Pes Anserine Tendino-Bursitis Injections Figures
While the pes anserine bursa has been shown to occupy the bulk of the proximal medial tibia, the area of maximal tenderness is palpable with the tip of the index finger in the same specific location − slightly posterior to the middle of a line drawn between the apex of the knee flexion crease and the tibial tubercle (Figure 1). This site appears to correspond to where the gracilis and sartorius tendons converge as they begin their attachment to the tibia, as seen in the anatomical study by Lee et al. In terms of the injection technique, the goal is to inject the bony periosteum in the area of maximal tenderness, which is consistently found in the same location, as described above. The injection is done using a 1 1/2-inch-long 22-gauge needle with an entry angle of approximately 45 degrees to the coronal plane of the tibia angling from anteromedial to posterolateral (Figure 2). Lidocaine (5cc of 1% lidocaine) in one syringe is injected into the subcutaneous and deeper layers all the way to bone (Figure 2). Then, without removing the needle, steroid (80 mg Kenalog) from a second syringe is injected around the bone (Figure 3). It should be noted that in cases in which the patient is morbidly obese, “puckering” of the tissues may be required to reach the bone (Figure 4). Reprinted with permission from Pompan D. Pes Anserine Tendino-Bursitis: An Underdiagnosed Cause of Knee Pain in Middle-Aged and Older Patients. Lower Extremity Review. 2018;10(9);31-14.
It was with great interest that I reviewed the article, “Pes Anserine Tendino-Bursitis: An Underdiagnosed Cause of Knee Pain in Middle-Aged and Older Patients,” by Dr. Donald Pompan in the September issue of Lower Extremity Review. Dr. Pompan makes several valid points regarding this often-missed area of knee pain in this population. He nicely points out the concerns for a diagnosis whose basis relies on imaging studies rather than upon the history and physical examination. He also nicely describes the issues regarding treating patients with knee pain based upon imaging studies and the now numerous studies pointing out the lack of efficacy and potential for progression of arthritis with arthroscopic meniscal debridement surgeries.
In my experience, insertional tendinopathy of the pes tendons is quite common and often seen in patients suffering from medial knee joint osteoarthritis. This is likely due to mechanical overload of these tendons on the medial side of the knee joint where there is loss of joint space. Unfortunately, Dr. Pompan perpetuates the myth that tenderness over this area is consistent with a “bursitis” similar to the ongoing inaccurate diagnosis of “greater trochanteric bursitis”, in patients suffering from lateral hip pain. In fact, in Dr. Pompan’s article he nicely points out the lack of objective findings of a bursitis noted in most patients with tenderness over the medial tibial flare in prior MRI and ultrasound studies.
Much like the treatment for the inaccurate diagnosis of “greater trochanteric bursitis”, Dr. Pompan recommends a palpation-guided injection with corticosteroid. Prior research has demonstrated that a palpation-guided injection of the “pes bursa” is highly inaccurate when compared to ultrasound-guided injection.1 Furthermore, given that a more accurate description of this painful condition is a tendinopathy, a corticosteroid injection would not be recommended nor indicated according to the recent literature where this treatment has been found to be harmful.2-4
I would highly agree with a comprehensive rehabilitation approach for the patient with medial knee pain and findings of pes insertional tendinopathy. That approach would start with an assessment of the entire kinetic chain to address increased pronation and hip girdle muscular weaknesses, which can also result in increased forces along the medial joint. In addition, if there is significant loss of medial joint space, an unloader brace can be quite helpful in a comprehensive nonoperative treatment approach. In refractory cases, consideration can be made for the use of a platelet-rich plasma (PRP) injection under ultrasound guidance to facilitate reduction in pain/inflammation and facilitation of the tendon. Further studies regarding this approach are certainly necessary although the research on PRP for tendinopathy in general is quite positive. 5-7
In conclusion, I would like to thank Dr. Pompan for raising an awareness of this often-missed diagnosis. Appropriate diagnosis can avoid unnecessary medical and surgical interventions.
Gerard A. Malanga, MD
Gerard Malanga, MD, is founder and partner of New Jersey Sports Medicine, LLC, and New Jersey Regenerative Institute in Cedar Knolls, NJ. He is board certified in Physical Medicine and Rehabilitation, Sports Medicine, and Pain Medicine. He is Professor of Physical Medicine and Rehabilitation at Rutgers University-New Jersey Medical School in Newark.
- Finoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accuracy of ultrasound-guided versus unguided pes anserinus bursa injections. PM&R .2010;2(8):732-739.
- Hart L. Corticosteriod and other injections in the management of tendiopathies: a review. Clin J Sport Med. 2011;21(6):540-541.
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-177.
- Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15(5):370-375.
- Malanga GA, Goldin M. PRP: review of the current evidence for musculoskeletal conditions. Curr Phys Med Rehabil Rep. 2014;2(1):1-15.
- Goldin M, Malanga GA .Tendinopathy: A Review of the pathophysiology and evidence for treatment. Phys Sportsmed. 2013;41(3):36-49.
- Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM&R. 2013;5(3):169-175.