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Pes Anserinus Bursitis

Original Editors - Glenn Demeyer

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Definition/Description

Pes Anserine bursitis is a common cause of medial knee pain.[1] It refers to an inflammatory condition of the bursa of the conjoined insertion of the sartorius, gracilis and semitendinosus on the tibia.[2] This bursa is also known as the tibial intertendinous bursa. It can be located at the proximal medial aspect of the Knee, 5 cm below the medial knee joint line deep to the pes anserinus tendons.[3][4][5]

Clinically Relevant Anatomy

Pes anserinus (highlighted in green) - anterior view
Pes anserinus (highlighted in green) - anterior view

The Pes Anserine bursa is a fluid filled sac. Similar to other bursae, it secretes synovial fluid in order to reduce friction between tissues, and also works as a cushion for bones, tendons and muscles.[6] Inflammation of the bursa does not usually occur suddenly, but rather progresses over a period of time. Bursitis can also occur in other bursae such as in the shoulder, knee, hip, elbow and big toe.

The Pes Anserine, colloquially referred to as the ‘Goose's Foot’, denotes the combined insertion of the sartorius, gracilis and semitendinosus muscles, which are conjoined proximally on the medial side of the Tibia (highlighted in green in diagram on the right). The three tendons of the Pes Anserine are located superficial to the medial collateral ligament (MCL) of the knee[7]. The sartorius and gracilis muscles are adductors of the leg (i.e. they pull the leg towards the median axis of the body). The semitendinosus muscle is part of the hamstrings muscle group located at the back of your upper leg. Together, these three muscles are primarily flexors of the knee and internal rotators[8].

Image: Pes anserinus (highlighted in green) - anterior view[9]

Epidemiology/Etiology

Pes Anserine bursitis often occurs when the related muscles are repeatedly used, by doing movements such as flexion and adduction. This causes friction and also increases pressure on the bursa. Tight hamstrings can create excessive pressure on the bursa.[1] Sports involving high amounts of lateral movements can also contribute to developing this condition.[1]

Bursitis can also occur from direct trauma to the Pes Anserine region. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tender or painful [4] and underlying Osteoarthritis of the knee[10].

Pes anserine bursitis is prevalent among obese middle-aged women, particularly those with knee osteoarthritis.[1] We can explain this by the fact that women have a wider pelvis, resulting in angulation of the knee in the frontal plane, which leads to more pressure in the area of insertion of the pes anserinus by genu valgum[11]. Flat feet also cause more pressure on the medial knee, predisposing to pes anserine bursitis.[1]

We can say that an inflamed bursa is not a primary pathology, but rather a consequence of an earlier complication.

Characteristics/Clinical Presentation

Pes Anserine bursitis causes pain around the anteromedial proximal knee (mostly during running or taking stairs), around 5-7cm distal to the medial joint line of the knee.[1] The patient may experience pain and tenderness at the insertion of pes anserine, often brought on by climbing stairs or performing sit-to-stands.[12] [4][2][13] Crepitus may also be present.[1]

Pain reproduced upon palpation, particularly when knee is fully extended. Palpation should be performed to distinguish between meniscal tear and bursitis. As well, the region around the bursa will be swollen or tender to touch.[14]

Other clinical presentations may include:

  • Decreased muscle strength
  • Gait deviations
  • Decreased function
  • Decreased ROM
  • Postural dysfunction/impaired lower extremity biomechanics

Aggravating factors include activities that require movements like flexion and endorotation, as well as exorotation and adduction. Pivoting, kicking, squatting or quick movements from side to side, such as in the sports mentioned above, may also cause further irritation.

