Pes Anserinus Bursitis: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


Pes Anserine [http://www.physio-pedia.com/index.php5?title=Bursitis bursitis] is an inflammatory condition of the conjoined insertion of the sartorius, gracilis and semitendinosus. We can locate this at the proximal medial aspect of the [[knee]]<ref name="Moschowitz">Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362</ref>.<br>  
Pes Anserine [http://www.physio-pedia.com/index.php5?title=Bursitis bursitis], also known as intertendinous bursa, is an inflammatory condition of bursa of the conjoined insertion of the sartorius, gracilis and semitendinosus<ref name="Rennie">Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395–8.</ref>. We can locate this at the proximal medial aspect of the [[knee]], two inches below the medial knee joint line between the pes anserinus tendons<ref name="Moschowitz">Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362</ref><ref name="Huang">Huang TW, Wang CJ, Huang SC. Polyethylene-induced pes anserinus bursitis mimicking an infected total knee arthroplasty: a case report and review of the literature. J Arthroplasty. 2003 Apr;18(3):383-6.</ref><ref name="Osman">Osman MK, Irwin GJ, Huntley JS.Swelling around a child's knee. Clin Anat. 2011 Oct;24(7):914-7.</ref>.<br>  


[[Image:SGT insertion.jpg|thumb|right|200px|Attachment of sartorius, gracilis, and semitendinosus at the medial border of the tibia]]<br>  
[[Image:SGT insertion.jpg|thumb|right|200px|Attachment of sartorius, gracilis, and semitendinosus at the medial border of the tibia]]<br>  
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== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The Pes Anserine bursa is a fluid filled vesicle. It secretes synovial fluid in order to reduce friction between tissues, and also works as a cushion for bones, tendons and muscles<ref name="Tschirch">Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.</ref>. The inflammation of the bursa does not appear suddenly, but rather progresses over an period of time. Bursitis can also occur in the [[Shoulder Bursitis|shoulder]], [[Prepatellar bursitis|knee]], [[Iliopsoas Bursitis|hip]], [[Olecranon Bursitis|elbow]] and big toe. <br>  
The Pes Anserine bursa is a fluid filled vesicle. It secretes synovial fluid in order to reduce friction between tissues, and also works as a cushion for bones, tendons and muscles<ref name="Tschirch">Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.</ref>. The inflammation of the bursa does not appear suddenly, but rather progresses over a period of time. Bursitis can also occur in the [[Shoulder Bursitis|shoulder]], [[Prepatellar bursitis|knee]], [[Iliopsoas Bursitis|hip]], [[Olecranon Bursitis|elbow]] and big toe. <br>  


The Pes Anserine, also called the ‘Goose Foot’ is the insertion of the sartorius, gracilis and semitendinosus muscles, which are conjoined proximally on the medial side of the [[tibia]]. The three tendons of the Pes Anserine are located superficial to the medial collateral ligament (MCL) of the knee<ref name="Wood">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.</ref>. The sartorius and gracilis muscles are adductors of the leg (i.e. they pull the leg towards the median axis of the body). The semitendinosus muscle is part of the hamstrings muscle group located at the back of your upper leg. Together, these three muscles are primarily flexors of the knee and internal rotators<ref name="Miller">Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.</ref>.<br>  
The Pes Anserine, also called the ‘Goose Foot’ is the insertion of the sartorius, gracilis and semitendinosus muscles, which are conjoined proximally on the medial side of the [[tibia]]. The three tendons of the Pes Anserine are located superficial to the medial collateral ligament (MCL) of the knee<ref name="Wood">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.</ref>. The sartorius and gracilis muscles are adductors of the leg (i.e. they pull the leg towards the median axis of the body). The semitendinosus muscle is part of the hamstrings muscle group located at the back of your upper leg. Together, these three muscles are primarily flexors of the knee and internal rotators<ref name="Miller">Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.</ref>.<br>  
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== Epidemiology/Etiology<br>  ==
== Epidemiology/Etiology<br>  ==


