eMedicine Specialties > Sports Medicine > Knee
Pes Anserine Bursitis: Treatment & Medication
Updated: Aug 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Patients with pes anserine bursitis need to work on both a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program. This type of program 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 need to 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, and an ice massage may help to reduce inflammation. Cutting back or eliminating the offending activities is also important.
Recreational Therapy
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.
Surgical Intervention
The need for surgery is very rare in cases of pes anserine bursitis. Surgery is usually indicated in cases in which an immunocompromised patient has a localized infection that does not resolve with standard antibiotic treatment. Surgical decompression of the bursa may be indicated in such cases.
Consultations
Recalcitrant cases that do not respond to a program of activity modification and exercise may need a referral to a specialty-trained, sports medicine physician, primary care physician, or orthopedic surgeon for evaluation.
Recovery Phase
Rehabilitation Program
Physical Therapy
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.
Medical Issues/Complications
Pes anserine bursitis is primarily a self-limiting condition, which responds well to an exercise/stretching program.4 Recalcitrant cases should be referred to a specialist to confirm the diagnosis and to rule out other causes of the patient's pain (eg, proximal tibial plateau fracture).
Surgical Intervention
See Treatment, Acute Phase, Surgical Intervention.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Continue to work on a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program.
Medication
In general, medications are not frequently used to treat pes anserine bursitis. In cases in which it may be warranted to help alleviate symptoms, the addition of an over-the-counter or prescribed anti-inflammatory medication may be indicated.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic and anti-inflammatory activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase 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
200-800 mg PO tid
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Orudis, Oruvail, Actron)
For relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprosyn, Anaprox, Naprelan)
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 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 the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients with 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
Precautions
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.
Anesthetic (Local) and Corticosteroid Combinations
Local anesthetics stabilize neuronal membranes and prevent the initiation and transmission of nerve impulses, thereby producing the local anesthetic action. Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, corticosteroids modify the body's immune response to diverse stimuli.
Celestone and 1% lidocaine
Compounded medication consisting of 0.5 mL of Celestone and 2.0 mL of 1% lidocaine without epinephrine.
Adult
One-time injection into the area of the pes anserine bursa; repeat (if beneficial the first time); one time/y maximum
Pediatric
Not established
None reported for this route of administration
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
Caution in the presence of bradycardia; caution if surrounding skin has decreased circulation
More on Pes Anserine Bursitis |
| Overview: Pes Anserine Bursitis |
| Differential Diagnoses & Workup: Pes Anserine Bursitis |
 Treatment & Medication: Pes Anserine Bursitis |
| Follow-up: Pes Anserine Bursitis |
| Multimedia: Pes Anserine Bursitis |
| References |
| « Previous Page | Next Page » |
References
Mochizuki T, Akita K, Muneta T, Sato T. Pes anserinus: layered supportive structure on the medial side of the knee. Clin Anat. Jan 2004;17(1):50-4. [Medline].
Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology. Feb 1995;194(2):525-7. [Medline]. [Full Text].
Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. Jul 2005;34(7):395-8. [Medline].
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. May 15 1996;53(7):2317-24. [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].
Cox JS, Blanda JB. Peripatellar pathologies. In: Delee JC, Drez D, Stanitski CL, eds. Orthopaedic Sports Medicine: Principles and Practice. Vol 3. Philadelphia, Pa: WB Saunders Co; 1994:1249-60.
Hemler DE, Ward WK, Karstetter KW, Bryant PM. 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].
Kelly SS, Erpelding JM, Kobs J. Knee and lower leg. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:306-65.
Marquis AM. Pes anserine bursitis. ONA J. Oct 1979;6(10):418-9. [Medline].
Medical Economics. Physician's Desk Reference. 54th ed. Montvale, NJ: Thomson Healthcare; 2000.
Mercier LR, Pettid FJ, Tamisiea DF, eds. The knee. Practical Orthopedics. 4th ed. St. Louis, Mo: Mosby-Year Book; 1995:226-7.
Muchnick J, Sundaram M. Radiologic case study. Pes anserine bursitis. Orthopedics. Nov 1997;20(11):1100; 1092-4. [Medline].
Seibel MO. Neuromuscular examination. In: Valmassy RL, ed. Clinical Biomechanics of the Lower Extremities. St. Louis, Mo: Mosby-Year Book; 1996:208-20.
Unlu Z, Ozmen B, Tarhan S, Boyvoda S, Goktan C. Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus. J Rheumatol. Feb 2003;30(2):352-4. [Medline].
Yoon HS, Kim SE, Suh YR, Seo YI, Kim HA. 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]. [Full Text].
Zaffagnini S, Golanò P, Farinas O, et al. Vascularity and neuroreceptors of the pes anserinus: anatomic study. Clin Anat. Jan 2003;16(1):19-24. [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].
Wood LR, Peat G, Thomas E, Duncan R. 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].
Nokes SR, Smith T. Acute pes anserine bursitis. J Ark Med Soc. Nov 2007;104(5):112. [Medline].
Clapp A, Trecek J, Joyce M, Sundaram M. Radiologic case study. Pes anserine bursitis. Orthopedics. Apr 2008;31(4):306, 407-8. [Medline].
Further Reading
Keywords
pes anserine bursitis, pes anserine tendonitis, pes anserine tendinitis, knee bursitis, pes anserinus tendinobursitis, pes anserine tendino-bursitis syndrome, PATB syndrome