Differential Diagnosis

Pes Anserine bursitis is often confused with other causes of medial knee pain[15][16][17][18]:

  • Pes Anserine tendinitis. Differentiating pes anserine bursitis and tendinitis can be difficult due to the proximity of the tendons and bursa. Regardless, management for either conditions is the same.[1]
  • Stress-fracture of the shin bone on the proximedial side will cause pain in the area of the Pes Anserine.
  • Patellofemoral syndrome
  • Medial meniscus lesion and osteoarthritis: Pain and sensitivity would be present at the medial joint line, while in the pes anserinus bursitis they are located inferior to the medial joint line (around 5cm inferior). Note that pes anserine bursal tenderness with a concomitant asymptomatic meniscal tear is common, necessitating comparison with the contralateral knee.
  • MCL tear: Pain & tenderness expected to be superoposterior to pes anserine bursa. Stress maneuvers of the medial collateral ligament, with or without instability, may contribute to the diagnosis of lesions of the medial collateral ligament.[19][11]
  • Knee pain secondary to L3-L4 radiculopathy is associated with lumbar pain without pain on digital pressure of the anserine region[11].
  • Panniculitis[13] occurs in obese individuals, and causes painful inflammation of subcutaneous fat at night.
  • Semimembranosus tendinitis will often occur as a running injury.
  • Medial Plica Syndrome, which can cause pain and tenderness on the medial side of the knee.
  • Extra-articular cystic lesions: synovial cyst, ganglionic cyst, parameniscal cyst, pigmented villonodular synovitis, synovial sarcoma[4]
  • Aseptic bursitis[1]
  • Osteomyelitis[1]
  • In addition to the conditions listed above, other problems to be considered include the following[2]:
    • Atypical medial meniscal cysts
    • Juxta-articular bone cysts
    • Semimembranosus bursitis
    • Tibial collateral ligament bursitis

Diagnostic Procedures

This condition is typically diagnosed clinically.[1] However, lateral x-ray views of the patient's knee are very useful for ruling out a stress fracture, arthritis or even Osteochondritis Dissecans. An MRI can clarify damage caused to other regions of the medial side of the knee. An MRI could prevent unnecessary arthroscopy. MRI findings should be compared with those of a physical examination[20][21]. Sinography (radiography of a sinus following the injection of a radiopaque medium) is the best method for establishing the diagnosis when other imaging modalities, including MRI and CT, are not feasible[4]. A Lidocaine/Corticosteriod injection in the area of the bursa which will help determine the contribution of this pathology to the patient's overall knee pain.

Outcome Measures

See Outcome Measures Database for more.

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)[13].

Examine hamstring length with the patient in the supine position. Bend the patient's hip 90° and then extend the knee as far as possible. How far the knee can be extended will indicate hamstring length and tightness. If the patient's knee can be straightened completely than the hamstrings are not tight.


With the sports-related variant of pes anserine bursitis, symptoms may be reproduced by means of resisted internal rotation and resisted flexion of the knee. With the chronic variant in older adults, flexion or extension of the knee usually does not elicit pain[13].

Medical Management

The initial treatment of pes anserinus bursitis should include ice, relative rest of the affected knee and non-steroidal anti-inflammatory drugs (NSAID)[2]. Additional modalities, including local injection of a corticoid such as methylprednisolone, are indicated in some cases. Intrabursal injection of local anesthetics, corticosteroids, or both constitutes a second line of treatment[2]. Surgical treatment is indicated in cases with failure to conservative treatments. Simple incision and drainage of the distended bursa can improve symptoms in some reported cases[4][2]. The bursa may be removed if chronic infection cannot be cleared up with antibiotics. After surgery, if the bursa is removed, follow the same steps of rehabilitation and recovery outlined under physical therapy management[11]. If the bursitis becomes infected and standard antibiotic treatments are ineffective, A surgical decompression of the bursa may be a solution in this case.

