Medial Knee Pain (Pes Anserinus Tendonitis/Bursitis)

| August 25, 2011

Over the years, I’ve had people come to me complaining of pain pretty much right where the Pes Anserinus Tendon/Bursa (PATB) should be.


The unfortunate thing is, I’m not a human MRI machine so I can’t diagnose these types of things.

However, I really wish I was!!

How profitable would that be!?)

The use of an MRI is often needed to establish exactly what the injury is and where exactly to treat the injury.

Location of Pes Anserinus Bursitis (PATB)

As you can see from the diagram to the right, the Pes Anserinus is located just below the knee on the inside of the shin bone.

This particular image is showing the inside of the right leg.

The rough looking bit to the left of it and slightly above is the tibial tuberosity; the bony attachment point for the quadriceps group.

The pes anserinus is a combination of the tendons of sartorius, gracilis and semitendinosus.

The first 2 muscles help to make up the ‘groin’ group, while semitendinosus is one of the 3 hamstring muscles.

If you look closely, you can see a blue looking bursa between the tendon and the bone.  Due to its position on the leg, injury can occur to both the bursa and the tendon, making a diagnosis a little more challenging.

Running downhill places extra stress on the tendon of pes anserinus. This image shows the additional challenge of maneuvering amongst a rocky landscape. Image from google.

What Causes It?

The bursa can become irritated if the inside hamstrings (semimembranosus and semitendinosus) are tight, or if the individual is ‘knock kneed’.

Another factor that could contribute would be the supination at the sub-talar joint.

Repetitive deceleration of the knee can be a contributing factor to this type of injury.

So those involved in fartlek training which is hilly in nature will be more at risk.  For those who don’t know what fartlek training is, it is a combination of different speeds, gradients and effort levels.

Tri-planar movement which we should all adhere to.

For example, the constant acceleration to get up one side of the hill will have to be met with a deceleration on the opposite side.

It’s this deceleration which forces the 3 muscles to act as brakes and it tugs on the attachment on the shin bone causing friction, and eventual discomfort.

As with most other injuries, an increase in training intensity and/or volume could also be a contributing factor to the onset of PATB.

Other Factors

Jumping sports such as volleyball, basketball or various track and field events can also be the cause of PATB.  The constant, repetitive loading of the legs that is typical in these types of activities can contribute to pain.

In a past article, I wrote about various types of swimming strokes and the effects that they have on the body.

The one stroke that I criticised was the breast stroke.

Personally, this type of stroke I mostly associate with retired people on a sunshine holiday.  Paddling around the pool in circles at a leisurely pace.

If done correctly, this stroke is one of, if not the most demanding strokes in swimming.  It requires a huge amount of technique, strength and skill to do it effectively.

Another factor which must be considered is the range of movement in the joints involved such as the hips, and shoulders.

Most people don’t have the ideal flexibility in these areas due to poor postures, which leads to compensations and eventually dysfunctional movement patterns.

I’m not a swimming expert by any means.  I leave that stuff to my girlfriend (who is a swim instructor), but all it takes is a bit of common sense to know that not all people can do this type of stroke well.

Swimming while holding a kick board out in front and doing a basic flutter kick would be a much better way to exercise.

How Do You Know If You Have PATB? 

Do you have any of the following?

  • The area is tender to touch
  • There are signs of swelling
  • Painful to stretch the hamstrings (particularly on the inside)
  • Isometric contractions (holding) of the hamstrings are painful (i.e. a bridge exercise)
Management of PATB
The management of PATB can be divided into 2 stages; Early, and Rehabilitation.
Early Management 
The management of PATB is quite similar to the treatment for patellar tendinitis.  The priorities include:
  1. modify activity levels, depending on the severity of the injury
  2. The onset of therapeutic exercises are important so reducing inflammation or decreasing any pain or swelling is priority.  NSAID’s would be recommended, as well as relative rest, ICE, and the relevant mode of electrotherapy.  If problem is severe, a cortisone injection may be the best choice.
At this point, you would have 2 choices.  Either quit the sport, or activities that caused the problems in the first place, or rehabilitate the weaknesses in your body to make sure that the problem does not return!
Soft Tissue Therapy
The main aim of this is to increase the circulation in the injured area.  With the increased circulation comes more blood flow, and healing agents that the body sends to the area.  Adhesions would be present along the fibres of the tendon, so gentle x-frictions would help to break them down and help re-align the fibres.
If a hamstring length test reveals tight restrictive structures, then some myofascial release techniques might be useful in

Images for the lying hip extension exercise. Otherwise known as a bridge. The position is held in the bottom position for the desired length of time. The exercise should be felt in the glutes mostly, as well as in the hamstrings. Image from Google

regaining flexibility.

