Pes anserine bursitis is a painful knee condition that occurs most commonly in young people involved in sports (such as running or swimming the breaststroke), middle-aged women who are obese, and people aged 50-80 who have osteoarthritis of the knee. Up to 75% of people who suffer 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. Sometimes, however, no direct cause can be identified. A physical therapist treats pes anserine bursitis to reduce pain, swelling, stiffness, and any associated weakness in the knee or lower extremity.
What is Pes Anserine Bursitis?
The pes anserine bursa is a small, fluid-filled sac located 2–3 inches below the inner side of the knee. It lies beneath 3 tendons of the hamstring muscle, and it prevents the tendons from rubbing on the shinbone of the lower leg. Bursitis means the bursa has become irritated and inflamed, and this condition is usually painful. Certain positions, motions, or disease processes can cause constant friction or stress on the bursa, leading to the development of bursitis.
Pes anserine bursitis can be caused by:
- Repetitive activities
- Incorrect sports training techniques, such as a lack of stretching, sudden increases in run distances, or too much uphill running
- Osteoarthritis of the knee
- Incorrect positioning of the knee (an "angling out" of the lower leg)
- Turning the leg sharply with the foot planted on the ground
- Injury, such as a direct hit to the leg
- Tight hamstring 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 inner, lower side of the knee, 2–3 inches below the knee joint
- Pain when touching the inner, lower side of the knee
- Swelling on the inner, lower side of the knee
- Pain when bending or straightening the knee
- Pain or difficulty walking, sitting down, rising from a chair, or climbing stairs
How Is It Diagnosed?
If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will also ask 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 will gently press on the inner side of your knee to see if it is painful to the touch, and may use additional tests to determine if other parts of your knee are injured. Your therapist will also observe how you are walking.
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. Stress fractures of the shinbone may show similar symptoms.
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 you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but results can be achieved in 6 to 8 weeks or less when a proper stretching and strengthening program is implemented.
During the first 24 to 48 hours following your diagnosis, your physical 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 to20 minutes every 2 hours.
- Consult with a physician for further services, such as medication or diagnostic tests.
Reduce Pain and Swelling
Your physical therapist may use different types of treatments and technologies to control and reduce your pain and swelling, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and hands-on therapy, such as massage.
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 therapist performs for you to gently move your leg and knee joint, and then progress to active exercises and stretches that you do yourself.
Pes anserine bursitis is often related to tight hamstring muscles. Your physical therapist will determine if your hamstring muscles or any other leg muscles are tight, and teach you how to stretch them.
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 strength and agility. These may include using cuff weights, stretch bands, weight-lifting equipment, and cardio-exercise equipment, such as treadmills or stationary bicycles.
Regaining your sense of balance is important after an injury. Your physical therapist will 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 you to a normal lifestyle, and reach your goals faster than you are likely to do on your own.
Return to Activities
Your physical therapist will discuss your goals with you and set up a treatment program to help you meet them. Your treatment program will help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.
If Surgery Is Necessary
Surgery is extremely rare in the case of pes anserine bursitis. If surgery is needed, you will follow a recovery program over several weeks guided by your physical therapist. Your therapist will help you minimize pain, regain motion and strength, and return to normal activities in the 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 future injury. These may include strength and flexibility exercises for the legs, knees, and core muscles.
To help prevent a recurrence of the 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 hamstrings and quadriceps muscles to maintain good physical conditioning, even in a sport's off-season.
- 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.
Real Life Experiences
Martha is a 40-year-old, obese woman whose goal is to lose 100 pounds with diet and exercise. She has joined a gym, and she has recently decided to try the latest craze—a zumba class. Martha enjoyed the first week of classes, but after the fourth class, noticed a sharp pain on 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. Martha didn’t want to quit her new exercise routine or zumba class, so she contacted her physical therapist right away.
Martha was able to see him that day. He performed special tests on the tendons and muscles around the knee, and found that Martha’s hamstring muscles were extremely tight and her quadriceps muscles were weak. Martha’s knee was tender to the touch, and mildly swollen 2–3 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, and he diagnosed pes anserine bursitis. 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. 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 her quadriceps muscle strength. He helped her use equipment in the clinic to gently move, stretch, and strengthen her knee and leg.
Martha received physical therapy treatments for 3 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, she was able to finish the full class. Martha has continued to do the stretches and exercises she learned in physical therapy, and she now is 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 therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists that 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 their 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.
Helfenstein M Jr, Kuromoto J. Anserine syndrome [article in English and Portuguese]. Rev Bras Reumatol. 2010;50(3):313–327. Free Article.
Handy JR. Anserine bursitis: a brief review. South Med J. 1997;90(4):376–377. 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.
Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging. 2012;22(1):27-30. Free Article.
Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis [erratum in Am Fam Physician. 1996;54(2):468]. Am Fam Physician. 1996;53(7):2317-2324. 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.
Authored by Andrea Avruskin, PT. Reviewed by the MoveForwardPT.com editorial board.