By Prodyut Das

Pes Anserine Bursitis

  • Pes anserine bursitis (tendinitis) involves inflammation of the bursa at the insertion of the pes anserine tendons on the medial proximal tibia.
  • The pes anserine or goose's foot is composed of the sartorius, gracilis, and semitendinosus tendons.
  • The superficial medial collateral ligament inserts onto the proximal tibia deep to the pes insertion.
  • Symptoms include medial pes swelling, pain to touch, warmth, and pain with hamstring activation.
  • The cause is usually overuse.
  • Treatment involves modification of activities, icing, and stretching.
  • Conservative treatment usually resolves this condition.

Pes Anserine Tendinopathy

Pes anserine tendinopathy can hit sartorius, gracilis, and semitendinosis muscle tendons in their insertion area. Overweight, biomechanical overburden, and improper posture could predispose to this pathology. In fact they provoke excessive friction on the common tendon insertion and underlying bursa that may cause overload work for these muscles and lead to inflammation. This pathology occurs mainly to long-distance runners, young athletes (because of their premature beginning of the sports practice), and especially in women. Symptoms consist in strong pain and burning sensation underneath and inside the knee, where pes anserine tendons insert. In most cases, tendinopathy is provoked by continual mechanical stress, causing repeated microtraumas. Therapy consists in rest and appropriate therapeutic and physiotherapeutic treatments.

Patient history with signs and symptoms

  • Acute trauma to the medial knee, athletic overuse, chronic mechanical (pes planus) process or degenerative process.
  • Pain, tenderness, and localized swelling over the medial knee.
  • Worse on ascending and possibly, descending stairs and when rising from a seated position; typically deny pain with walking on level surfaces.
  • May have chronic, refractory pain in setting of arthritis or obesity.
  • More common in sports requiring side-to-side movements and cutting.
  • May have coexistent medial collateral ligament pathology (tenderness superior and posterior to the pes bursa).
  • Bilateral symptoms in one third of patients.

Physical Examination

a) Observation

  • Localised swelling

b) Palpation

  • Tenderness over the proximal medial tibia at the insertion of the pes anserine, approximately 2 to 5 cm distal to the anteromedial joint line.
  • Bursa usually not palpable unless effusion and thickening present.
  • Crepitus over the bursa occasionally present.
  • Absence of joint line pain.
  • Exostosis (a benign outgrowth of cartilaginous tissue on a bone) of the tibia may contribute to chronic symptoms in athletes.

c)Range of motion

  • May have pain with resisted internal rotation, resisted flexion, and valgus stress (especially in athletes).

Diagnosis

  • Plain radio-graphs- indicated in all patients thought to have pes anserine bursitis.
  • Additional tests- complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing maybe indicated.
  • MRI of knee- indicated to quantify the extent of internal derangement of the knee and rule out occult mass or tumor.
  • Bone scan- maybe used to identify occult stress fractures involving the joint.

Differential Diagnosis

  • Degenerative arthritis of knee
  • Lumbar radiculopathy
  • Bursitis of other bursae of knee
  • Entrapment neuropathies of lower extremity, such as femoral neuropathy
  • Primary and metastatic tumors of the femur and spine

Treatment

  • Initial treatment for pes anserine bursitis starts with activity modification, rest, topical ice (Apply ice packs to the area for 15 to 20 minutes every 2 hours) and non-steroidal anti-inflammatory drugs (NSAIDS) or (COX-2) inhibitors.
  • Activity modification consists of modification of inciting activity, for example- reducing the duration, frequency, and intensity of running in a marathoner.
  • In overweight subjects it is very important lose weight.
  • The use of pillow between the thighs at night times is strongly recommended.
  • Biomechanical assessment of the lower limb and analysis of the athlete’s training regime are called for where there is no history of injury.
  • Ultrasound therapy has been documented to reduce the inflammatory process.

Exercises for pes anserine bursitis

  • Stretching of Quadriceps
  • Stretching of sartorius, gracilis, and semitendinosus tendons is strongly recommended.
  • Calf Stretch
  • Butterfly stretch- seated adductor stretch. Passive and active stretching can promote an important reduction in the tension on the anserine bursa.
  • Heel Slides
  • Isometric Hamstrings
  • Isometric Quadriceps
  • Straight Leg Raises
  • Dynamic Quadriceps
  • Hamstring Curls
  • No-Impact Aerobics

During the rehabilitation program, after 2-3 week

  • Add squats and lunges
  • 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
  • Progression of these exercises may involve closed-kinetic chain exercises such as single-knee dips, squats and leg presses. Resisted leg-pulls using elastic tubing are also included.

Pes anserine bursitis recovery time

A regular program of physical therapy usually results in alleviation of the pain and discomfort from pes anserine bursitis anywhere between 2-8 weeks, depending on extent of the damage.

For patients who do not respond to these treatment, injection of the coronary pes anserine bursa with a local anaesthetic and steroid may be a reasonable next step. Surgical excision, bursectomy, is reserved for refractory cases and is rarely needed.

References

  • The Lower Limb Tendinopathies: Etiology, Biology and Treatment edited by Giannicola Bisciotti, Piero Volpi
  • Essential Orthopaedics By Mark D. Miller, Jennifer Adele Hart, John M. MacKnight
  • Common Musculoskeletal Problems in the Ambulatory Setting , An Issue of ... By Matthew Silvis
  • Atlas of Uncommon Pain Syndromes By Steven D. Waldman
  • Orthoinfo

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