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Pes Anserine Bursitis

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(Redirected from Pes Anserinus Bursitis)

Other Names

  • Pes Anserine Pain Syndrome (PAPS)
  • Anserine bursitis
  • Pes Anserine Pain
  • Pes Anserinus Tendinitis or Bursitis (PATB)
  • Pes anserinus tendino-bursitis syndrome

Background

  • This page refers to inflammation of the pes anserine bursa, commonly referred to as pes anserine tendinitis or bursitis (PATB)

History

  • First published in 1996 by Butcher et al[1]

Epidemiology

  • In a large Mexican population, the incidence was 0.34% among 13,000 surveyed individuals[2]
  • Another study found a prevalence of 0.54% in males and 0.7% in females among Indigenous Mexican sand Argentinians[3]
  • An MRI study of symptomatic knees found an incidence of 2.5%[4]

Introduction

Illustration of the pes anserinus
Drawing of the medial knee including the pes anserine bursa[5]

General

  • Overuse injury presenting with inferomedial knee pain
  • Etiology is often mixed but has inflammatory component, often associated with repetitive flexion/adduction
  • Historically called a bursitis, bursal distension is rarely seen and pain syndrome is a better descriptor
  • Diagnosis is primarily clinical and supported by US/MRI imaging
  • Treatment is non-surgical

Diagnostic Criteria

  • No widely agreed upon or established diagnostic criteria
  • Consider in patients with:
    • Medial knee pain
    • Tenderness over superomedial tibia between pes anserine and joint line
    • Absence of localized swelling or induration

Etiology

  • Etiology is generally speculative as true inflammation is rarely present
  • Inflammation
    • Historically, thought to cause local inflammation to surrounding tendinous structures
    • Includes Medial Meniscus, Medial Collateral Ligament which may irritate pes anserine bursa
    • Studies rarely show inflammation of the bursa[6]
  • Overuse leading to tendinopathy
    • Thought to be due to repetitive flexion, adduction
    • Some authors suggest semitendinosus is the most common culprit
  • Other implicated etiologies
    • Direct trauma
    • Obesity

Anatomy of the Pes Anserine

Associated Conditions

Pediatric Considerations

  • Rare in skeletally immature pediatric patients
  • Consider physeal fracture in the setting of medial tibial pain

Risk Factors

Sports[9]

  • Running
  • Basketball
  • Racquet Sports

Other

Differential Diagnosis

Differential Diagnosis: Medial Knee Pain

Differential Diagnosis Knee Pain

Anatomic landmarks of the medial knee[10]
Palpation of pes bursa and associated pes anserine tendons. Note knee is flexed to 90°[11]

Clinical Features

History

  • Medial knee pain
  • Worse with standing, climbing stairs, crossing leg
  • Worse laying down with one knee pressing on the other, often disturbing sleep
  • Subjective weakness, diminished range of motion
  • Worsening progression of knee pain in patients with arthritis

Physical Exam

  • Swelling may or may not be present
  • Tenderness over the pes anserine at the medial, proximal tibia, with knee at 90°
  • In extension, tenderness may be over medial joint line
  • Pain with resisted internal rotation and flexion of the knee
  • Location: 3-4 cm medial to tibial tubercle, 3 cm below anteromedial tibial plateau
  • Patients are often obese
  • Knee valgus/ varus deformities are common

Special Tests

  • No tests specific to Pes Anserine
Pes Anserine bursitis with fluid in the bursa seen in long axis (arrow)[12]

Evaluation

Radiographs

  • Standard Knee Radiographs
  • Findings
    • No specific findings for the pes anserine are typically seen
    • Underlying osteoarthritis is common

Ultrasound

  • Findings
    • Swelling
    • Bursal fluid
    • Thickened pes anserine, especially in patients with knee OA[13]

MRI

  • Not typically indicated
  • Findings[14]
    • Increased bursal fluid
    • Thickened bursal wall
    • Surrounding tissue edema
    • Abnormal wall / surrounding tissue enhancement

