Pes Anserine Bursitis Treatment & Management
- Author: P Mark Glencross, MD, MPH, FACOEM, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD more...
Pes anserine bursitis is primarily a self-limiting condition. Patients generally are treated successfully with conservative measures and typically should receive outpatient physical therapy. For preventive purposes, every athlete should participate in a regular stretching program for the hamstring tendons.
Intrabursal injection of local anesthetics, corticosteroids, or both constitutes a second line of treatment. Surgical therapy is indicated only in very rare cases.
In patients whose symptoms last more than several months, consideration may be given to referring the patient to a specialist to confirm the diagnosis and rule out other potential causes of the patient’s pain (eg, proximal tibial plateau fracture). Cases that do not respond to a program of activity modification and exercise may be referred to a specialty-trained, sports medicine physician, primary care physician, or orthopedic surgeon for evaluation.
Rest, NSAIDs, and Physical Therapy
Rest, including cutting back or eliminating the offending activities, is essential to treatment. Along with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), it represents first-line treatment.
Physical therapy is beneficial and often is indicated for patients with pes anserine bursitis. Rehabilitative exercise for persons with significant medial knee stress follows general physiatric principles for knee disorders and includes the following:
Stretching and strengthening of the adductor, abductor, and quadriceps groups (especially the last 30° of knee extension using the vastus medialis)
Stretching of the hamstrings
Thus, patients with pes anserine bursitis need to work on both a hamstring stretching program and a concurrent closed-chain quadriceps and pelvifemoral strengthening program. Such programs can usually be taught to the patient by an athletic trainer or physical therapist. Patients should understand that to gain the maximum benefit from this program, they must stretch their hamstrings frequently during the day, sometimes hourly. The quadriceps strengthening program is recommended in most patients because of other concurrent pathology in the knee.
A regular program of hamstring stretching and quadriceps strengthening usually results in alleviation of the pain from pes anserine bursitis in approximately 6-8 weeks. Addition of a nonsteroidal anti-inflammatory drug (NSAID) may help to alleviate some of the pain at this time. In addition, and an ice massage may help to reduce inflammation. 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.
During the rehabilitation program, the patient should incorporate the following measures:
Continue with activity modification as necessary
Begin a gradual resumption of activities
Continue alternative training for cardiovascular fitness
After regaining full, pain-free motion with good isometric strength, work on improving strength and endurance
Other appropriate means of and ideas for treating pes anserine bursitis include the following:
Ultrasonography – This is reportedly effective in reducing inflammation associated with pes anserine bursitis
Electrical stimulation – This has been used in other forms of bursitis, although its use has not been documented specifically in pes anserine bursitis
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 managing 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) exercises until 3 weeks after surgery, then begin progressive resistive exercises (PREs).
Injection of Local Anesthetics or Corticosteroids
Intrabursal injection of local anesthetics, corticosteroids, or both represents a second-line treatment option. It should be considered only for refractory cases that have not responded to physical therapy, rest, ice, and NSAIDs. A study found no difference in short-term pain relief between 3-5 mL of 1% lidocaine with methylprednisolone and the same amount of lidocaine without the corticosteroid.
Injection can be directed to the point of maximal tenderness. Care should be taken to avoid injecting any of the 3 tendons converging at the pes anserinus; injection within the tendons themselves can weaken these structures and intensify the patient’s pain. Ultrasound guidance has demonstrated effectiveness in cadaveric studies, increasing accuracy from 17% (unguided) to 92%.
Occasionally, an area 0.5-1 cm higher than the tendons is injected in order to include the medial collateral ligament (MCL) bursa, which also may be a pain generator. Injection of the knee joint itself may be beneficial in recalcitrant cases.
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. 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). No more than 3 injections should be used over a 1-year period, with intervals of at least 1 month between injections. It should be kept in mind, however, that patients who do not respond to the initial injection rarely respond to repeat treatments. Patients who do not respond to initial injection rarely respond to repeated bursal injections.
Surgical Decompression and Resection
Surgical management of pes anserine bursitis is very rarely warranted. Surgery is usually indicated when an immunocompromised patient has a localized infection that does not resolve with standard antibiotic treatment. Surgical decompression of the bursa may be performed in such cases.
Clinically, pes anserine bursitis can mimic distal anteromedial knee disorders or internal derangement of the knee, sometimes leading to unnecessary surgery. In an investigation of 509 magnetic resonance imaging (MRI) studies done on patients thought to have an internal knee derangement, the prevalence of pes anserine bursitis was found to be 2.5%.
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.
In patients with generalized anterior knee pain, activity modification may be necessary to allow the joint to quiet down and to allow the hamstring tightness to resolve. In most patients, this modification involves minimizing the use of stairs, climbing, or other activities that cause irritation of the joint.
Athletes and active patients may return to play or activities as their symptoms permit. In more severe cases, restrictions on activities may be necessary. Athletes who play contact sports may benefit from the use of a protective pad over the affected area.
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].