Updated: 7/8/2018

Pes Anserine Bursitis

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  • Snapshot
    • An obese 47-year-old woman with diabetes presents to her orthopedist reporting left medial knee pain for the past 6 months. She denies any inciting injury or trauma. The pain is worse when she climbs stairs or rises from a seated position. On physical exam, there is tenderness to palpation over the anteromedial proximal tibia. A radiograph reveals no fracture and a follow-up magnetic resonance imaging of the left knee shows fluid accumulation around the pes anserine bursa.
  • Introduction
    • Clinical definition
      • inflammation of the medial knee that often coexists with other knee disorders and is characterized by spontaneous pain
    • Associated conditions
      • Osgood-Schlatter syndrome
      • osteoarthritis
  • Epidemiology
    • Demographics
      • female > male
      • common in young adults who actively do sports
      • common in overweight middle-aged women
      • common in older adults with osteoarthritis
    • Location
      • the pes anserine bursa and its tendons are located along the medial proximal aspect of the tibia
    • Risk factors
      • female sex
      • diabetes
      • obesity
      • valgus knee deformity
  • Etiology
    • Pathogenesis
      • extra stress or friction can cause irritation and inflammation of the bursa, the associated tendons, or the pannus (especially in obese individuals)
        • currently, it is unclear which structure surrounding the pes anserine bursa is responsible for the symptoms
      • trauma can also cause inflammation in the area
    • Tight hamstrings
    • Acute trauma or athletic overuse
    • Degenerative processes
  • Presentation
    • Symptoms
      • mild or moderate knee pain when
        • arising from a seated position
        • climbing stairs
      • pain is worse at night
    • Physical exam
      • tenderness and swelling of the proximal medial tibia 6-7 cm below the anteromedial joint line of the knee
      • may have palpable crepitus
      • shortened hamstring to popliteal angle
  • Imaging
    • Radiography
      • indication
        • only indicated to rule out proximal tibial stress fracture if there is any clinical suspicion
      • recommend views
        • anteroposterior and lateral
      • findings
        • typically normal
    • Magnetic resonance imaging
      • indication
        • only indicated if diagnosis and radiograph is unclear
      • findings
        • increased signal intensity
        • fluid accumulation around the bursa
  • Studies
    • Diagnostic injection with lidocaine or lidocaine-corticosteroids
      • alleviation of pain with injection suggests the diagnosis of pes anserine bursitis
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Tibial stress fracture
      • distinguishing factor
        • very severe pain over proximal tibia
    • Medial meniscus injury
      • distinguishing factors
        • often presents with knee locking or catching
        • positive McMurray test
  • Treatment
    • Conservative
      • rest and physical therapy
        • indication
          • for all patients
        • modalities
          • stretching of pes anserine tendons
    • Medical
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • indication
          • pain management
      • intrabursal injection with lidocaine and/or corticosteroids
        • indication
          • second-line pain management
  • Complications
    • Persistent pain
  • Prognosis
    • Self-limited and responds well to exercises and stretches
    • Time to resolution varies from weeks to years
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(M2.OR.15.78) An obese 42-year-old female presents to her primary care physician with a complaint of left knee pain for the past 3 months. She describes the pain as affecting the inside part of the knee as well as the front of her knee, below the kneecap. She denies any inciting injury or trauma to the knee but reports that the pain is worse when she is climbing up stairs or rising from a chair. Physical examination is significant for localized tenderness to palpation over the left anteromedial proximal tibia, 6 cm inferior to the joint line. There is no joint effusion noted. Valgus stress testing is negative for any pain or instability of the knee joint. Radiographs of the left knee are obtained and reveal only mild arthritis, without evidence of any fractures or bony lesions. Which of the following is the most likely diagnosis in this patient?

QID: 106151

Stress fracture of proximal tibia

3%

(1/36)

Medial meniscus tear

3%

(1/36)

Medical collateral ligament (MCL) sprain

3%

(1/36)

Pes anserine bursitis

67%

(24/36)

Patellar tendonitis

22%

(8/36)

M 7 E

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