Classification

  • Not applicable

Management

Nonoperative

  • Indication
    • Vast majority of cases
  • When appropriate, treatment should be directed at underlying etiology
    • For example, osteoarthritis
  • Relative rest
  • Activity modification
  • NSAIDS
  • Weight Loss
  • Physical Therapy
    • Emphasis on strengthening quadriceps muscles
    • Also if indicated, core, gluteal, short hip rotator strengthening
  • A soft Hinged Knee Brace may be helpful

Procedures

Operative

  • Indications
    • Rarely, failure of conservative treatment
  • Technique
    • Bursal incision and drainage
    • Bursectomy

Rehab and Return to Play

Rehabilitation

  • Closed kinetic chain exercises
  • Isometric quadriceps setting exercises performed with the legs in extension

Return to Play

  • No clear return to play guidelines

Complications & Prognosis

Prognosis

  • Unknown

Complications

  • Chronic pain
  • Inability to return to sport

See Also

Internal

External

References

  1. ↑ Butcher, Janus D., Keith L. Salzman, and W. A. Lillegard. "Lower extremity bursitis." American Family Physician 53.7 (1996): 2317-2324.
  2. ↑ Alvarez-Nemegyei, Jose, et al. "Prevalence of rheumatic regional pain syndromes in adults from Mexico: a community survey using COPCORD for screening and syndrome-specific diagnostic criteria." The Journal of Rheumatology Supplement 86 (2011): 15-20.
  3. ↑ Alvarez-Nemegyei, José, et al. "Prevalence of rheumatic regional pain syndromes in Latin-American indigenous groups: a census study based on COPCORD methodology and syndrome-specific diagnostic criteria." Clinical rheumatology 35 (2016): 63-70.
  4. ↑ Rennie, W. J., and A. Saifuddin. "Pes anserine bursitis: incidence in symptomatic knees and clinical presentation." Skeletal radiology 34 (2005): 395-398.
  5. ↑ image courtesy of uptodate.com
  6. ↑ Uson, J., et al. "Pes anserinus tendino-bursitis: what are we talking about?." Scandinavian journal of rheumatology 29.3 (2000): 184-186.
  7. ↑ Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF. Common Soft Tissue Musculoskeletal Pain Disorders. Prim Care. 2018 Jun;45(2):289-303.
  8. ↑ Alvarez-Nemegyei J, Peláez-Ballestas I, Goñi M, et al. Prevalence of rheumatic regional pain syndromes in Latin-American indigenous groups: a census study based on COPCORD methodology and syndrome-specific diagnostic criteria. Clin Rheumatol. 2016 Jul;35 Suppl 1:63-70.
  9. ↑ Sapp GH, Herman DC. Pay Attention to the Pes Anserine in Knee Osteoarthritis. Curr Sports Med Rep. 2018 Feb;17(2):41.
  10. ↑ Image courtesy of uptodate.com
  11. ↑ Cowles, Larry M., and Anthony I. Beutler. "Pes Anserine Pain Syndrome." Common Pediatric Knee Injuries: Best Practices in Evaluation and Management (2021): 207-216.
  12. ↑ Image courtesy of ultrasoundcases.info, "Pes anserinus tendons"
  13. ↑ Toktas, Hasan, et al. "Ultrasonographic assessment of pes anserinus tendon and pes anserinus tendinitis bursitis syndrome in patients with knee osteoarthritis." Modern rheumatology 25.1 (2015): 128-133.
  14. ↑ Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology. 194 (2): 525-7.
  15. ↑ 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. 2005 Feb;20(1):109-12.
  16. ↑ Babaei-Ghazani, Arash, et al. "Ultrasound-Guided Pes Anserine Bursitis Injection Choices: Prolotherapy or Oxygen-Ozone or Corticosteroid: A Randomized Multicenter Clinical Trial." American journal of physical medicine & rehabilitation 103.4 (2024): 310-317.
Created by:
John Kiel on 10 June 2019 17:09:49
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Last edited:
26 February 2025 16:32:47
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