eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Pes Anserinus Bursitis: Treatment & Medication
Updated: Sep 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Physical therapy is beneficial and often is indicated for patients with pes anserine bursitis. Rest and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment. Other appropriate means of and ideas for treating pes anserine bursitis include the following:- Ice in foam cups can be applied and rubbed directly on the patient's skin (ice massage) for up to 10 minutes at a time. Other forms of cryotherapy (eg, cold packs) also may be used.
- Ultrasonography has been reported to be effective in reducing inflammation associated with pes anserine bursitis.
- Electrical stimulation has been used in other forms of bursitis, although its use has not been documented specifically in pes anserine bursitis.
- Rehabilitative exercise for athletes with significant medial knee stress follows general physiatric principles for knee disorders (stretching and strengthening of the adductor and quadriceps groups [especially the last 30 º of knee extension using the vastus medialis muscle] and stretching of the hamstrings). For cases caused by restricted flexibility of muscles/tendons, stretching may promote significant reduction of tension over the bursa.
- Advise older patients and those with chronic pain to avoid muscle atrophy from disuse. Address obesity in cases in which it is a contributing factor.
- A small cushion placed between the thighs before sleeping is useful in medial knee bursitis.
- If resective surgery is performed, the knee remains in extension or slight flexion within an immobilizer for 1-2 weeks after surgery. Pursue active range of motion (AROM) until 3 weeks postsurgery, and then begin progressive resistive exercises (PREs).
Surgical Intervention
In cases of disability, such as those causing 6-8 weeks of limitation in athletes, some surgeons advocate resection, especially if mature exostosis is present and causing irritation. The operation includes excision of the bursa and any bony exostosis.
Other Treatment
Intrabursal injection with local anesthetics and/or corticosteroids is a second line of treatment. A study found no difference in short-term pain relief afforded by 3-5 mL of 1% lidocaine with or without methylprednisolone. Injection can be directed to the point of maximal tenderness. Take care to avoid injection within the tendons themselves. Occasionally, an area 0.5-1 cm higher than the tendons is injected in order to include the MCL bursa, which also may be a pain generator. Relief is usually immediate but may not be complete.
Repeated lidocaine injections or the use of corticosteroids may result in longer-lasting relief (from 1 to several months). Generally, use a 22-gauge or 23-gauge needle to inject 1-3 mL of 1% lidocaine and corticosteroid (20-40 mg of triamcinolone, 20-40 mg of methylprednisolone, or 6 mg of betamethasone). If infection—which is rarer here than in the bursae of the anterior knee—is suggested, use a larger, 19- or 20-gauge needle and a 20-30 mL syringe for aspiration. Patients who do not respond to initial injection rarely respond to repeated bursal injections. Injection of the knee joint itself may be beneficial in recalcitrant cases.
Medication
When appropriate, NSAIDs are first-line therapy. Injection with anesthetic, with or without corticosteroid, may be helpful.
Nonsteroidal anti-inflammatory drugs
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
> 2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Indomethacin (Indocin, Indochron E-R)
Rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)
Cyclooxygenase-2 inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or in abnormal liver lab results
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Triamcinolone (Aristocort, Kenalog, Amcort, Aristospan Intra-articular)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
20-40 mg intrabursal, usually limited to 3 injections in 12-mo period, at least 30 d apart to minimize risk of complications
Pediatric
Not established
Coadministration with barbiturates, phenytoin, and rifampin decreases effects
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis
Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
20-40 mg intrabursal, usually limited to 3 injections in a 12-mo period, at least 30 d apart to minimize risk of complications
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Betamethasone (Celestone, Soluspan)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
6 mg intrabursal usually limited to 3 injections in a 12-mo period, at least 30 d apart to minimize risk of complications
Pediatric
Not established
Effects decrease with coadministration of barbiturates, phenytoin and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
More on Pes Anserinus Bursitis |
| Overview: Pes Anserinus Bursitis |
| Differential Diagnoses & Workup: Pes Anserinus Bursitis |
 Treatment & Medication: Pes Anserinus Bursitis |
| Follow-up: Pes Anserinus Bursitis |
| Multimedia: Pes Anserinus Bursitis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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. Jun 2008;16(6):647-53. [Medline].
Moschowitz E. Bursitis of sartorius bursa, an undescribed malady simulating chronic arthritis. JAMA. 1937;109:1362.
Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5. [Medline].
Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. Apr 2007;13(2):63-5. [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. Oct 2007;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. Feb 2008;128(2):155-8. [Medline].
Marra MD, Crema MD, Chung M, et al. MRI features of cystic lesions around the knee. Knee. Dec 2008;15(6):423-38. [Medline].
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. Apr 1991;72(5):336-7. [Medline].
Voorneveld C, Arenson AM, Fam AG. Anserine bursal distention: diagnosis by ultrasonography and computed tomography. Arthritis Rheum. Oct 1989;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. Feb 2005;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. Feb 1995;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. Jan-Feb 1993;17(1):137-40. [Medline].
Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. Jul 2005;34(7):395-8. [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. Feb 2003;30(2):352-4. [Medline].
Abeles M. Anserine bursitis. Arthritis Rheum. Jun 1986;29(6):812-3. [Medline].
Handy JR. Anserine bursitis: a brief review. South Med J. Apr 1997;90(4):376-7. [Medline].
Katzenstein PL, Malemud CJ, Pathria MN, et al. Early-onset primary osteoarthritis and mild chondrodysplasia. Radiographic and pathologic studies with an analysis of cartilage proteoglycans. Arthritis Rheum. May 1990;33(5):674-84. [Medline].
Larsson LG, Baum J. The syndrome of anserina bursitis: an overlooked diagnosis. Arthritis Rheum. Sep 1985;28(9):1062-5. [Medline].
Muchnick J, Sundaram M. Radiologic case study. Pes anserine bursitis. Orthopedics. Nov 1997;20(11):1100; 1092-4. [Medline].
Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3rd ed. Baltimore, Md: Lippincott William & Wilkins; 1996:236-7.
Larson RL, Grana WA, eds. The Knee: Form, Function, Pathology, and Treatment. Philadelphia, Pa: WB Saunders; 1993:327-9.
Windsor RE, Lox DM. Soft Tissue Injuries: Diagnosis and Treatment. Philadelphia, Pa: Hanley & Belfus; 1998:118-9.
Further Reading
Related eMedicine topics:
Bursitis [Emergency Medicine]
Bursitis [Orthopedic Surgery]
Knee, Extensor Mechanism Injuries (MRI)
Knee, Collateral Ligament Injuries (MRI)
Pes Anserine Bursitis [Sports Medicine]
Keywords
pes anserinus bursitis, pes anserine bursitis, knee pain, bursitis, bursa, tendinitis, tendonitis, knee swelling, bursitis knee, pes anserinus, bursitis treatment, bursitis symptoms, bursitis pain, bursitis therapy, sartorius, gracilis, pes anserine, sartorius muscle, semitendinosus, bursitis knee, bursae, bursitis of the knee, bursitis exercise, anserine bursitis syndrome, conjoined tendon, breaststroker's knee, pes anserinus tendino-bursitis, pes anserinus tendinobursitis, pes anserinus tendino-bursitis syndrome
