Pes Anserinus Bursitis

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Definition/Description[edit | edit source]

Pes Anserine 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[1].

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[2]. The inflammation of the bursa does not appear suddenly, but rather progresses over an 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[3]. 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[4].

Epidemiology/Etiology
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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 [5] and underlying osteoarthritis of the knee[6].

Characteristics/Clinical Presentation
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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[7]. 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.

Differential Diagnosis[edit | edit source]

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[8][9][10][11]. Panniculitis[12] 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.

Diagnostic Procedures[edit | edit source]

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[13][14]. 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.

Outcome Measures[edit | edit source]

See Outcome Measures Database

Examination[edit | edit source]

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.).

Medical Management
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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.

Physical Therapy Management
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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[15][16][17].

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.

Key Research[edit | edit source]

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Resources
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add appropriate resources here

Clinical Bottom Line[edit | edit source]

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


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References[edit | edit source]

 

  1. ↑ Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.
  5. ↑ Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5.
  6. ↑ Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.
  7. ↑ Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.
  8. ↑ Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.
  12. ↑ Glencross PM. Medscape: Pes Anserine Bursitis. www.emedicine.medscape.com/article/308694-diagnosis (accessed 26 December 2013).
  13. ↑ 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.
  14. ↑ Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.
  15. ↑ O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.
  16. ↑ Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.
  17. ↑ 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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