CASE REPORT
Knee Pain: Osteoarthritis or Anserine
Bursitis?
Nallini Gnanadesigan, MD, MPH, and Rick L. Smith, MD
Knee pain is a very common ailment in the elderly and
is often attributed to osteoarthritis (OA) of the knee. OA
of the knee and anserine bursitis can coexist, and in such
situations, anserine bursitis may be the cause of knee pain.
Attributing the pain to OA can lead to invasive interven-
tions such as intraarticular injections or joint replacement,
without pain relief. Treating the anserine bursitis with
ultrasound or local corticosteroid injection is reported to
often result in dramatic pain relief.1 As such, management
of knee pain requires that physicians be able to recognize
the cause of the knee pain and use the appropriate treat-
ment modalities for relief of pain and restoration of
function.
CLINICAL PROBLEM
The anserine bursa is located at the upper medial aspect of
the tibia, at the insertion of the conjoined tendon (pes anse-
rinus) of the sartorius, gracilis, and semitendinous muscles
(Figure 1).1 When inflamed, it causes knee pain, especially
when climbing stairs, difficulty getting out of chairs, difficulty
bending the knee and “giving way of the legs.” Marked ten-
derness over the pes anserinus, located approximately 2 inches
below the medial joint margin, is a consistent finding.2 It was
first described in 1937 by Moschovitz.3 He found it to be
present almost exclusively in women.3 Because of the broad
pelvic area in women, with resultant angulation at the knee
joint, putting more pressure at the pes anserinus attachment,
women seem predisposed to anserine bursitis. Larsson and
Baum found anserine bursitis to be a common disease, partic-
ularly in obese middle aged or elderly females with refractory
knee pain and diagnoses of degenerative joint disease (DJD).1
Kang and Han reported 29 of 62 patients with DJD to have
anserine bursitis.4
DIFFERENTIAL DIAGNOSIS
Other conditions causing medial knee pain include medial
meniscus injury, L3–L4 radiculopathy, fibromyalgia, and de-
Jewish Home for the Aging (N.G.), and Medical Director, Grancell Village
(R.L.S.), Jewish Home for the Aging, Reseda, CA 91335.
Address correspondence to Nallini Gnanadesigan, MD, Jewish Home for the
Aging, 7150 Tampa Avenue, Reseda, CA 91335. nallini@pacbell.net.
Copyright ©2003 American Medical Directors Association
DOI: 10.1097/01.JAM.0000064461.69195.58
164 Gnanadesigan and Smith
generative arthritis. Medial meniscus injury presents with
medial joint liner tenderness as does OA, whereas anserine
bursitis tenderness is inferomedial to the joint line. Medial
knee pain in L3–L4 radiculopathy is associated with low back
pain and local tenderness over the anserine bursa is absent.
Fibromyalgia has other characteristic tender areas and trigger
points, one of which may include the medial aspect of the
knee.
The diagnosis is usually made on clinical grounds. Ul-
trasound, computed tomography, and magnetic resonance
(MR) imaging are of limited value to diagnose the condi-
tion. Uson et al. did not find ultrasound evidence of ten-
dinitis or bursitis in patients diagnosed with pes anserine
tendino-bursitis.5 MR imaging can be useful in acute bur-
sitis with fluid accumulation6 and in the evaluation of
indeterminate soft tissue masses in the area.7 It is important
to recognize anserine bursitis causing knee pain, as it is
easily treated with local injection of lidocaine and steroid,
with prompt relief of symptoms.
TREATMENT
Ice applied over the bursa may control some of the pain and
swelling. Most elderly persons are intolerant of nonsteroidal
antiinflammatory drug (NSAID) therapy because of coexist-
ing illnesses such as hypertension, compromised renal func-
tion, congestive heart failure and increased risk of gastroin-
testinal bleeding.
In the study by Larsson and Baum, 76% of the patients with
anserine bursitis had symptoms for more than one year. They
noted immediate pain relief after injection and at follow up
(mean time 13 ⫾ 17.4 months). Approximately 70% of the
patients injected experienced significant pain relief. There
was no difference initially between use of lidocaine alone or
use of a mixture of lidocaine and long-acting steroids. One
month after the injection of steroids, there was significant
improvement. If the improvement was not long-lasting, in-
jections were repeated.2 Brookler and Mongan also reported
symptom relief with ultrasound therapy.1
We injected three elderly women (mean age, 88), two
with acute exacerbation of chronic knee pain and one with
an acute onset of knee pain. On clinical examination, all
three had marked tenderness over the anserine bursa and
no pain in the joint itself. After the injection, all three had
immediate pain relief. Two of them remained pain free 1
JAMDA – May/June 2003

Fig. 1. Pes anserine bursa.
and 5 months after the injection respectively. The third
one was injected less than a week before the writing of this
paper and no follow-up data was available.
