Medial Knee Pain and Pes Anserine Bursitis
By Anna Staehli Wiser, DPT, FAAOMPT
Medial knee pain is a common complaint among patients, often described as discomfort localized along the medial joint line. While intra-articular sources such as medial meniscus pathology or medial compartment osteoarthritis are frequently considered primary culprits, it is essential not to overlook the surrounding soft tissue structures, which may also contribute significantly to symptoms in this region.
The semitendinosus (medial hamstring tendon), gracilis (long adductor), and sartorius (movement synergist), all converge at the pes anserinus, an insertion site located on the anteromedial aspect of the proximal tibia. This confluence of tendons plays a dynamic role in stabilizing the knee during functional movement. Additionally, the saphenous nerve traverses this area and may become entrapped within inflamed soft tissues, further contributing to medial knee pain1.
Biomechanical Contributors
Chronic stress at the pes anserine insertion often arises from faulty lower extremity mechanics. Excessive pronation at the foot can induce internal tibial rotation from below, while proximal weakness—particularly in the lateral hip stabilizers—can allow femoral adduction and internal rotation from above2,3 . When these biomechanical faults occur simultaneously, the medial knee becomes a site of compensatory overload, leading to irritation of the tendons and adjacent bursal tissue. In many cases, the knee is merely the “victim” of dysfunction occurring at the foot and hip.
Conservative Treatment Strategies
Before considering surgical consultation, conservative management strategies should be thoroughly explored. Addressing both distal and proximal contributors is essential for lasting relief. Recommended interventions include:
Foot Strengthening & Arch Support: Targeted foot intrinsic exercises, along with orthotic support when appropriate, can help reduce excessive pronation and limit internal tibial rotation4.
Lateral Hip Strengthening: Exercises that target the gluteus medius and other lateral hip stabilizers help prevent femoral adduction and internal rotation, offloading stress from the medial knee5.
Low-Impact Aerobic Activity: Gentle activities such as stationary cycling, heel slides, and hamstring curls can enhance blood flow and promote tendon healing6.
Flexibility Exercises: Regular stretching of the hamstrings and adductors can improve mobility and reduce tension across the pes anserinus region7.
Conclusion
Medial knee pain should not automatically be attributed to intra-articular pathology. In cases where symptoms are unresponsive to joint-specific interventions, a thorough evaluation of the kinetic chain—including foot, ankle, hip, and surrounding soft tissues—can reveal the true origin of pain. Conservative care targeting mechanical contributors is often effective and should be prioritized prior to surgical consideration.
References:
1. Hemler DE, Ward WK, Karstetter KW, Bryant PM. Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 1991;72(5):336-337.
2. Larsson LG, Baum J. The syndrome of anserina bursitis: an overlooked diagnosis. Arthritis Rheum. 1985;28(9):1062-1065.
3. Coplan JA. Rotational motion of the knee: a comparison of normal and pronating subjects. J Orthop Sports Phys Ther. 1989;10(9):366-369.
4. Mohaddis M, Maqsood SA, Ago E, Singh S, Naim Z, Prasad S. Enhancing functional rehabilitation through orthotic interventions for foot and ankle conditions: A narrative review. Cureus. Published online November 20, 2023. doi:10.7759/cureus.49103
5. Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of Patellofemoral pain: A multicenter randomized controlled trial. J Athl Train. 2015;50(4):366-377.
6. Sarifakioglu B, Afsar SI, Yalbuzdag SA, Ustaömer K, Bayramoğlu M. Comparison of the efficacy of physical therapy and corticosteroid injection in the treatment of pes anserine tendino-bursitis. J Phys Ther Sci. 2016;28(7):1993-1997.
7. Grover R, Rakhra K. Pes anserine bursitis - an extra-articular manifestation of gout. Bull NYU Hosp Jt Dis. 2010;68(1):46-50.
