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Pes anserine bursitis: Incidence in symptomatic knees and clinical presentation

Article  in  Skeletal Radiology · August 2005

DOI: 10.1007/s00256-005-0918-7 · Source: PubMed

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10.1007/s00256-005-0918-7

Skeletal Radiology
Journal of the International Skeletal Society A Journal of Radiology, Pathology and Orthopedics
© ISS 2005
10.1007/s00256-005-0918-7

Scientific Article

Pes anserine bursitis: incidence in symptomatic

knees and clinical presentation
W. J. Rennie1 and A. Saifuddin1, 2

(1) The Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore,
Middlesex , HA6 4LP, UK
(2) Institute of Orthopaedics and Musculoskeletal Sciences, University College London, UK

A. Saifuddin
Email: asaifuddin@aol.com
Phone: +44-20-89095443
Fax: +44-20-89095281

Received: 26 October 2004 Revised: 14 December 2004 Accepted: 3 March 2005 Published online:
7 June 2005

Abstract
Objective To determine the prevalence and associated clinical symptoms of pes anserine bursitis in
symptomatic adult knees.
Materials and methods A retrospective review was performed of the reports of 509 knee MRI studies
obtained from July 1998 to June 2004 on 488 patients presenting to an orthopaedic clinic with knee
pain suspected to be due to internal derangement. The MRI studies and case histories of all patients
reported to have pes anserine bursitis were reviewed. The management of these patients was also
noted.
Results and conclusions The prevalence of pes anserine bursitis as detected on MRI is 2.5%. The
commonest clinical presentation was pain along the medial joint line mimicking a medial meniscal
tear. We suggest that an accurate diagnosis of pes anserine bursitis on MRI will help prevent
unnecessary arthroscopy and possibly initiate early treatment of the condition. Axial imaging is
important in these cases to differentiate the bursa from other medial fluid collections.

Keywords Knee - MRI - Pes anserinus bursitis

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Introduction
Inflammation of the conjoined insertion of the sartorius, gracilis and semitendinosus muscles along
the proximal medial aspect of the tibia is recognized as pes anserine bursitis and was first described
almost 70 years ago [1]. These muscles are primarily flexors of the knee and have a secondary
internal rotational influence on the tibia, protecting the knee against rotatory as well as valgus stress
[2]. Cases of chronic bursitis have been reported in patients with underlying degenerative joint disease
or rheumatoid arthritis [3, 4, 5, 6, 7]. Acute pes anserine bursitis is a cause of medial knee pain that
can be differentiated from other causes with MRI and this thus obviates unnecessary arthroscopy [7,
8].

Fluid-filled anserine bursae have been reported with a prevalence of 5% in asymptomatic knees [9].
However, the prevalence of pes anserine bursitis on MRI in symptomatic knees has not been
investigated. The purpose of this study was to determine the prevalence of pes anserine bursitis in a
symptomatic adult population and its commonest associated clinical symptoms.

Materials and methods

A retrospective review of MRI examinations of the knee performed at a tertiary orthopaedic centre
from July 1998 to June 2004 was performed. A review of all cases reported by a single consultant
musculoskeletal radiologist was undertaken and all cases reported with pes anserine bursitis were
identified. The case histories and MRI studies of the patients were reviewed to determine the
symptoms they presented with and the clinical signs of these patients. Five hundred and nine MRI
studies were identified in 488 patients, 277 male and 211 female. All patients presented to the knee
clinic with knee pain and/or swelling and a clinical diagnosis of suspected internal derangement. All
MRI studies were obtained using a 1.0-T unit (Polaris; Marconi/Philips, Cleveland, OH, USA) with a
dedicated quadrature knee coil. The examinations consisted of T1-weighted spin echo (repetition
time, TR/echo time, TE, 631 ms/16 ms) and T2*-weighted gradient echo (TR/TE/flip angle,
776 ms/17 ms/30°) sagittal oblique sequences (parallel to the lateral femoral condyle) and T2-
weighted fat-suppressed fast spin echo (TR/TE, 4,291 ms/108 ms) coronal images. The examinations
were supplemented in some patients by dual echo T2-weighted fat-suppressed fast spin echo (TR/TE,
4,291 ms/12,108 ms) sequences in the axial plane. The field of view was 18 cm, the slice thickness
was 4 mm and the interslice gap was 0.5 mm. The number of acquisitions was either 1 or 2. The
imaging matrix used was 256×224. All MRI studies for which a pes anserine bursa had been reported
were re-evaluated by two observers who reached a consensus for the location of the identified bursa.
At image review, the diagnostic criteria used for a pes anserine bursa were as follows: fluid signal
intensity inferior to the joint line along the medial aspect of the tibia, superficial to the tibial collateral
ligament and related to the semitendinosus tendon (Figs. 1, 2). Also, no communication with other
bursae or the knee joint should be identified. A careful review of available axial images was also

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undertaken, which in some cases resulted in pes anserine bursae being re-classified as medially
directed popliteal cysts.

