What is the management of Pes Anserine Bursitis?

Management of Pes Anserine Bursitis

The optimal management of pes anserine bursitis includes initial conservative treatment with NSAIDs, relative rest, ice, and physical therapy, followed by corticosteroid injection for refractory cases.

Diagnosis and Clinical Presentation

• Pes anserine bursitis is an inflammation of the bursa located between the medial aspect of the tibia and the hamstring muscles (sartorius, gracilis, and semitendinosus)
• Common symptoms include:
  • Pain and tenderness over the proximal medial tibia (approximately 2-4 cm below the joint line)
  • Pain aggravated by climbing stairs, rising from a seated position
  • Possible local swelling and warmth
  • Pain on resisted knee flexion

Initial Conservative Management

1. NSAIDs:

   • First-line pharmacological treatment for pain and inflammation 1
   • Naproxen 500mg twice daily is an effective option, with dose adjustments based on patient response 1
   • Lower doses may be sufficient for long-term administration in chronic cases

2. Activity Modification:

   • Relative rest from aggravating activities
   • Avoid activities that involve repetitive knee flexion and extension
   • Open-backed shoes to reduce pressure if footwear aggravates symptoms 2

3. Physical Measures:

   • Ice application for 15-20 minutes several times daily
   • Compression with an elastic bandage
   • Elevation when possible

4. Physical Therapy:

   • Stretching exercises for hamstring muscles
   • Strengthening of quadriceps muscles
   • Correction of biomechanical issues that may contribute to the condition

Advanced Management for Persistent Cases

If symptoms persist after 6-8 weeks of conservative treatment:

1. Corticosteroid Injection:

   • Ultrasound-guided injection into the pes anserine bursa 3, 4
   • Methylprednisolone acetate 20-40mg is appropriate for medium-sized bursae 3
   • Technique: Use sterile preparation, 20-24 gauge needle, inject directly into the bursa 3
   • Provides significant short-term pain relief 4

2. Alternative Injection Therapies (for cases not responding to corticosteroids):

   • Oxygen-ozone therapy has shown longer-lasting effects than corticosteroid injections 4
   • Prolotherapy (dextrose 20%) may provide longer-term relief 4

3. Immobilization:

   • In particularly acute or refractory cases, a brief period of immobilization with a fixed-ankle walker-type device may be beneficial 2

Special Considerations

• Obesity: Weight loss should be recommended for overweight patients as excess weight increases stress on the medial knee
• Biomechanical Factors: Address any underlying gait abnormalities, foot pronation, or knee malalignment
• Comorbidities: Consider underlying conditions that may contribute to bursitis, such as osteoarthritis or inflammatory arthritis 5
• Diabetic Patients: Monitor closely as they may be more prone to infection and delayed healing

Follow-up and Monitoring

• Re-evaluate after 2-4 weeks of initial treatment
• If symptoms persist beyond 6-8 weeks despite conservative measures, consider advanced interventions
• For recurrent cases, evaluate for underlying biomechanical issues or systemic conditions

Treatment Efficacy

• Most cases respond well to conservative treatment within 2-4 weeks
• Corticosteroid injections have shown good short-term efficacy (1-4 weeks) 4
• Oxygen-ozone and prolotherapy injections may provide more sustained relief (up to 8 weeks) 4
• Mesotherapy with diclofenac has shown effectiveness in managing pes anserine bursitis in knee osteoarthritis patients 5

Pitfalls and Caveats

• Avoid multiple corticosteroid injections in the same area (limit to 3-4 per year) to prevent tissue atrophy and tendon weakening
• Ensure accurate diagnosis, as medial knee pain can also be caused by medial meniscal tears, MCL injuries, or osteoarthritis
• Ultrasound guidance improves accuracy of injections and should be used when available 4
• Patients with diabetes may experience transient elevation in blood glucose levels following corticosteroid injections

By following this structured approach to the management of pes anserine bursitis, most patients can achieve significant symptom relief and return to normal activities.