Everything You Need to Know About Pes Anserine Tendinitis

Knee pain is common in runners. However, if your pain is inside your knee, you might have pes anserine bursitis or lower hamstring tendonitis. What does pes anserine tendinitis mean, and how do you manage it?

What is pes anserine bursitis? 

Pes Anserine means ‘goose’s foot. It is where the three tendons on the inside of your knee attach to the lower leg. These three tendon attachment looks like a ‘goose’s foot. These three tendons are the sartorius, gracilis, and semitendinosus. Bursitis is just another term for paratendonitis. Therefore, we should treat this condition as tendon swelling or pes anserine tendinitis.

How does lower pes anserinus tendinitis present?  

Generally, pes anserine pain is usually felt at the inside bottom part of the knee, just below the inside (medial) part of the joint. Sometimes, the pain moves up toward the lower hamstring muscles. Usually, pain warms up with activity but is often worse after training. Occasionally, people report localised swelling at the inside of the knee.

When assessing your knee, it is essential to rule out other causes of pain inside your knee. Additional causes of knee pain on the inside include stress fracture, torn meniscus, patellofemoral arthritis, fat pad impingement, and pain referred from the hip or spine. Remember, not all pain inside your knee is pes bursitis.

Sometimes, pain can be due to another tendon inside your knee called the semimembranosus tendon.

Often, we suggest investigations to confirm changes in pes anserine tendinitis and exclude other causes. Generally, MRI is the investigation we choose to sort out a reason.

Pes anserine tendinitis vs. medial meniscal tear

Both conditions cause pain on the inside of the knee. However, in general, there are significant differences between these two conditions. Firstly, pes bursitis usually occurs gradually due to overload, whereas a medial meniscal tear can happen after a twisting injury. Secondly, the pain of pes bursitis is generally lower inside the knee compared to a medial meniscal tear, where the pain is higher at the medial joint line. Sometimes, a meniscal tear causes swelling, locking, or giving way. Generally, most experienced doctors can tell the difference between these two conditions.

Pes anserine bursitis causes

A repetitive overload of the tendons usually causes this condition. This overload leads to swelling and pain. Often, patients report a change in the usual intensity or frequency of running or sport. Sometimes, a fall onto the inside of the knee causes swelling and pain in the pes bursa.

How to fix lower hamstring tendonitis 

Generally, physiotherapy is the mainstay of treatment for pes anserine tendinitis. Typically, exercise therapy will consist of flexibility, strength, and balance. Stretches to increase flexibility include hamstring, hip, and thigh exercises. Strengthening often focuses on the knee and hip. Balance exercises on a wobbleboard or uneven surfaces may help. Finally, correcting lifting and squatting patterns is also essential.

Activity modification is also an essential component of improving symptoms. For example, as symptoms improve, you can gradually resume more running or team sports exercises.

Finally, anti-inflammatory treatments such as ibuprofen and ice can settle the inflammation.

Is a Pes Anserine bursitis injection helpful? 

Yes, an injection is helpful if you have tried simple treatments without effect.

A cortisone injection will improve pain and allow you to push on with treatment and your sport.

An ultrasound-guided pes bursal injection should be considered for the following patients: 

• Pain not improving with physiotherapy or rehab exercises

• Severe night pain 

• Pain with low-load activities such as walking or stairclimbing 

• Pain preventing you from training for an upcoming marathon or running event 

The key with an injeciton is to place the cortisone deep into the pes bursal tendons between the tendons and the tibia bone. Injection should be done with ultrasound guidance to improve accuracy and reduce side effects.

After a cortisone injection for pes bursitis, you should rest from activity for about a week. You can restart rehab exercises after a week and run after approximately ten days. 

Further details on the pros and cons of cortisone injections can be found in this recent blog.

How long does pes anserine bursitis take to heal? 

Generally, like most tendon problems, pes bursitis can be slow and take up to 3-6 months to completely recover. However, in some cases, early recovery of fewer than six weeks is possible.

Hamstring tendonitis after TKR

Lower hamstring tendonitis is seen after a total knee replacement (TKR). Generally, it is difficult to know whether pain after a TKR is due to a problem with the implant or another issue, such as infection or tendon swelling. Therefore, we suggest you see your surgeon before considering a tendon cause of pain after a TKR.

Other commonly asked questions on pes bursitis:

Can I run with pes anserine bursitis? 

Yes. But it would be best if you undertook rehab exercises simultaneously. 

Will a kneecap brace help pes anserine tendinitis? 

Overall, we suggest that you try a kneecap brace for this condition. We think a brace provides support to the kneecap, which can improve pain from pes bursitis.

Is swimming good for pes anserine tendinitis? 

Any aerobic activity that improves the conditioning of the pelvis and lower limb muscles will help pes anserine tendinitis. However, we suggest you avoid breaststroke as this stroke puts more load on the pes bursal tendons.

What about PRP injections for pes bursitis? 

PRP or platelet-rich plasma is standard for joints and tendons. We spin blood from your arm to separate the cells from the plasma. Then, we split the plasma and injected it into the target under ultrasound. Although there is no evidence for use in pes anserine bursitis, we would consider using PRP in cases that fail other treatments, including a cortisone injection.

Final word from Sportdoctorlondon about pes anserine bursitis

Pes anserine bursitis causes pain on the inside of your knee. It is essential to rule out other causes, such as a meniscal tear or a stress fracture. You should always start with simple treatments followed by an ultrasound-guided cortisone injection if there is no improvement. If you’re thinking about an injection, you should always do your homework first. We suggest you find a doctor who is experienced in ultrasound and injections.

Other related knee conditions:

• patellar tendinopathy
• meniscal tears
• best treatment for knee arthritis 
• Baker’s cyst
• How long does it take for a cortisone shot to work: FAQs