Fig. 1A, B Pes anserinus bursa. A T1-neighted spin echo medial para-sagittal image of the knee in a 51-year-
old female runner with symptoms of medial knee pain, suspicious of a meniscal tear. An oval intermediate
signal intensity lesion related to the semitendinosus tendon (arrow) is demonstrated; semimembranosus
tendon (double arrows). B T2*-weighted gradient echo medial para-sagittal image shows the lesion to be
uniformly hyperintense, consistent with its fluid nature. Semitendinosus tendon (single arrow),
semimembranosus tendon (double arrows)

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Fig. 2A,B Pes anserinus bursa. A T2*-weighted gradient echo medial para-sagittal image of the knee in a 30-
year-old female patient with medial joint pain shows a lobulated hyperintense lesion related to the distal aspect
of the pes anserinus. B Coronal fat-suppressed T2-weighted fast spin echo image shows the lesion adjacent to
the medial tibial metaphysis at the site of insertion of the pes anserinus. Note previous anterior cruciate
ligament reconstruction and medial compartment osteoarthritis

Results
Twenty-four patients (age range 30–50 years and mean age 35 years; 12 males and 12 females) were
reported to have fluid in the pes anserine bursa from the imaging reports. Three knees were
reclassified on the basis of axial imaging as medially directed popliteal cysts (Fig. 3), seven as
semimembranosus bursae and one as a parameniscal cyst. The prevalence of pes anserine bursitis in
our study was therefore 2.5% (13 knees). Review of the case notes indicated that the commonest
symptom the patients presented with was pain on the medial or posteromedial side of the knee on
running or ascending/descending stairs. The commonest suspected clinical diagnosis was a medial
meniscal tear. One patient presented unusually with lateral symptoms suspicious of an iliotibial band
syndrome. Five patients were successfully managed with physiotherapy. Three patients are awaiting
arthroscopy, one for an associated meniscal tear, one for a patellar graft inspection and the other for

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loose bodies. One patient is awaiting an examination under anaesthesia. Four patients were lost to
follow-up.

Fig. 3A,B Medially directed popliteal cyst initially diagnosed as a pes anserinus bursa. A T2*-weighted
gradient echo medial para-sagittal image of the knee in a 61-year-old female patient with symptoms of medial
joint pain and instability shows a lobulated hyperintense lesion related to the posterior aspect of the
semitendinosus tendon (arrow). B Axial fat-suppressed proton-density-weighted image shows this to represent
a small medially directed popliteal cyst extending between the tendon of the medial head of the gastrocnemius
(arrowhead) and the semimembranosus tendon (double arrows), and extending posterior to the
semitendinosus tendon (single arrow)

Discussion
The conjoined tendons of the sartorius, gracilis and semitendinosus muscles form a structure
reminiscent of a goose s webbed foot and are named by anatomists from the Latin pes for foot and
anserinus for goose. Pes anserine bursitis is believed to result from overuse friction to the bursa due to

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excessive valgus or rotatory stresses to the knee or by direct contusion [8]. Patients with pes anserine
bursitis may present with classic symptoms of tenderness and swelling along the proximal medial
tibia or may complain of vague medial knee pain, which may mimic medial meniscal or tibial
collateral ligament injury [9]. Exacerbation of symptoms may occur on ascending or descending
stairs. The distinction between pes anserine bursitis and tenosynovitis of the pes anserinus tendon is
clinically difficult and not truly significant because the treatment is the same for both conditions.
Bursitis occurs more frequently and responds more quickly to treatment than tenosynovitis. Pes
anserinus syndrome (tendonitis and bursitis) is frequently found in long-distance runners [10].
Although the common symptoms the patients presented with were proximal tibial swelling and pain
along the medial joint line, most of our patients presented with either posteromedial joint pain or
medial joint line pain, raising a suspicion of a medial meniscal tear, with none presenting with
proximal tibial swelling.

The prevalence of fluid in the pes anserine bursa in asymptomatic knees has been previously reported
as 5%, thus leading the authors to suggest that fluid in the pes anserine bursa does not imply bursitis
[11]. Our study assessed the prevalence in symptomatic knees only and we emphasize that our
diagnosis of bursitis was based on the clinical presentation and the lack of any other significant
findings on MRI. We assumed that the patient s symptoms were related to the bursa. None of our
patients had active treatment related to the bursa, such as steroid injection or surgical debridement,
and we cannot therefore be absolutely sure that the medial joint pain was due to the presence of a pes
anserine bursitis.

The differential diagnosis on imaging includes atypical medial meniscal cysts, juxtarticular bone
cysts, semimembranosus bursitis and tibial collateral ligament bursitis [12, 13, 14]. The importance of
axial imaging in accurately differentiating semimembranosus bursae and Baker s cysts was apparent
in our study from the reclassification of ten knees on review of the axial images. Axial images provide
far greater clarity regarding the anatomy of the various tendons in the posteromedial corner of the
knee, including the tendons of the medial head of the gastrocnemius and semimembranosus tendons.
A small extension of cyst fluid between these two tendons clarifies a diagnosis of popliteal cyst, as
opposed to any other posteromedial periarticular cyst. The findings of this study, based on the cases in
which axial images were performed, support the use of axial T2-weighted images for clarifying the
site of occurrence of posteromedial periarticular cysts.

Physiotherapy is the mainstay in the treatment of pes anserinus syndrome and consists of ice initially
followed by heat, anti-inflammatory drugs, restricted activity and later by muscle-conditioning
exercises. Steroid injections and ultrasound have also been reported as useful in alleviating
inflammation [3, 5, 8]. As the treatment regime is primarily non-invasive, an accurate diagnosis of pes
anserine bursitis on MRI may help prevent unnecessary arthroscopy and possibly initiate early
treatment of the condition.

In summary, pes anserine bursitis has prevalence on MRI in symptomatic adults of 2.5% and
commonly presents with medial or posteromedial joint pain, mimicking medial meniscal tears. Axial
imaging is useful in differentiating the anserine bursa from other posteromedial fluid collections.

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Recognition of fluid in the pes anserine bursa correlated with clinical symptoms allows the radiologist
to suggest the diagnosis and avoid unnecessary arthroscopy for the patient.

References

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2. Miller RH III. Knee injuries. In: Canale ST, ed. Campbell s operative orthopaedics. St Louis: Mosby; 1998:
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4. Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197–199.

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12. Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J
Bone Joint Surg 1990; 72A:286–290.

13. Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa.
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14. Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344–346.

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