Physical Therapy Management

Pes anserine bursitis is generally self-limiting, typically responding well to exercise and stretching programs.[1] To temper the pain caused by the bursitis, the most important thing of all is rest. Avoid stairs, climbing, or other irritating activities to quiet down the bursa and the related pain[2]. Nonsteroidal anti-inflammatory drugs (NSAID) can be taken to alleviate the pain. Restrict movement and alternately apply ice during the inflammatory phase. An ice massage of 15 minutes every 4-7 hours will reduce the inflammation. An elastic bandage can be wrapped around the knee to reduce any swelling or to prevent swelling from occurring[2]. Be careful not to increase friction.

Teach the patient muscle-conditioning exercises[22]. These may include leg stretching exercises such as hamstring stretch, standing calf stretch, standing quadriceps stretch, hip adductor stretch, heel slide, quadriceps isometrics, hamstrings isometrics[2]. Hamstring stretching exercises if hamstrings are assessed as tight are especially important as tight hamstrings add pressure on the bursa. Strengthening of key muscle groups includes the quads and hamstrings, adductors and abductors.[1] 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.

The closed-kinetic chain exercises are also a recommended method to prevent the development of collateral knee instability, which occurs to be a risk factor of Pes Anserine bursitis.[23]

Ultrasound has been documented as effective in the reduction of the inflammatory process in pes anserine bursitis.[11] Some patients receive an injection which consists of a solution of anesthetic and steroid. Afterwards, a physiotherapist will give a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program that has to repeated several times a day. This will result in less pain at about 6-8 weeks.

Kinesiotaping is more effective than naproxen or physical therapy in reduction of pain and swelling.[24]

Clinical Bottom Line

Pes anserine bursitis is commonly associated with osteoarthritis and/or overweight females. A typical characteristic is spontaneous anteromedial knee pain on climbing or descending stairs. The differential diagnosis is very encompassing. It does not disappear without treatment such as rest, ice application, stretching and ultrasound. Another frequently used treatment is intrabursal injection of corticosteroids.

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Mohseni M, Mabrouk A, Li D, et al. Pes Anserine Bursitis. [Updated 2024 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532941/
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395–8.
  3. ↑ Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Huang TW, Wang CJ, Huang SC. Polyethylene-induced pes anserinus bursitis mimicking an infected total knee arthroplasty: a case report and review of the literature. J Arthroplasty. 2003 Apr;18(3):383-6.
  5. ↑ Osman MK, Irwin GJ, Huntley JS.Swelling around a child's knee. Clin Anat. 2011 Oct;24(7):914-7.
  6. ↑ Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.
  7. ↑ Wood LR, Peat G, Thomas E, et al. The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults. Osteoarthritis Cartilage. Jun 2008;16(6):647-53.
  8. ↑ Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.
  9. ↑ Pes anserinus (highlighted in green) - anterior view image - © Kenhub https://www.kenhub.com/en/library/anatomy/lower-leg-and-knee-anatomy
  10. ↑ Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010 May-Jun;50(3):313-27.
  12. ↑ Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996 May 15;53(7):2317-24. Erratum in: Am Fam Physician 1996 Aug;54(2):468. PMID: 8638508.
  13. ↑ 13.0 13.1 13.2 13.3 Glencross PM. Medscape: Pes Anserine Bursitis. www.emedicine.medscape.com/article/308694-diagnosis (accessed 26 December 2013).
  14. ↑ Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.
  15. ↑ Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.
  16. ↑ Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.
  17. ↑ Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.
  18. ↑ Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.
  19. ↑ Uson J, et al. Pes anserinus tendino-bursitis: what are we talking about? Scand J Rheumatol. 2000;29(3):184-6.
  20. ↑ Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.
  21. ↑ Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.
  22. ↑ O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.
  23. ↑ Alvarez-Nemegyei, José. "Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study." JCR: Journal of Clinical Rheumatology 13.2 (2007): 63-65.
  24. ↑ Homayouni, Kaynoosh, Shima Foruzi, and Fereshte Kalhori. "Effects of kinesiotaping versus non-steroidal anti-inflammatory drugs and physical therapy for treatment of pes anserinus tendino-bursitis: A randomized comparative clinical trial." The Physician and sportsmedicine 44.3 (2016): 252-256.


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