What is Pes Anserine Bursitis
Pes Anserinus is the anatomical term used to describe the common insertion point of a group of thigh muscles (sartorius, gracilis, semtendinosis) on the anterior-medial aspect of the knee. With excess stress or overuse one or more of these muscles can become strained or overloaded, which will cause the muscle(s) to pull on their insertion point at the anterior-medial knee, or to compress a small bursa located underneath the tendon where it inserts onto the knee. Either of these situations will cause pain on the front/inside aspect of the knee.
Signs and Symptoms of Pes Anserine Bursitis
- Gradual onset of pain at, or just below the anterior-medial aspect of the knee
- Pain will often be aggravated by climbing up stairs
- Stiffness or tightness may be present in the groin, thigh, or hamstrings
- Tenderness and/or swelling just below the medial knee
- When the bursa is involved night pain may occur
- In the early stages pain symptoms usually improve with warm-up or exercise
- In later stages pain may worsen and be present during activity
What Causes Pes Anserine Bursitis?
Pes Anserine Bursitis is an example of a repetitive strain injury. Unlike a traumatic injury which is caused abruptly following a trauma or accident, repetitive strain injuries (referred to as a RSI for short) are associated with very small amounts of tissue stress and damage that accumulates slowly over time.
Here’s how this works….
As the muscles are stressed and over-used it can lead to small scale damage. This damage is referred to as ‘micro-trauma. Although only small this damage still needs to be repaired. The body does this by forming new tissue in and around the injured tissue, in this case, in and around the pes anserinus muscles or tendons. This new tissue, often referred to as scar tissue or soft tissue adhesions, is very sticky and acts to ‘glue’ the damaged tissues back together. For an analogy, think of a big rubber band with a pin prick in it. This little pin-prick does not affect the rubber band much, but we still want to repair it so we put a little dab of glue over the area.
If the overload at the iliotibial band continues (this is almost always associated with problems at the hip or foot, which will be discussed below) there will be ongoing micro-trauma and subsequent repair of this micro-trauma. Overtime, this scar tissue will build up and will start to interfere with the normal strength and flexibility of the muscles. Going back to our analogy, think of this as more and more pin pricks in that rubber band, followed by a big build up of glue around the area. This will in turn make the rubber band tighter and less elastic. In the case of the pes anserinus group (sartorius, gracilis, semtendinosis). This increased tension and tightness will cause the muscle to pull on their insertion point at the anterior-medial knee, or to compress a small bursa located underneath the tendon where it inserts onto the knee.
Why the hip and foot are important with Pes Anserine Bursitis
It is important to realize that virtually every RSI involving the knee – including pes anserinus problems – is related to a problem at the hip, pelvis, and/or foot. If these key joints are not working properly it will create excessive stress and overload at the knee. This will often be seen as a misalignment of the knee during activities such as walking, running, climbing stairs, or with exercises at the gym. (“Do you want to know if you knee pain is linked to a problem at your hip or foot – try a squat test, 1 leg squat test, or lunge test… click each test to find out more). This altered alignment will increase the demand on the muscles of the leg as they must work harder to move and protect the knee, and try to pull the knee back into the proper alignment. Based on our experience in treating knee pain, hip and/or foot problems actually occur in most non-traumatic knee problems. If these issues are not addressed the knee pain will not fully resolve, and will likely come back in the future.
Treatment – Resolving Pes Anserine Bursitis?
The proper treatment of pes anserinus problems must not only address pain and tissue damage at the sartorius, gracilis, semitendinosis, or pes anserine bursa, but MUST correct any biomechanical problems at the foot and/or hip and pelvis.
For treatment to be effective we have found that there are certain steps that must be followed, and these steps must be performed in the right order if we are to expect the right results. Here is our approach when pes anserine bursitis problems in our clinic….
Step 1 – Resolve scar tissue adhesions and facilitate healing
Perhaps the most critical most critical step is to treat the scar tissue adhesions. These adhesions are a sign that the muscles are not healthy, and unhealthy tissue will not respond well to traditional stretches and exercises – think of trying to stretch out that rubber band caked with glue. Resolving scar tissue adhesions is a critical step in resolving knee pain, including pes anserinus problems, but it is often a missed or underappreciated step as many practitioners do not have the clinical skills to address this problem.
Scar tissue adhesions do not resolve with stretching or traditional massage or soft tissue methods, but instead must be treated with advanced soft tissue techniques. One of the most effective methods is to use a technique known as Active Release Techniques (ART). For those who are unfamiliar with this treatment method, ART is a new and highly successful hands-on treatment method that was specifically designed to identify and address scar tissue adhesions that are interfering with the normal movement of the body.
During an ART treatment the practitioner will first shorten the muscle, tendon, ligament, or joint capsule and then apply a very specific tension with their hands as they stretch and lengthen the tissues. As the tissue lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment. When scar tissue adhesions are felt the amount and direction of tension can be modified to treat the problematic area (click here for more information on ART treatment).
In addition to ART treatment, we have found the use of Laser Therapy is an effective way to speed up the healing and regeneration of damaged tissue and inflamed bursa around the knee.
Step 2 – Correct strength and flexibility
Simply treating the scar tissue adhesions will make the damaged tissue healthier, and will often result in a significant reduction in pain. In fact, it is not uncommon to see a significant improvement in just a few visits. However, although addressing the scar tissue makes the muscles healthier, they may still be somewhat tight or weak. When this is the case specific stretches or exercises can be incorporated into a home exercise/rehabilitation routine to help support in office care. Initially the focus is on correcting local muscle deficiencies (i.e., at the knee, hip, or foot).
Step 3 – Re-Train Functional Movement Patterns
The final stage with treatment is to ensure proper alignment and movement coordination of the foot, knee, hip, and trunk with functional movement patterns. This ensures movement of the hip, knee, and foot are coordinated and working together as a unit. This is what is required during real life activities such as running, walking, cycling, and climbing stairs (the key functional movement patterns with respect to knee problems include the squat, 1 leg squat, and lunge).
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“My first meeting with Dr. Nick helped to put the pain in context. Finally, an explanation and some real answers.”
– Jeff Smith, Sackville, NS