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Updated: Jul 8 2018

Pes Anserine Bursitis

  • 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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