Physical Therapist's Guide to Pes Anserine Bursitis
Pes anserine bursitis is a condition that produces pain on the inside of the knee and lower leg. It occurs most commonly in young people involved in sports (eg, running or swimming the breaststroke), middle-aged women who are overweight, and people aged 50 to 80 years who have osteoarthritis of the knee. Up to 75% of people who have osteoarthritis of the knee have symptoms of pes anserine bursitis. The condition is also commonly associated with type 2 diabetes; 24% to 34% of patients with type 2 diabetes who report knee pain are found to have pes anserine bursitis. However, in some cases no direct cause can be identified. Physical therapists treat people with pes anserine bursitis to reduce pain, swelling, stiffness, and weakness, as well as identify and treat the underlying cause of the condition.
What is Pes Anserine Bursitis?
The pes anserine bursa is a small, fluid-filled sac located 2 to 3 inches below the knee joint on the inside of the lower leg. It lies beneath 3 tendons that attach to muscles of the thigh, and prevents the tendons from rubbing on the shinbone (tibia). The term “bursitis” describes a condition where the bursa has become irritated and inflamed. This condition is usually painful and associated with some swelling in the affected area. Certain positions, motions, or disease processes can cause increased friction or stress on the bursa, leading to the development of bursitis.
Pes anserine bursitis can be caused by:
- Repetitive activities, like squatting, stair climbing, and other work or household activities that are often repeated
- Incorrect sports training techniques, such as a lack of stretching, sudden increases in run distances, or too much uphill running
- Osteoarthritis of the knee
- Valgus positioning of the knee (ie, a “knock-knee” position where the knees angle inward)
- Turning the leg sharply with the foot planted on the ground
- Injury, such as a direct hit to the leg
- Tight hamstring (back of the thigh) muscles
- A tear in the cartilage of the knee
- Flat feet
How Does it Feel?
With pes anserine bursitis, you may experience:
- Pain and swelling on the inside of the lower leg, 2 to 3 inches below the knee joint; this pain may also extend to the front of the knee and down the lower leg
- Pain when touching the inside of the lower leg, 2 to 3 inches below the knee joint
- Pain when bending or straightening the knee
- Pain or difficulty walking, sitting down, rising from a chair, or climbing stairs
How Is It Diagnosed?
Your physical therapist will conduct a thorough examination that includes taking your health history as well as asking you detailed questions about your injury, such as:
- How and when did you notice the pain?
- Did you feel pain or hear a "pop" when you injured your leg?
- Did you turn your leg with your foot planted on the ground?
- Did you change direction quickly while running?
- Did you receive a direct hit to the leg while your foot was planted on the ground?
- Did you see swelling around the knee in the first 2 to 3 hours following the injury?
- Does your knee feel like it is buckling or “giving way” when you try to use it?
Your physical therapist also will perform special tests to help determine the likelihood that you have pes anserine bursitis. Your therapist may:
- Gently press on the inner side of your knee to see if it is painful to the touch
- Assess the range of motion you have at the knee and hip, as well as the strength of some of the muscles at these joints
- Observe how you are walking, squatting, and performing other functional and sports-specific tasks as appropriate
To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider, who may order further tests, such as an x-ray, to confirm the diagnosis and to rule out other damage to the knee.
How Can a Physical Therapist Help?
Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities.
The First 24 to 48 Hours
If you see a physical therapist within 24 to 48 hours of your injury, your therapist may advise you to:
- Rest the area by avoiding walking or any activity that causes pain.
- Apply ice packs to the area for 15 to 20 minutes every 2 hours.
- Consult with a physician for further services, such as medication or diagnostic tests.
Depending on your condition and goals, your individualized rehabilitation plan may include treatments to:
Reduce pain and swelling. Your physical therapist may use different types of treatments to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as massage.
Improve motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and leg. These might begin with "passive" motions that the physical therapist performs for you to gently move your leg and knee joint, and then progress to active exercises that you do yourself.
Improve flexibility. Pes anserine bursitis is often related to tight hamstring (back of the thigh) muscles. Your physical therapist will determine if your hamstring muscles or any other leg muscles are tight, and teach you how to stretch them.
Improve strength. Certain exercises will aid healing at each stage of recovery. Your physical therapist will choose and teach you the correct exercises and equipment to steadily restore your muscle strength and power. These may include using cuff weights, stretch bands, weight-lifting equipment, and cardio-exercise equipment, such as treadmills or stationary bicycles.
Improve balance. Regaining your sense of balance is important after an injury. Your physical therapist may teach you exercises to improve your balance skills.
Speed recovery time. Your physical therapist is trained and experienced in choosing the best treatments and exercises to help you heal, return to a normal lifestyle, and reach your goals faster than you are likely to do on your own.
Return to activities. Initially, your physical therapist may recommend that you reduce or eliminate activities that aggravate your condition for a period of time. Your physical therapist will discuss your goals with you and set up a treatment program to help you meet them in the safest, fastest, and most effective way possible. You may learn specific exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your own unique goals.