INJECTION TECHNIQUE
The patient is kept in the supine position, with the leg
extended and externally rotated.8,9 The tibial tubercle, medial
knee joint line, and midline of the medial lower leg are
marked. The point of entry is at the point of maximal ten-
derness, usually directly across the tibial tubercle, approxi-
mately 11/2 inches below the medial joint line. After cleaning
the area with povidone iodine, ethyl chloride is sprayed on
the skin. A 22-gauge needle is inserted perpendicular to the
skin, up to the periosteum of the tibia and immediately
withdrawn 1/8 inch. Local anesthetic and steroid (a mixture
of 1 to 3 mL of 1% lidocaine without epinephrine and 20 to
40 mg of triamcinolone or methyl prednisolone) are injected,
after aspirating to verify that the needle is not in a vascular
space. Injection should be free-flowing, with little resistance.
The injection is repeated in 4 to 6 weeks if symptoms and
signs have not been reduced by half. Usually, the number of
injections should be limited to 3 in a 12-month period to
minimize the risk of complications, including subcutaneous
atrophy, skin depigmentation, and tendon rupture.9,10
SIDE EFFECTS
The usual precaution of asking about allergy to any drugs is
important. Intrabursal steroids can cause postinjection flare.
All patients must be warned about the 30% chance of sore-
ness or pain after the injection and 10% risk of steroid flare
reaction. These are treated with local ice application and
analgesics.8 If more than 20 mL of lidocaine is used, systemic
toxicity, affecting the heart and brain can occur.10 This dose
limit is for a healthy adult of medium build, and in the elderly,
a lower dose limit should be used.
CASE REPORT
Table 1. Case Details
Number surveyed 18
Mean age (yrs) 84
Male 5 (28%)
Female 13 (72%)
Presence of anserine tenderness 8 (44%)
Presence of knee pain 4 (22%)
Bilateral anserine tenderness 7 (39%)
SCREENING AND SURVEILLANCE
Larsson and Baum found that about 75% of the individ-
uals referred to a tertiary care rheumatology clinic with
degenerative joint disease and knee pain were diagnosed
with anserine bursitis syndrome when it was actively
looked for.2 We surveyed all the ambulatory residents of
one of the authors at a nursing facility (Table 1) Of the 17
residents surveyed, 5 were men (29%) and 12 (71%) were
women. Eight of the seventeen (47%) had significant an-
serine bursa tenderness, and all but one had tenderness on
both sides. All the eight with anserine tenderness were
women. Three of the eight with anserine tenderness had
knee pain, though two of them did not complain about it
until asked. Only one resident had knee pain without any
anserine bursa tenderness.
DISCUSSION
A review of the literature reveals a paucity of data on the
prevalence of this problem in the geriatric population. There are
no reported studies among residents in long-term care settings.
Chronic knee pain is a common symptom in these residents,
affecting their quality of life from pain and functional limitation.
Currently, it is not known what percentage of chronic knee pain
in elderly long-term care residents is attributable to anserine
bursitis, what the most appropriate treatment is, or what the
response to each treatment modality is. In our preliminary
survey, more than half of the residents with anserine bursa
tenderness did not complain of any knee pain. This may be
because they ambulated on level surfaces only. Whether they
will remain symptom-free is not known. More importantly, two
of the three with significant knee pain complained about it only
when asked. This may be because knee pain is attributed to
aging itself and ignored as an untreatable problem. Because
anserine bursitis is an easily treatable condition, it is important
for physicians to recognize it in the elderly and manage it
appropriately. Educating the elderly about anserine bursitis may
also improve early recognition of the problem. From our obser-
vation, anserine bursitis may be an unrecognized cause of knee
pain in long-term care residents. Timely diagnosis and optimal
management can make a significant impact in their quality of
life by reducing pain and improving function.
REFERENCES
1. Brookler MI, Mongan ES. Anserine bursitis. A treatable cause of knee
pain in patients with degenerative arthritis. Calif Med 1973;119:8 –10.
2. Larsson, L-G, Baum J. The syndrome of anserine bursitis: An overlooked
diagnosis. Arthritis Rheum 1985;28:1062–1065.
Gnanadesigan and Smith 165
3. Moschovitz E. Bursitis of sartorius bursa: An undescribed malady simu-
lating chronic arthritis. JAMA 1937;109:1362.
4. Kang J, Han SW. Anserine bursitis in patients with OA of the knee.
South Med J 2000;93:207–209.
5. Uson J. Pes anserine bursitis: What are we talking about? Scand
J Rheumtol 29:184 – 6.
6. Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR
imaging. Radiology 1995;194:525–527.
166 Gnanadesigan and Smith
7. Muchnick J, Sundaram M. Radiologic case study. Orthopedics 1997;20:
1092–94.
8. Bruce Carl Anderson. Office Orthopedics for Primary Care: Diagnosis and
Treatment, 2nd Ed. Philadelphia: W.B. Saunders, 1999, pp. 157–158.
9. Glencross PM, Little JP. Pes Anserine Bursitis. eMedicine Journal 2001;
2:1–18.
10. Saunders S, Cameron G. Injection Techniques in Orthopedic and Sports
Medicine. Philadelphia: W.B. Saunders, 1997, p. 8.
JAMDA – May/June 2003