INJECTION THERAPY FOR PES ANSERINE TENDINOPATHY

What is pes anserine tendinopathy?

 The combined insertion of the three hamstring tendons on the inside of the leg, immediately below the knee joint, is known as the pes anserinus. Any activity that involves bending the knee involves these tendons, which connect the muscles to the bone. Pes anserine tendinopathy is a type of overuse injury that is increased by activities like jogging, cycling, and squatting. If the pes anserine bursa is implicated as well as the tendon, the discomfort can be extremely severe. When you do anything active, the discomfort usually goes away, but it comes back stronger.
 
Ice, activity moderation, and physiotherapy are all used in the treatment. Specific exercises will be used in physiotherapy to repair the tendons and stimulate the healing process within the tendon. For more difficult, resistant patients, shockwave therapy or an ultrasound guided steroid injection are viable treatment options.
 

What are the symptoms of pes anserine tendinopathy?

  • Pain on the inside of the leg, directly beneath the knee joint, is the most common symptom.
  • Repetitive activities that bend the knee, such as running, cycling, and squatting, increase the pain.
  • Tenderness on the inside of the leg right below the knee joint when touched.
If this sounds like your issue, keep reading…
 

Other conditions that mimic pes anserine tendinopathy

  • Meniscal (cartilage) tear
  • Knee osteoarthritis 
  • Pain in the patellofemoral (knee cap) joint
  • Bursitis of the prepatella
  • Patella tendinopathy (jumper’s knee) is a condition that affects athletes.

pes anserine tendinopathy vs meniscal (cartilage) tear

Localized discomfort and soreness on the inside of the knee joint are symptoms of pes anserine tendinopathy. A cartilage (meniscal tear), particularly the medial meniscus, causes pain on the inside of the knee, but it is usually accompanied by swelling and limited movement. Cartilage tears cause ‘locking’ and ‘catching’ of the knee joint, but not in cases of pes anserine tendinopathy.
 

Anatomy of  pes anserine tendons and bursa

On the inside of the knee, there are three pes anserine tendons. A tendon is a connective tissue that connects a muscle to a bone. Three muscles from the inside of the thigh attach to a common insertion point on the inside of the tibia bone by the pes anserine tendons (just below the knee joint).
 
The anatomy is seen in the image below. Three major muscles in the upper thigh are the sartorius (A), gracilis (B), and semitendinosus (C). They are in charge of pulling your legs together and bending your knee (adduction). These three muscles join together to form a single tendon. The pes anserine tendon (Latin for “goose foot”) is a common tendon.
 
The bursa is a tiny sac that surrounds the tendons on the bone’s connection. At this attachment site, this bursa may also be involved in discomfort (more later).
 

How is pes anserine injured?

Overuse of the pes anserine tendon is prevalent. The continual transmission of compressive and tensile strain on the tendon during recurrent knee movement might lead to overuse. For example, whether walking, jogging, or riding for an extended period of time.
 
The body has a thin sac called the bursa to help reduce the risk of an overuse injury at this ‘anatomical hotspot.’ This bursa serves as a shock absorber, minimising friction and allowing for smooth movement between structures.
 
These structures can endure repetitive load if they are not overloaded, and the tendon and bursa will not become inflamed. If this is not the case, or if you increase your training too quickly, that is, if you do too much too soon, the tendons and bursa can become inflamed and cause pain.
 
A pes anserine tendonopathy occurs when the tendons become painful, whereas a pes anserine bursitis occurs when the bursa becomes irritated. They frequently (but not always) occur together, and determining whether your problem is a tendon or a bursa can affect your treatment options.
 

When compared to a bursa problem, the origin and symptoms of a tendon problem can vary. There is, however, a lot of overlap between the two. A diagnostic ultrasonography scan or an MRI is required to distinguish these diseases. In your initial appointment with Joint Injection, we always do a diagnostic ultrasound (at no additional fee).
Pes Anserine Bursitis
The bursa can become injured during the following activities:

  • Weightlifting (especially heavy squats), trekking, cycling, and running are all activities that require repetitive knee flexion (bending).
  • Squash, tennis, volleyball, and basketball are examples of sports that require a lot of lunging and jumping.
  • Crossing your legs or standing for an extended period of time are examples of sustained postures.
  • Long amounts of time spent resting directly on the knee – such as when kneeling, especially on hard, uneven ground.

