pes anserine bursa.
Nerve injuries causing medial joint pain include trauma to the infrapatellar branch of the saphenous nerve and injury during knee surgery, especially arthroscopy. Pain can be reproduced with the Tinel sign. One case report documents distal tibial pain from entrapment of the saphenous nerve caused by pes anserine bursitis. Medial knee pain associated with back pain also could represent an L3-L4 radiculopathy. Electrodiagnostic tests, such as electromyography (EMG) and nerve conduction velocity tests, may be useful.
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].
Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SH. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013 Jul. 26(3):249-54. [Medline]. [Full Text].
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].
Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology. 1995 Feb. 194(2):525-7. [Medline]. [Full Text].
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].