You are in: eMedicine Specialties > Sports Medicine > Knee Pes Anserine BursitisArticle Last Updated: Oct 16, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Robert F LaPrade, MD, PhD, Professor, Department of Orthopaedic Surgery, Divisions of Sports Medicine and Shoulder Services, University of Minnesota Robert F LaPrade is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America Coauthor(s): Scott D Flinn, MD, Medical Director, Directorate for Primary Care, Primary Care, Naval Medical Center San Diego Editors: Gerard A Malanga, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, New Jersey Medical School; Director of Pain Management, University of Medicine and Dentistry at New Jersey, Overlook Hospital; Director of Sports Medicine, Mountainside Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Author and Editor Disclosure Synonyms and related keywords: pes anserine tendonitis/tendinitis, knee bursitis, pes anserinus tendinobursitis/tendino-bursitis syndrome, PATB syndrome INTRODUCTIONSection 2 of 11
  BackgroundBursae are small, synovial tissue-lined structures that help different tissues glide over one another, such as a tendon sliding over another tendon or bone. Bursae may become painful when irritated, damaged, or infected. Pes anserine bursitis is a common finding in patients and/or athletes who present with complaints of anterior knee pain. The pes anserine bursa, along with its associated medial hamstring tendons, is located along the proximomedial aspect of the tibia. This condition is usually found in patients who have tight hamstrings, although it also can be caused by trauma (eg, a direct blow). In most patients, pes anserine bursitis is a self-limiting condition that responds to a program of hamstring stretching and quadriceps strengthening. FrequencyUnited StatesThe exact incidence of pes anserine bursitis is unknown. It is not commonly recorded as an individual entity by many physicians but may be reported with the clinical diagnosis of anterior knee pain or patellofemoral syndrome. Pes anserine bursitis is recognized as occurring in a large number of patients who present to a physician's office with anterior knee pain. Functional AnatomyThe pes anserine bursa is formed just proximal and medial to the primary attachment of the medial hamstring tendons on the proximal tibia.1 From proximal to distal, the medial hamstring tendons that form the roof of the pes anserine bursa are the sartorius, gracilis, and semitendinosus. The pes anserine bursa serves as a potential space where motion occurs between these hamstring tendons and the underlying superficial medial collateral ligament (tibial collateral ligament). Sport-Specific BiomechanicsThe pes anserine bursa serves as a space where motion occurs between the medial hamstrings and the superficial medial (tibial) collateral ligament. When a patient has tight hamstrings or experiences a contusion to this area, the synovial cells in the lining of the bursa may secrete more fluid and the bursa becomes inflamed and painful. CLINICALSection 3 of 11
HistoryThe chief complaint of patients with pes anserine bursitis, either as a main component or as part of several causes of knee pain, is pain along the medial aspect of the knee. Although patients sometimes point to an area directly over the pes anserine bursa, they may often point to a rather diffuse region over the medial aspect of the knee. This diffuse pain may occur because many of these patients may also have plical irritation or medial joint compartment pathology (eg, medial meniscal tears, medial compartment arthritis). PhysicalOn physical examination, the pes anserine bursa can be palpated at a point slightly distal to the tibial tubercle and about 3-4 cm medial to it (about 2 fingerbreadths). Pain in this area indicates an underlying inflammation of the pes anserine bursa or a bursitis. Palpation of this area of the knee is important in a patient who complains of medial-sided knee pain because the examiner needs to ensure that the pain is truly from joint line pathology or from pes anserine bursal pathology (or both). Concurrent with the physical examination finding, the hamstring-popliteal angle should be assessed to determine the patient's underlying amount of hamstring tightness. This assessment is made by having the patient's hip flex to 90°, and then passively extending the leg. The angle formed between a perpendicular line to the femoral shaft and the tibial shaft is the hamstring-popliteal angle. At its worst, pes anserine bursal pain is only mild to moderate. Intense pain could suggest a proximal tibial stress fracture. CausesThe main cause of pes anserine bursitis is underlying tight hamstrings, which are believed to place extra pressure on the bursa, causing bursal irritation. In addition, some patients may have bursal irritation due to a direct blow and experience a contusion to this area, as well as resultant inflammation. Pes anserine bursitis is a common finding in patients who have concurrent Osgood-Schlatter syndrome, suprapatellar plical irritation, or other causes of joint irritation, which may make the hamstrings spasm (eg, meniscal tears, underlying arthritis). Patients with planovalgus feet and the resultant overpronation with running may also be at risk for irritation of the bursa. DIFFERENTIALSSection 4 of 11
Jumper's Knee Knee Osteochondritis Dissecans Medial Synovial Plica Irritation Osgood-Schlatter Disease Patellofemoral Joint Syndromes Other Problems to Be ConsideredMedial meniscal tear WORKUPSection 5 of 11
Lab Studies
Imaging Studies
Procedures
TREATMENTSection 6 of 11
Acute PhaseRehabilitation ProgramPhysical TherapyPatients 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 TherapyIn 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 InterventionThe 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. ConsultationsRecalcitrant 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 PhaseRehabilitation ProgramPhysical TherapyDuring the rehabilitation program, the patient should incorporate the following measures:
Medical Issues/ComplicationsPes 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 InterventionSee Treatment, Acute Phase, Surgical Intervention. Maintenance PhaseRehabilitation ProgramPhysical TherapyContinue to work on a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program. MEDICATIONSection 7 of 11
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.
Drug Category: Nonsteroidal anti-inflammatory drugsNSAIDs 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.
Drug Category: Anesthetic (local) and corticosteroid combinationsLocal 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.
FOLLOW-UPSection 8 of 11
Return to PlayAthletes/patients may return to play or activities based upon their symptoms. In the more severe cases, restrictions on activities may be necessary. In athletes who play contact sports, the use of a protective pad over the affected area may prove useful. ComplicationsA small risk of infection exists in recalcitrant cases in which the patient may have undergone an injection; however, if this procedure is performed properly under sterile conditions, the risk of infection is small. PreventionThe best means to prevent pes anserine bursitis is to make sure that every athlete participates in a regular stretching program for the hamstring tendons. PrognosisBy itself, pes anserine bursitis is usually a self-limiting condition, which has few long-term sequelae if the individual decides to try to participate in sports or activities and play through the pain. In most patients, a 6-8 week stretching and exercise program alleviates the symptoms. EducationEducate patients, trainers, and coaches regarding a gradual increase in the patient's activity level and activity duration based on his or her symptoms. For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Bursitis. MISCELLANEOUSSection 9 of 11
Medical/Legal Pitfalls
MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: Oct 16, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