Pes Anserine bursitis often occurs when the related muscles are repeatedly used, by doing movements such as flexion and adduction. This causes friction and also increases pressure on the bursa. The bursitis can also be due to a trauma, such as a direct hit in the Pes Anserine region. Some sports, like basketball, dancing, and, most of all, running, require flexion and endorotation movements more often then others, and are therefore more likely to lead to bursitis. Other important risk factors include Pes Planus (flat feet), obesity, age, and valgus deformities. Because the sartorius, gracilis and semimembranosus protect the knee against valgus stress, when a person has valgus deformities it means that the three muscles are not protecting the knee properly. Other risk factors include incorrect training techniques (i.e. neglecting to stretch, excessive hill training, and sudden increases of mileage), diabetes&nbsp;<ref name="Cohen">Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5.</ref> and underlying osteoarthritis of the knee<ref name="Stuttle">Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.</ref>.  
Pes Anserine bursitis often occurs when the related muscles are repeatedly used, by doing movements such as flexion and adduction. This causes friction and also increases pressure on the bursa. The bursitis can also be due to a trauma, such as a direct hit in the Pes Anserine region. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tendered or painful <ref name="Huang">. Some sports, like basketball, dancing, and, most of all, running, require flexion and endorotation movements more often then others, and are therefore more likely to lead to bursitis. Other important risk factors include Pes Planus (flat feet), [[obesity]], age, and valgus deformities. Because the sartorius, gracilis and semimembranosus protect the knee against valgus stress, when a person has valgus deformities it means that the three muscles are not protecting the knee properly. Other risk factors include incorrect training techniques (i.e. neglecting to stretch, excessive hill training, and sudden increases of mileage), [[diabetes]],<ref name="Cohen">Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5.</ref> and underlying [[osteoarthritis]] of the [[Knee Osteoarthritis|knee]]<ref name="Stuttle">Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.</ref>.
 
Reports suggest that anserine bursitis is more common in overweight middle-aged females. We can explain this by the fact that women have a wider pelvis, resulting in angulation of the knee in the frontal plane, which leads to more pressure in the area of insertion of the pes anserinus by genu valgum<ref name="Helfenstein">Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010 May-Jun;50(3):313-27.</ref>.
 
We can say that an inflamed bursa is not a primary pathology, but rather a consequence of an earlier complication.


== Characteristics/Clinical Presentation<br>  ==
== Characteristics/Clinical Presentation<br>  ==


The Pes Anserine Bursitis causes pain on the inside of the knee (mostly during running or taking stairs). Also the region around the bursa will be swollen or tender to touch<ref name="Forbes">Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.</ref>. It gets most irritated due to activities that require movements like flexion, endorotation but also exorotation and adduction. Pivoting, kicking, squatting or quick movements from side to side. Like in sports mentioned above.  
Pes Anserine bursitis causes pain on the inside of the knee (mostly during running or taking stairs). The patient may experience spontaneous anteromedial knee pain on climbing or descending stairs and tenderness at the PA <ref name="Huang"/><ref name="Rennie"/><ref name="Glencross"/>. As well, the region around the bursa will be swollen or tender to touch<ref name="Forbes">Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.</ref>.  
 
Other clinical presentations may include:
*Decreased muscle strength
*Gait deviations
*Decreased function
*Decreased ROM
*Postural dysfunction/impaired lower extremity biomechanics
 
Aggravating factors include activities that require movements like flexion and endorotation, as well as exorotation and adduction. Pivoting, kicking, squatting or quick movements from side to side, such as in the sports mentioned above, may also cause further irritation.  


