What is the best treatment for pes anserine (knee pain at the insertion of the sartorius, gracilis, and semitendinosus muscles) bursitis in a new runner?

Treatment of Pes Anserine Bursitis in a New Runner

The best treatment for pes anserine bursitis in a new runner is a comprehensive approach centered on eccentric strengthening exercises combined with stretching, with relative rest from aggravating activities and ice application for short-term pain relief. 1

First-Line Interventions

• Eccentric strengthening exercises targeting the pes anserine tendons (sartorius, gracilis, and semitendinosus) should be the primary physical therapy approach, as these have demonstrated effectiveness in reducing pain and improving function in tendinopathies 1
• Stretching exercises for the involved muscles (hamstrings and adductors) should be incorporated to improve flexibility and reduce tension on the tendon insertion 1
• Relative rest from aggravating running activities while continuing non-painful activities is essential to prevent ongoing damage without causing muscular atrophy 1
• Ice application through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1
• NSAIDs may be used for short-term pain control if appropriate, though they don't affect long-term outcomes 1, 2

Treatment Algorithm

Initial Phase (1-2 weeks)

• Relative rest from running activities that aggravate symptoms 1
• Ice application for 10-minute periods several times daily 1
• Gentle stretching of hamstrings and adductors 1
• NSAIDs for pain control if appropriate and not contraindicated 1, 2

Intermediate Phase (2-6 weeks)

• Progressive eccentric strengthening exercises targeting the pes anserine muscles 1
• Continue and advance stretching program 1
• Deep transverse friction massage to reduce pain and promote healing in the tendon 1
• Address biomechanical issues with appropriate orthotics if excessive foot pronation or pes planus is contributing to the condition 1
• Consider kinesiotaping, which has shown superior effectiveness in reducing pain and swelling compared to NSAIDs plus physical therapy 3

Advanced Phase (6+ weeks)

• Running-specific exercises with gradual return to running activities 1
• Biomechanical assessment and running retraining if needed 4
• Maintenance program to prevent recurrence 1

Adjunctive Therapies

• Biomechanical assessment and correction of running form may be beneficial, as running gait analysis and retraining have been recommended for lower extremity injuries 4
• Addressing core and proximal strength is important to optimize lower extremity biomechanics during running 4
• For refractory cases not responding to conservative treatment after 6-8 weeks, consider:
  • Extracorporeal shock wave therapy (ESWT), which has shown effectiveness in reducing pain in pes anserine bursitis 5
  • Platelet-rich plasma injections, which have demonstrated effectiveness in providing pain relief in 84.8% of patients with chronic pes anserine pain syndrome 6
  • Mesotherapy with diclofenac has shown effectiveness in managing anserine bursitis in the short and mid-term 2

Common Pitfalls and Caveats

• Avoid complete immobilization as it leads to muscle atrophy and deconditioning 1
• Corticosteroid injections should be used with caution; while they may provide faster short-term relief, they don't improve long-term outcomes and could potentially weaken the tendon structure 1
• Avoid direct injections into the tendon substance due to risk of rupture 1
• Premature return to running before adequate healing can lead to symptom recurrence and chronicity 1
• Inadequate addressing of biomechanical factors contributing to the condition may lead to persistent symptoms 4, 1