Other underlying medical issues might cause the bursa to become inflamed and irritating, such as:

  • Rheumatoid arthritis is a type of arthritis that affects the joints.
  • Reactive arthritis 
  • Gout
  • Diabetes

There may be an underlying diagnosis if your physiotherapist is suspicious; they will be able to refer you to the relevant specialist.
Symptoms of Pes Anserine Bursitis

  • Sharp pain when bending and straightening your knee repeatedly, such as when jogging, cycling, or squatting.
  • Aching pain on the side of the knees, especially at night or when lying down
  • Pain with full knee flexion (bend) and straightening, as well as a stiffness sensation.
  • Direct pressure on the area causes pain and soreness.

Pes Anserine Tendinopathy (sometimes known as tendinitis)

The pes anserine tendon can become inflamed and uncomfortable if it is overused. Because tendon tissue has a minimal blood supply, it can take a long time to repair. They can take months to fully heal, just like most tendon problems.

Symptoms of Pes Anserine Bursitis Tendinopathy

  • Directly over the tendon, there is a strong discomfort.
  • After a time of rest, such as waking up first thing in the morning, pain with movement occurs.
  • Pain usually begins without warning and is accompanied by an increase in activity, such as running or jumping.
  • Pain while performing regular tasks such as climbing and descending stairs and walking.
  • Pain from hamstring workouts like gym hamstring curls, bridging exercises, and/or pulling your shoe off with the other foot.
  • A feeling of stiffness that is linked to an irritated tendon. This could limit the joint’s range of motion.

Because the pes anserine tendons and the bursa are located in the same anatomical area, the symptoms are often comparable.
How is Pes Anserine Bursitis / Tendinopathy Diagnosed?
A clinical examination can determine whether your pain is caused by the bursa or the tendon, but it can’t tell which one is causing it or whether both are. In some circumstances, determining which exact structure is implicated is critical so that we can choose the best intervention for you. 

During your first visit to Joint Injections, we will assess the sore area using a number of clinical tests in order to assist us develop a diagnosis. These exams include range of motion and strength tests for the knees, as well as more functional exercises like squatting and a running style evaluation (if you’re a runner!). We might also take a look at your footwear. Footwear is important in lower limb injuries and should be examined during the evaluation.

As previously stated, making an accurate diagnosis of pes anserine pathology simply only on clinical tests might be difficult. Diagnostic imaging is required to accurately evaluate the presence of a pes anserine pathology and determine whether there is a bursitis or a tendinopathy (or both) according to research (Rennie et al, 2004). A diagnostic ultrasound scan is performed on your initial appointment to offer this diagnostic clarity.

Pain on the inside of the knee, around the pes anserine tendon and bursa, can be caused by a variety of disorders. These are some of them:

  • meniscus in the middle (cartilage tear)
  • Knee osteoarthritis 
  • medial collateral ligament discomfort

During your initial evaluation, your physician will take these factors into account.

Ultrasound imaging for diagnostic purposes
The pes anserine tendon and bursa have been demonstrated to be ideal candidates for diagnostic ultrasonography imaging (Sarifakioglu et al,2016). It has been shown in studies to be as effective as MRI in detecting tendon pathology. Diagnostic ultrasound is also extremely sensitive and specific when it comes to determining the quantity of inflammation in your body. This can aid in determining how long your ailment will take to heal and whether an ultrasound-guided injection is necessary.
Joint Injections has a team of fully qualified physiotherapists and musculoskeletal sonographers who have a wealth of experience.

Treatment of Pes Anserine Bursitis
Physiotherapy works successfully for the majority of persons with pes anserine pain.
Modifying (reducing) your load/activity levels, i.e. those activities that aggravate your discomfort, is critical. This does not always imply you should cease all workouts; for example, if you are experiencing pain when running, we recommend that you reduce your running load and/or switch to a low-impact sport like cycling or swimming.

