What is the recommended physical therapy approach for managing pes anserine tendonitis?

Physical Therapy Approach for Pes Anserine Tendonitis

Eccentric strengthening exercises combined with stretching should be the primary physical therapy approach for managing pes anserine tendonitis, as these interventions have demonstrated effectiveness in reducing pain and improving function in tendinopathies. 1

First-Line Physical Therapy Interventions

• Active exercise therapy should be prioritized over passive modalities, as active interventions promote self-management and have shown greater effectiveness in tendinopathies 1
• Eccentric strengthening exercises specifically targeting the pes anserine tendons (sartorius, gracilis, and semitendinosus) are recommended to reduce symptoms, increase strength, and promote tendon healing 1
• Stretching exercises for the involved muscles should be incorporated to improve flexibility and reduce tension on the tendon insertion 1
• Rest from aggravating activities is important to prevent ongoing damage while continuing activities that don't worsen pain; complete immobilization should be avoided to prevent muscular atrophy 1

Adjunctive Therapies

• Ice application through a wet towel for 10-minute periods is effective for short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1
• Deep transverse friction massage can be used to reduce pain and promote healing in the tendon 1
• Correction of biomechanical issues with appropriate orthotics may be beneficial, particularly if excessive foot pronation or pes planus is contributing to the condition 1

Comparative Effectiveness of Treatment Options

• Physical therapy and corticosteroid injections both result in significant improvements in pain and function for pes anserine tendino-bursitis, though injection may provide faster relief 2
• Kinesiotaping using space-correction (lifting) technique has shown superior results in reducing pain and swelling compared to NSAIDs plus physical therapy in one study 3
• Ultrasound-guided injections are significantly more accurate and effective than blind injections for this condition 4

Treatment Algorithm

1. Initial phase (1-2 weeks):

   • Relative rest from aggravating activities
   • Ice application (10-minute periods through wet towel)
   • Gentle stretching of hamstrings and adductors
   • NSAIDs for pain control if appropriate 1

2. Intermediate phase (2-6 weeks):

   • Progressive eccentric strengthening exercises
   • Continue stretching program
   • Deep transverse friction massage
   • Address biomechanical issues with orthotics if needed 1

3. Advanced phase (6+ weeks):

   • Sport or activity-specific exercises
   • Return to normal activities as tolerated
   • Maintenance program to prevent recurrence 1

Common Pitfalls and Caveats

• Avoid complete immobilization as it leads to muscle atrophy and deconditioning 1
• Corticosteroid injections may provide faster short-term relief but don't improve long-term outcomes and could potentially weaken the tendon structure 1
• Injections around tendons should be performed with caution; particularly avoid direct injections into the tendon substance due to risk of rupture 1
• Peri-tendon injections at the pes anserine area should be ultrasound-guided for greater accuracy and effectiveness 4
• For persistent cases not responding to conservative measures, newer injection options like oxygen-ozone therapy or prolotherapy may provide longer-lasting effects than corticosteroids 5