== Differential Diagnosis  ==
== Differential Diagnosis  ==


Pes Anserine bursitis is often confused with other medial knee pain. To start with a stress-fracture of the shinbone on the proximedial side will cause pain in the area of the Pes Anserine. Another example is the patellofemoral syndrome or arthritis<ref name="Safran">Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.</ref><ref name="Matsumoto">Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.</ref><ref name="Hennigan">Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.</ref><ref name="Kerlan">Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.</ref>. Panniculitis<ref name="Glencross">Glencross PM. Medscape: Pes Anserine Bursitis. www.emedicine.medscape.com/article/308694-diagnosis (accessed 26 December 2013).</ref> is something that happens to people who are obese and will cause just like bursitis more pain at night. Semimembranosus tendinitis will often appear after running of cutting activities just like Pes Anserine bursitis. But also the medial plica syndrome which can cause pain and tenderness on the medial side of the knee are often confused with Pes Anserine bursitis.
Pes Anserine bursitis is often confused with other causes of medial knee pain<ref name="Safran">Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.</ref><ref name="Matsumoto">Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.</ref><ref name="Hennigan">Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.</ref><ref name="Kerlan">Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.</ref>:
*[[Leg and Foot Stress Fractures|Stress-fracture]] of the shinbone on the proximedial side will cause pain in the area of the Pes Anserine.
*[[Patellofemoral Pain Syndrome|Patellofemoral syndrome]]
*[[Medial Collateral Ligament Injury of the Knee|Medial meniscus lesion]] and [[osteoarthritis|osteoarthritis]]: Pain and sensitivity would be present in the medial compartment, while in the pes anserinus bursitis they are located inferomedial to the medial joint interline. Stress maneuvers of the medial collateral ligament, with or without instability, may contribute to the diagnosis of lesions of the medial collateral ligament<ref name="Uson">Uson J, et al. Pes anserinus tendino-bursitis: what are we talking about? Scand J Rheumatol. 2000;29(3):184-6.</ref><ref name="Helfenstein"/>.
*Knee pain secondary to L3-L4 [[Lumbar Radiculopathy|radiculopathy]] is associated with lumbar pain without pain on digital pressure of the anserine region<ref name="Helfenstein"/>.
*Panniculitis<ref name="Glencross">Glencross PM. Medscape: Pes Anserine Bursitis. www.emedicine.medscape.com/article/308694-diagnosis (accessed 26 December 2013).</ref> occurs in obese individuals, and causes painful inflammation of subcutaneous fat at night.  
*Semimembranosus tendinitis will often occur as a running injury.  
*Medial [[Plica Syndrome]], which can cause pain and tenderness on the medial side of the knee.
*Extra-articular cystic lesions: synovial cyst, ganglionic cyst, parameniscal cyst, pigmented villonodular synovitis, synovial sarcoma<ref name="Huang"/>
*In addition to the conditions listed above, other problems to be considered include the following<ref name="Rennie"/>:
**Atypical medial meniscal cysts
**Juxta-articular bone cysts
**Semimembranosus bursitis
**Tibial collateral ligament bursitis


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Lateral views of the knee of the patient are very useful to say whether or not out patient has to deal with a stressfracture, arthritis or even Osteochondritis Dissecans. But to be sure that we are not dealing with these injuries we have to take an X-ray. To clarify damage caused to other regions of the medial side of the knee, an MRI is needed. This MRI could prevent you from an unnecessary arthroscopy. Of course you have to correlate the MRI with a physical examination<ref name="Zeiss">Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.</ref><ref name="Hall">Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.</ref>. Another procedure is a Lidocaine/Corticosteriod injection in the area of the bursa which will help us determine the contribution of this pathology with the pathology of his overall knee.  
Lateral x-ray views of the patient's knee are very useful for ruling out a stress fracture, arthritis or even [[Osteochondritis Dissecans of the Knee|Osteochondritis Dissecans]]. An MRI is needed to clarify damage caused to other regions of the medial side of the knee. An MRI could prevent unnecessary arthroscopy. MRI findings should be compared with those of a physical examination<ref name="Zeiss">Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.</ref><ref name="Hall">Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.</ref>. Sinography (radiography of a sinus following the injection of a radiopaque medium) is the best method for establishing the diagnosis when other imaging modalities, including MRI and CT, are not feasible<ref name="Huang"/>.
A Lidocaine/Corticosteriod injection in the area of the bursa which will help determine the contribution of this pathology to the patient's overall knee pain.  