An eccentric strengthening programme to help increase the tensile strength of the tendons that join the bony landmark would be advised.
This would largely involve muscles that extend the hip, such as the hamstring group.
Easier floor exercises such as the bridge (picture above) should be performed first.  Once this has been completed, more dynamic strengthening exercises can be included, revolving around movements similar to the ones you need for whatever you do.
If you’re a tennis player with lots of rotation and side to side movements, you can implement some of those into your new strengthening regime.  If you’re a court athlete, as in basketball, or netball, then specific movements to that sport should be used.  Start off at a lower level of intensity and Range and slowly increase both until you mimic game type situations.
That’s the only true way you’ll be 100% ready for full activity in your sport again.  Without training the area to be strong throughout all the ranges it will face in a game/competitive situation will expose any weaknesses and develop

Neural stretches, such as the 'slump test' are often needed to help calm down inflamed nerves. Stretches should only be prescribed by a professional and held for a short period of time (3 + seconds)

compensations, leading to new dysfunctions.

Tingles or Short Sharp Shooting Pains?
If there are any neural symptoms present, then neural stretches such as the slump test, or straight leg raises could be prescribed.
These can be quite painful, and should only be applied for a short length of time (3 seconds for example).  This attempts to increase the length of the nerve, which may relive the symptoms.    An example of a neural stretch would be the slump test.
It is always best that a trained professional guide you through anything to do with the spine (for obvious reasons!), but a short video demonstrating what it is is below.

Supination of the right sub talar joint (STJ). This places more strain on the tendon of pes anserinus, causing irritation to the bursa and/or tendon. Image from Google

Tape and Braces

The tendon might need support at its attachment down on the shin bone.  This is particularly true as the exercise becomes more intense and dynamic in nature.

Bomechanical Factors

Bomechanical factors such as GAIT analysis, movement patters specific to the activity causing the onset, and food alignment should all be considered.

By correcting any faulty movement patterns, there will be less stress going through the body and a decreased risk of injury.

There are a lot of circumstances which can contribute to PATB, however if you manage your fitness regime well, you should be able to dodge that bullet.

Drop me a note if you’re struggling with this and we might just come up with the solution.

Until then,

Keep Your Knees Pain Free

Category: Knee Injury Rehabilitation

Comments (3)

Trackback URL | Comments RSS Feed

  1. Brandon says:

    Pretty insightful. Thanks!

  2. maggie says:

    Hi Craig,

    I am sort of freaking out. Was diagnosed with PATB ( Tendonistis and not bursitis – as the latter were clear and not filled). I took a course of Anti-inflammatory, I am icing religiously and have started physio therapy along with Ultrasound – twice a week. It is important to note that due to a fall on my knees I also developed a misalignment at the Patella ( Pattelar Syndrom ?) which is also being corrected.

    I am a rock climber, I roller blade a hell of a lot and walk a great deal(hiking and fast walking) and do yoga. I also started biking which I think started the PATB. Physio told me that my immer knees are very week and that I am compensating from my hips and thigh muscles. He was impressed with the strength of my hip and lateral muscles and shocked at how weak my knees were.

    I haven’t exercised in two weeks and I am becoming restless. I heard comments that PATB is a SOAB and doesn’t go away and might become chronic. Is this the case? Can I start exercising? I am concerned , should I start or not or give it another week? Should I do the hard tissue massage?

    I need another opinion as to what exercises I can do and what to ease into and , well the lot.


  3. Akiko says:

    Thanks! Great info., and now I feel I have a better handle on what direction to proceed.