Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pes Anserine Bursitis Workup

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

Approach Considerations

The diagnosis of pes anserine bursitis usually is made on clinical grounds, and further workup is not necessarily indicated. In unusual cases (those that are persistent or suggestive of infection), a further workup can be obtained. In the rare cases where infection appears possible, appropriate laboratory studies may be ordered. If other pathology is suggested, radiography, radionuclide bone scanning, rheumatoid factor measurement, or other rheumatologic testing should be considered.

A diagnostic or therapeutic lidocaine or lidocaine-corticosteroid injection into the area of the pes anserine bursa may help the clinician to determine the contribution of pes anserinus bursitis to a patient’s overall knee pathology, as well as possibly alleviate the patient’s symptoms.

Next

Laboratory Studies

Infections of the pes anserine bursa are very rare and occur primarily in immunocompromised patients. These patients typically have a localized area of warmth, pain, and swelling. In such cases, a standard laboratory workup for infection is indicated, including determination of the erythrocyte sedimentation rate (ESR), a complete blood count (CBC) with differential, and measurement of the C-reactive protein (CRP) level.

If the bursa or joint is aspirated for this or other reasons, analysis of the fluid may include a cell count, assessment of fluid appearance, Gram staining, culture, and polarized light microscopy.

Previous
Next

Radiography

As a rule, radiography of the knee is not indicated for bursitis. However, plain radiographs (standing anteroposterior [AP] and lateral views) can be useful for ruling out a proximal tibial stress fracture, as well as for helping to diagnose concurrent pathology, such as medial compartment arthritis, osteochondroma, or osteochondritis dissecans, which could contribute to tight hamstrings and pes anserine bursal irritation. Arthritis may be observed in older adults. In rare cases, young, athletic patients have an exostosis in the metaphyseal area.

Previous
Next

Ultrasonography

Ultrasonography can facilitate the diagnosis of pes anserine bursitis.[22, 23] Large, cystic bursal swellings have been identified by means of ultrasonography and computed tomography (CT). However, published reports suggest that in most suspected cases, ultrasonographic findings are lacking.[24] This lack of ultrasonographic findings has led some to question the frequency of pes anserine bursitis and its accepted pathophysiology.

In one study, only 3 of 29 patients with suspected pes anserinus tendinobursitis were found to have tendinitis on ultrasonographic images when compared with the uninvolved extremity or healthy controls.[24] In a study of patients with type 2 diabetes mellitus, 4 out of 14 patients who were clinically diagnosed with pes anserine tendinobursitis syndrome were found to have ultrasonographically apparent morphologic changes in the pes anserine tendons.[15]

Previous
Next

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is the preferred imaging technique for confirming the diagnosis of pes anserine bursitis and differentiating it from concurrent pathology of the medial compartment.[25, 26] On MRI, the pes anserine bursa is observed between the pes anserinus (ie, the insertion of the conjoined gracilis, semitendinosus, and sartorius tendons into the anteromedial proximal tibia) and the upper tibial metaphysis.

The appearance of pes anserine bursitis on MRI is characterized by increased signal intensity and fluid formation around the area of the pes anserinus bursa. A collection of fluid with low signal intensity is observed on T1-weighted images, and a homogenous increase in signal intensity is observed on T2-weighted images. Fluid-filled anserine bursae have been reported with a prevalence of 5% in asymptomatic knees; consequently, the diagnosis of pes anserine bursitis cannot be based solely on MRI findings.[25]

Limited axial and sagittal T2-weighted or T2 gradient-echo sequences usually are adequate for diagnosis. More extensive imaging with additional planes may be required to exclude other clinically relevant possibilities. Axial images are particularly helpful for differentiating fluid in the pes anserine bursa from other medial fluid collections, such as Baker and meniscal cysts, bone cysts, and fluid in the semimembranosus bursa.[27] MRI also is helpful for ruling out a proximal tibial stress fracture.[25]

At least 1 case of chronic pes anserine bursitis manifested as a solid, inflammatory synovial mass. One report describes tibial erosion under bursitis. Pigmented villonodular synovitis with hemosiderin deposits can occur focally in the bursae.

Previous
 
 
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.

References
  1. 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].

  2. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996 May 15. 53(7):2317-24. [Medline].

  3. 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].

  4. Moschowitz E. Bursitis of sartorius bursa, an undescribed malady simulating chronic arthritis. JAMA. 1937. 109:1362.

  5. Grover RP, Rakhra KS. Pes anserine bursitis - an extra-articular manifestation of gout. Bull NYU Hosp Jt Dis. 2010. 68(1):46-50. [Medline].

  6. Rainey CE, Taysom DA, Rosenthal MD. Snapping pes anserine syndrome. J Orthop Sports Phys Ther. 2014 Jan. 44(1):41. [Medline].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005 Jul. 34(7):395-8. [Medline].

  13. Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010 May-Jun. 50(3):313-27. [Medline].

  14. Alvarez-Nemegyei J, Canoso JJ. Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis. J Clin Rheumatol. 2004 Aug. 10(4):205-6. [Medline].

  15. 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].

  16. Kang I, Han SW. Anserine bursitis in patients with osteoarthritis of the knee. South Med J. 2000 Feb. 93(2):207-9. [Medline].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. Voorneveld C, Arenson AM, Fam AG. Anserine bursal distention: diagnosis by ultrasonography and computed tomography. Arthritis Rheum. 1989 Oct. 32(10):1335-8. [Medline].

  23. 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].

  24. 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].

  25. Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology. 1995 Feb. 194(2):525-7. [Medline]. [Full Text].

  26. 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].

  27. Marra MD, Crema MD, Chung M, et al. MRI features of cystic lesions around the knee. Knee. 2008 Dec. 15(6):423-38. [Medline].

  28. 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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.