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Pes Anserine Bursitis Differential Diagnoses

  • Author: P Mark Glencross, MD, MPH, FACOEM, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 10, 2016
 
 

Diagnostic Considerations

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Medial meniscal tear
  • Spontaneous osteonecrosis
  • Tumors
  • 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.[17] 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.[21] 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.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

P Mark Glencross, MD, MPH, FACOEM, FAAPMR Physician in Occupational and Environmental Medicine, Physical Medicine and Rehabilitation, and Sports Medicine, Medical Director of Employee Health, The Methodist Hospital; Medical Director of Occupational Medicine, College Station Medical Center

P Mark Glencross, MD, MPH, FACOEM, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Florida Society of Physical Medicine and Rehabilitation, American College of Occupational and Environmental Medicine, Air Medical Physician Association, Florida Association of Occupational and Environmental Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert F LaPrade, MD, PhD Complex Knee and Sports Medicine Surgeon, The Steadman Clinic; Chief Medical Research Officer, Steadman Philippon Research Institute; Co-Director, Sports Medicine Fellowship Program, Director, International Scholar Program, Adjunct Professor, Department of Orthopedic Surgery, University of Minnesota Medical School; Affiliate Faculty, College of Veterinary Medicine and Biomedical Sciences, Colorado State University

Robert F LaPrade, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Cartilage Repair Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Scott D Flinn, MD Officer in Charge, Surface Warfare Medicine Institute

Scott D Flinn, MD is a member of the following medical societies: American Academy of Family Physicians and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

James P Little, MD, MBA, FAAPMR Medical Director, Siskin Hospital for Physical Rehabilitation; Chairman, Associate Professor, Department of Physical Medicine, Southern Rehab Group

Disclosure: Nothing to disclose.

Gerard A Malanga, MD Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, and North American Spine Society

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

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Location of pes anserinus bursa on medial knee. MCL = medial collateral ligament.
Pes anserinus bursa is located on proximomedial aspect of tibia between superficial medial (tibial) collateral ligament and hamstring tendons (ie, sartorius, gracilis, and semitendinosus). This bursa serves as space where motion occurs between these hamstring tendons and underlying superficial tibial collateral ligament.
 
 
 
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