What is the best treatment approach for an adult patient, possibly with a history of knee problems or obesity, diagnosed with Pes Anserine bursitis?

Treatment of Pes Anserine Bursitis

For adults with pes anserine bursitis, initiate treatment with a combination of topical or oral NSAIDs plus a structured quadriceps strengthening exercise program, reserving local corticosteroid injection for patients with acute exacerbations or inadequate response to initial conservative therapy. 1, 2

Initial Conservative Management

The foundation of treatment should combine pharmacological and non-pharmacological approaches rather than relying on single interventions. 1

Pharmacological Options

• Start with NSAIDs (topical or oral) as first-line therapy for pain relief and inflammation reduction, with topical NSAIDs preferred in patients ≥75 years due to superior safety profile 1
• Acetaminophen (up to 4,000 mg/day) serves as an alternative first-line option for patients who cannot tolerate NSAIDs 1, 3
• Oral NSAIDs demonstrated significant pain reduction in pes anserine bursitis patients, with mesotherapy administration showing sustained effects at 30 and 90 days follow-up 4

Exercise and Rehabilitation

• Implement quadriceps strengthening exercises as a core component, focusing on both isometric and dynamic exercises for the lower limb 5, 1
• Prescribe strengthening exercises at moderate to vigorous intensity (60-80% of one repetition maximum) for 8-12 repetitions, at least 2 days per week 5
• Include 30-60 minutes of low-impact aerobic activity most days of the week 6, 3
• Provide at least 12 directly supervised physical therapy sessions initially, as this demonstrates superior outcomes compared to fewer sessions (effect size 0.46 for pain vs 0.28 for <12 sessions) 5

Mechanical Interventions

• Recommend appropriate footwear with shock-absorbing properties to reduce mechanical stress on the knee 5, 1
• Consider walking aids (canes) or insoles to reduce pressure on the affected medial knee area 1, 6
• Soft braces may provide additional support for knee stability 5

Weight Management (If Applicable)

For overweight or obese patients (BMI ≥25 kg/m²):

• Target minimum 5% body weight reduction through structured weight-loss programs with explicit goals 5, 6
• Combine dietary modification with exercise for optimal results, as programs with explicit weight-loss goals achieve mean reductions of -4.0 kg compared to -1.3 kg without goals 5
• Weight reduction significantly decreases medial compartment loading and improves functional outcomes 6

Injection Therapy for Refractory Cases

When conservative measures fail after 4-8 weeks or for acute exacerbations with significant effusion:

• Local corticosteroid injection (40 mg methylprednisolone acetate) into the pes anserine bursa under ultrasound guidance is the most effective injection option 2, 7
• Corticosteroid injection demonstrates statistically significant superiority over PRP and ESWT at 1 week and 8 weeks for pain reduction (WOMAC scores, VAS) and functional improvement 2
• Ultrasound guidance ensures accurate bursa localization and reduces complications 2, 8, 7
• Corticosteroid provides short-term relief lasting 4-8 weeks 3

Alternative Injection Options

• Oxygen-ozone injection shows longer-lasting effects than corticosteroids (sustained benefit at 8 weeks) and may be considered for patients requiring prolonged relief 7
• Prolotherapy (dextrose 20%) demonstrates comparable long-term efficacy to oxygen-ozone at 8 weeks 7
• PRP injection is less effective than corticosteroid injection for pes anserine bursitis 2

Common Pitfalls to Avoid

• Do not use glucosamine or chondroitin, as these lack evidence for clinically important outcomes in knee bursitis 6
• Avoid routine use of opioids including tramadol, as current evidence does not support their use and they carry significant adverse event risks 3
• Do not recommend acupuncture, as evidence is insufficient 5
• Ensure proper diagnosis through physical examination revealing tenderness over the proximal medial tibia at the pes anserine insertion, with pain on resisted knee flexion 8, 9

Patient Education and Self-Management

• Provide individualized education addressing the inflammatory nature of bursitis, expected recovery timeline (typically 10 days to several months), and importance of activity modification 4, 9
• Teach activity pacing principles: "small amounts often" rather than peaks and troughs of activity 5
• Link exercise regimens to daily activities (e.g., before morning shower) to promote adherence 5
• Include written or digital educational materials to reinforce verbal instructions 5

Follow-Up and Reassessment

• Evaluate response at 1-2 weeks after initiating conservative treatment 2, 7
• If inadequate improvement after 4-8 weeks of conservative management, proceed to ultrasound-guided corticosteroid injection 2, 9
• Chronic or recurrent cases unresponsive to multiple injection therapies may rarely require surgical bursa excision 9