== Outcome Measures  ==
== Outcome Measures  ==


See [[Outcome Measures|Outcome Measures Database]]  
*Lower Extremity Functional Scale (LEFS) <br>
See [[Outcome Measures|Outcome Measures Database]] for more.


== Examination  ==
== Examination  ==


First of all it’s important to examine the tightness of the hamstring. The patient is in the supine position. Then we bend the hip 90° and the knee is straightened as far as possible. How far the knee can be extended will indicate if the Hamstrings are tight or not and how tight they are (If you can straighten your knee completely than your Hamstrings are not tight.).  
First, examine hamstring length with the patient in the supine position. Bend the patient's hip 90° and then extend the knee as far as possible. How far the knee can be extended will indicate hamstring length and tightness. If the patient's knee can be straightened completely than the hamstrings are not tight.


== Medical Management <br>  ==
== Medical Management <br>  ==


When someone has Pes Anserine bursitis, surgical intervention is something that doesn’t occur. Only when your patient has to deal with a local infection and the standard antibiotic treatment doesn’t work a surgical decompression of the bursa could be a solution.<br>  
Surgical intervention is not indicated for this condition, unless the bursitis becomes infected and standard antibiotic treatments are ineffective. A surgical decompression of the bursa may be a solution in this case. <br>  


== Physical Therapy Management <br>  ==
== Physical Therapy Management <br>  ==


Physiotherapy is the mainstay in the treatment of the Pes Anserine syndrome. To temper the pain that the bursa is causing, the most important thing of all is rest. Take nonsteroidal anti-inflammatory drugs (NSAID) to alleviate the pain, restrict movement, alternate ice (An ice massage of 15 minutes every 4-7 hours will reduce the inflammation.) followed by heat and at last some muscle-conditioning exercises<ref name="O'Donoghue">O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.</ref><ref name="Larsson">Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.</ref><ref name="Brookler">Brookler MI, Morgan EF. Anserina bursitis. A treatable cause of knee pain in patients with degenerative arthritis. Calif Med 1973; 119:8-10.</ref>.<br>  
Physiotherapy is the mainstay in the treatment of the Pes Anserine syndrome. To temper the pain caused by the bursitis, the most important thing of all is rest. Nonsteroidal anti-inflammatory drugs (NSAID) can be taken to alleviate the pain. Restrict movement and alternately apply ice. An ice massage of 15 minutes every 4-7 hours will reduce the inflammation. Teach the patient muscle-conditioning exercises<ref name="O'Donoghue">O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.</ref><ref name="Larsson">Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.</ref><ref name="Brookler">Brookler MI, Morgan EF. Anserina bursitis. A treatable cause of knee pain in patients with degenerative arthritis. Calif Med 1973; 119:8-10.</ref>.<br>  


Sometimes people get an injection which consists of a solution of anaesthetic and steroid. Afterwards a physiotherapist will give a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program that has to repeated several times a day. This will result in less pain at about 6-8 weeks.<br>  
Some patients receive an injection which consists of a solution of anaesthetic and steroid. Afterwards, a physiotherapist will give a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program that has to repeated several times a day. This will result in less pain at about 6-8 weeks.<br>  


== Key Research  ==
== Key Research  ==
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
== References  ==


&nbsp; <references /><br>
<references /><br>

Revision as of 23:38, 28 December 2013

Original Editors - Daan Vandebriel, Glenn Demeyer, Stefanie Van De Vijver

Top Contributors - Admin, Stefanie Van De Vijver, Glenn Demeyer, Kim Jackson, Daphne Jackson, Laure Leyers, Wanda van Niekerk, Rachael Lowe, 127.0.0.1, WikiSysop, Phaedra Plas, Candace Goh, Joao Costa, Hamelryck Sascha, Celine De Wolf and Claire Knott  

Definition/Description[edit | edit source]

Pes Anserine bursitis, also known as intertendinous bursa, is an inflammatory condition of bursa of the conjoined insertion of the sartorius, gracilis and semitendinosus[1]. We can locate this at the proximal medial aspect of the knee, two inches below the medial knee joint line between the pes anserinus tendons[2][3][4].