Other Treatment Options
Studies have shown that some patients who do not respond to conservative treatment, such as physical therapy, may benefit from medical therapy. Your physical therapist may recommend that you discuss other treatment options with your physician, including surgery. Although surgery is rarely prescribed for pes anserine bursitis, it sometimes is needed. If surgery is required for your condition, you will follow a recovery program over several weeks guided by your physical therapist. Your physical therapist will help you minimize pain, regain motion and strength, and return to normal activities in the safest and speediest manner possible.
Can this Injury or Condition be Prevented?
Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your knees, upper legs, and abdomen to help prevent the onset or recurrence of pes anserine bursitis. These may include strength and flexibility exercises for the legs, knees, and core muscles.
To help prevent a recurrence of the injury, or prevent its onset if you seek guidance before injury, your physical therapist may advise you to:
- Learn correct knee positioning when participating in athletic activities.
- Follow a consistent flexibility and strength exercise program, especially for the leg and hip muscles, to maintain good physical conditioning.
- Practice balance and agility exercises and drills.
- Always warm up before starting a sport or heavy physical activity.
- Avoid sudden increases in running mileage or uphill running.
- Wear shoes that are in good condition and fit well.
- Maintain a healthy weight.
- Treat and manage diabetes very closely.
- Wear orthotics to reduce flat feet and valgus (knock-knee) positioning of the lower extremities.
- Wear a knee brace to support the knee and reduce strain on the inside of the joint.
Real Life Experiences
Martha is a 40-year-old secretary who has become obese. Her goal is to lose 100 pounds with diet and exercise. To reach that goal, Martha recently joined a gym, and decided to try the latest craze—a Zumba class. Martha enjoyed the first week of classes, but when leaving the gym after the fourth class, she felt a sharp pain in the inner, lower side of her right knee. It got worse when she bent and straightened her knee and when she walked upstairs to go to bed that night. The next day, the pain was still there, making it hard for her to get to work. She contacted her physical therapist.
Martha’s physical therapist performed special tests on the tendons and muscles around the knee, and found that her hamstring (back of the thigh) muscles were extremely tight and her quadriceps (front of the thigh) muscles were weak. Martha’s knee was tender to the touch, and mildly swollen 2 to 3 inches below the knee joint on the inner side of the leg, where the pes anserine bursa is located.
Martha's physical therapist explained that her pes anserine bursa was irritated and swollen. He applied ice and electrical stimulation to the area for 20 minutes. He also applied some tape to gently support Martha's hamstring muscles and alleviate the swelling and pain. He showed her how to stretch her hamstring muscles at home, and how to apply ice every few hours. He recommended that she not attend her Zumba class until her symptoms cleared up.
When Martha returned for her next visit, her physical therapist taught her some exercises to improve the strength of the muscles of her legs and “core,” and to improve her balance. Martha and her physical therapist worked together consistently over the next few weeks. Her treatment program, both in the clinic and at home, as well as her return to activity, were carefully adjusted to help ensure her safe and effective recovery.
Martha received physical therapy treatments for 6 weeks, at which time she felt almost 100% pain free—and much stronger. Martha returned to the gym to perform the exercises and stretches she learned in physical therapy as well as a modified fitness program. By the fourth week, she was able to participate in half of the Zumba class and by the fifth week, to finish the full class.
Martha has continued to do the stretches and exercises she learned from her physical therapist, and is proud to report to her friends and family that she is now pain free—and losing weight!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat pes anserine bursitis. However, you may want to consider:
- A physical therapist who is experienced in treating people with orthopedic injuries. Some physical therapists have a practice with an orthopedic focus.
- A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends, or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have your type of injury.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of pes anserine bursitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Uysal F, Akbal A, Gökmen F, Adam G, Reşorlu M. Prevalence of pes anserine bursitis in symptomatic osteoarthritis patients: an ultrasonographic prospective study. Clin Rheumatol. 2015;34(3):529–533. Article Summary in PubMed.
Klontzas ME, Akoumianakis ID, Vagios I, Karantanas AH. MR imaging findings of medial tibial crest friction. Eur J Radiol. 2013;82(11):e703–e706. Article Summary in PubMed.
Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging. 2012;22(1):27-30. Free Article.
Helfenstein M Jr, Kuromoto J. Anserine syndrome [article in English and Portuguese]. Rev Bras Reumatol. 2010;50(3):313–327. Free Article.
Alvarez-Nemegyei J. Risk factors for pes anserinus tendinitis/bursitis syndrome: a case control study. J Clin Rheumatol. 2007;13(2):63–65. Article Summary in PubMed.
Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34:395–398. Article Summary in PubMed.
Handy JR. Anserine bursitis: a brief review. South Med J. 1997;90(4):376–377. Article Summary on PubMed.
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis [published correction in: Am Fam Physician. 1996;54(2):468]. Am Fam Physician. 1996;53(7):2317-2324. Article Summary on PubMed.
Hemler DE, Ward WK, Karstetter KW, Bryant PM. Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 1991;72(5):336–337. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Daniel Farwell, PT, DPT, a board-certified sports clinical specialist.Authored by Andrea Avruskin, PT. Reviewed by the MoveForwardPT.com editorial board.
Provided by the