The goal of physiotherapy treatment is to:

  • Pain and inflammation reduction – this could include ice, medication, exercise, and/or injectable treatment.
  • Increasing the range of motion of the knee joint – if the joint is restricted in complete flexion or extension, this must be restored.
  • Stretch your hamstrings and adductors if you experience a restriction (a good start is to compare your muscle length to the other side)
  • Lower limb muscular strengthening – a fundamental component of most rehabilitation programmes, this might include the core, gluteal, quadriceps, hamstring, and calf muscles.
  • Increasing the balance and stability of the lower limbs
  • Squatting and lunging are examples of functional activities that require correct movement patterns.
  • Identifying and correcting faults in walking and running gait patterns

What to do if PT alone isn’t enough to relieve my pain?
If conservative management does not relieve your pain, there are still some effective therapy options accessible to you:

Extracorporeal shockwave therapy (ESWT) 
Shockwave therapy is an evidence-based treatment approach for tendon pathology, and there is growing evidence that it can help treat pes anserine tendinopathy (Khosrawi et al, 2017). Before choosing shockwave therapy, you should determine whether your discomfort is caused by a tendon or a bursa. Shockwave is more beneficial for tendon problems than for bursa problems. Prior to administering shockwave, we always perform a diagnostic ultrasound scan to confirm that it is the best treatment option for you.

Shockwave is a sequence of high-pressure waves that cause a tiny amount of controlled microtrauma in the tendon. These soundwaves promote tendon restoration and stimulate the healing process. Desensitization of local nerve fibres often results in an immediate reduction in pain for patients. It has demonstrated to be effective when used with shockwave and takes 3-5 therapy sessions.

Corticosteroid injection guided by ultrasound
If your discomfort persists despite physiotherapy, an ultrasound-guided steroid injection may be an effective therapeutic choice for you. A corticosteroid is a powerful anti-inflammatory injectable medicine that is used to treat chronic pain and inflammation. You will have a ‘window of opportunity’ to begin a complete rehabilitation programme with a physiotherapist after receiving an injection.
A diagnostic ultrasonography scan is utilised to deliver a tiny dose of corticosteroid medication and local anaesthesia to the pes anserine bursa and/or tendon directly. Joint Injection’s experts have a lot of expertise with ultrasound-guided injections for this problem.

Ultrasound-guided injections have been shown in clinical studies to be more accurate and successful in reducing pain and inflammation than landmark-guided injections, which do not use a needle. At Joint Injections, we think that these injections should be ‘directed’ to guarantee that only one injection is needed and that any negative effects to the surrounding tissues are minimised.

For the following patients, an ultrasound-guided injection should be considered:

1. Patients with a substantially inflamed pes anserine bursitis as seen by a diagnostic ultrasonography. If this is the case, an ultrasound-guided steroid injection combined with physiotherapy works wonders. If you haven’t improved after physiotherapy and are experiencing throbbing pain at night, you may have an inflamed bursa.
2. With full physiotherapy input and a reduction in training/exercise, pain does not improve or worsens.
3. Pain that keeps you up at night.
4. Severe discomfort when doing low-intensity exercises like walking (i.e. the pain is effecting simple everyday tasks.
5. Pain is keeping you from finishing a crucial race/competition, such as a marathon, and you don’t have time or the pain isn’t improving with physiotherapy

Only if participating in the injection will not give you any long-term problems will it be considered. If you’re experiencing pain throughout your marathon training, it’s critical to acquire a firm diagnosis as soon as possible to avoid losing valuable training weeks.

On all ultrasound-guided injections, Joint Injections may provide same-day service. Our clinicians are all independent prescribers who can provide the most effective treatment. Prior to doing an ultrasound-guided injection, we will perform a detailed clinical examination and a diagnostic ultrasound during your initial consultation. A recommendation from your doctor is not required

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all knee disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.