Attachment of sartorius, gracilis, and semitendinosus at the medial border of the tibia


Clinically Relevant Anatomy[edit | edit source]

The Pes Anserine bursa is a fluid filled vesicle. It secretes synovial fluid in order to reduce friction between tissues, and also works as a cushion for bones, tendons and muscles[5]. The inflammation of the bursa does not appear suddenly, but rather progresses over a period of time. Bursitis can also occur in the shoulder, knee, hip, elbow and big toe.

The Pes Anserine, also called the ‘Goose Foot’ is the insertion of the sartorius, gracilis and semitendinosus muscles, which are conjoined proximally on the medial side of the tibia. The three tendons of the Pes Anserine are located superficial to the medial collateral ligament (MCL) of the knee[6]. The sartorius and gracilis muscles are adductors of the leg (i.e. they pull the leg towards the median axis of the body). The semitendinosus muscle is part of the hamstrings muscle group located at the back of your upper leg. Together, these three muscles are primarily flexors of the knee and internal rotators[7].

Epidemiology/Etiology
[edit | edit source]

Pes Anserine bursitis often occurs when the related muscles are repeatedly used, by doing movements such as flexion and adduction. This causes friction and also increases pressure on the bursa. The bursitis can also be due to a trauma, such as a direct hit in the Pes Anserine region. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tendered or painful Cite error: Closing </ref> missing for <ref> tag and underlying osteoarthritis of the knee[8].

Reports suggest that anserine bursitis is more common in overweight middle-aged females. We can explain this by the fact that women have a wider pelvis, resulting in angulation of the knee in the frontal plane, which leads to more pressure in the area of insertion of the pes anserinus by genu valgum[9].

We can say that an inflamed bursa is not a primary pathology, but rather a consequence of an earlier complication.

Characteristics/Clinical Presentation
[edit | edit source]

Pes Anserine bursitis causes pain on the inside of the knee (mostly during running or taking stairs). The patient may experience spontaneous anteromedial knee pain on climbing or descending stairs and tenderness at the PA [3][1][10]. As well, the region around the bursa will be swollen or tender to touch[11].

Other clinical presentations may include:

  • Decreased muscle strength
  • Gait deviations
  • Decreased function
  • Decreased ROM
  • Postural dysfunction/impaired lower extremity biomechanics

Aggravating factors include activities that require movements like flexion and endorotation, as well as exorotation and adduction. Pivoting, kicking, squatting or quick movements from side to side, such as in the sports mentioned above, may also cause further irritation.

Differential Diagnosis[edit | edit source]

Pes Anserine bursitis is often confused with other causes of medial knee pain[12][13][14][15]:

  • Stress-fracture of the shinbone on the proximedial side will cause pain in the area of the Pes Anserine.
  • Patellofemoral syndrome
  • Medial meniscus lesion and osteoarthritis: Pain and sensitivity would be present in the medial compartment, while in the pes anserinus bursitis they are located inferomedial to the medial joint interline. Stress maneuvers of the medial collateral ligament, with or without instability, may contribute to the diagnosis of lesions of the medial collateral ligament[16][9].
  • Knee pain secondary to L3-L4 radiculopathy is associated with lumbar pain without pain on digital pressure of the anserine region[9].
  • Panniculitis[10] occurs in obese individuals, and causes painful inflammation of subcutaneous fat at night.
  • Semimembranosus tendinitis will often occur as a running injury.
  • Medial Plica Syndrome, which can cause pain and tenderness on the medial side of the knee.
  • Extra-articular cystic lesions: synovial cyst, ganglionic cyst, parameniscal cyst, pigmented villonodular synovitis, synovial sarcoma[3]
  • In addition to the conditions listed above, other problems to be considered include the following[1]:
    • Atypical medial meniscal cysts
    • Juxta-articular bone cysts
    • Semimembranosus bursitis
    • Tibial collateral ligament bursitis

Diagnostic Procedures[edit | edit source]

Lateral x-ray views of the patient's knee are very useful for ruling out a stress fracture, arthritis or even Osteochondritis Dissecans. An MRI is needed to clarify damage caused to other regions of the medial side of the knee. An MRI could prevent unnecessary arthroscopy. MRI findings should be compared with those of a physical examination[17][18]. Sinography (radiography of a sinus following the injection of a radiopaque medium) is the best method for establishing the diagnosis when other imaging modalities, including MRI and CT, are not feasible[3]. A Lidocaine/Corticosteriod injection in the area of the bursa which will help determine the contribution of this pathology to the patient's overall knee pain.

Outcome Measures[edit | edit source]

  • Lower Extremity Functional Scale (LEFS)

See Outcome Measures Database for more.

Examination[edit | edit source]

First, examine hamstring length with the patient in the supine position. Bend the patient's hip 90° and then extend the knee as far as possible. How far the knee can be extended will indicate hamstring length and tightness. If the patient's knee can be straightened completely than the hamstrings are not tight.

Medical Management
[edit | edit source]

Surgical intervention is not indicated for this condition, unless the bursitis becomes infected and standard antibiotic treatments are ineffective. A surgical decompression of the bursa may be a solution in this case.

Physical Therapy Management
[edit | edit source]

Physiotherapy is the mainstay in the treatment of the Pes Anserine syndrome. To temper the pain caused by the bursitis, the most important thing of all is rest. Nonsteroidal anti-inflammatory drugs (NSAID) can be taken to alleviate the pain. Restrict movement and alternately apply ice. An ice massage of 15 minutes every 4-7 hours will reduce the inflammation. Teach the patient muscle-conditioning exercises[19][20][21].

Some patients receive an injection which consists of a solution of anaesthetic and steroid. Afterwards, a physiotherapist will give a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program that has to repeated several times a day. This will result in less pain at about 6-8 weeks.

Key Research[edit | edit source]

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources
[edit | edit source]

add appropriate resources here

Clinical Bottom Line[edit | edit source]

add text here

Recent Related Research (from Pubmed)[edit | edit source]


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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395–8.
  2. ↑ Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362
  3. ↑ 3.0 3.1 3.2 3.3 Huang TW, Wang CJ, Huang SC. Polyethylene-induced pes anserinus bursitis mimicking an infected total knee arthroplasty: a case report and review of the literature. J Arthroplasty. 2003 Apr;18(3):383-6.
  4. ↑ Osman MK, Irwin GJ, Huntley JS.Swelling around a child's knee. Clin Anat. 2011 Oct;24(7):914-7.
  5. ↑ Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.
  6. ↑ 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.
  7. ↑ Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.
  8. ↑ Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.
  9. ↑ 9.0 9.1 9.2 Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010 May-Jun;50(3):313-27.
  10. ↑ 10.0 10.1 Glencross PM. Medscape: Pes Anserine Bursitis. www.emedicine.medscape.com/article/308694-diagnosis (accessed 26 December 2013).
  11. ↑ Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.
  12. ↑ Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.
  13. ↑ Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.
  14. ↑ Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.
  15. ↑ Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.
  16. ↑ Uson J, et al. Pes anserinus tendino-bursitis: what are we talking about? Scand J Rheumatol. 2000;29(3):184-6.
  17. ↑ Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.
  18. ↑ Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.
  19. ↑ O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.
  20. ↑ Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.
  21. ↑ Brookler MI, Morgan EF. Anserina bursitis. A treatable cause of knee pain in patients with degenerative arthritis. Calif Med 1973; 119:8-10.


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