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JCR: Journal of Clinical Rheumatology:

Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis

Alvarez-Nemegyei, Jose MD, MSc*; Canoso, Juan J. MD†

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From the *Servicio de Reumatología, Hospital de Especialidades, Centro Médico Nacional “Ignacio García Téllez,” Instituto Mexicano del Seguro Social, Mérida, Yucatán, México; †ABC Medical Center, México, and the Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.

Reprints: José Alvarez Nemegyei, MD, MSc, Calle 57 Num. 503, Centro, CP 97000, Mérida, Yucatán, México. E-mail:

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Anserine bursitis is a frequent cause of medial knee pain. Despite its name, the structure at fault causing the symptoms remains unknown. Diabetes mellitus is a known predisposing factor leading to the condition. Overweight and knee osteoarthritis are possible additional risk factors, but their role has yet to be assessed. Anserine bursitis is diagnosed clinically based on medial knee pain and localized tenderness at the inferomedial knee. Current treatment of anserine bursitis includes nonsteroidal anti-inflammatory dugs, physiotherapy, and local glucocorticoid injections. Of these, only the latter has been shown effective in clinical trials. Knowledge gaps in the epidemiology, pathology, and pathogenesis of anserine bursitis should lead to additional research efforts on this common and perplexing condition.

Anserine bursitis (AB) is a frequently encountered condition in clinical practice. However, there are no studies addressing its prevalence.1 Also, there is controversy regarding the structure at fault in AB. In early MRI studies, the presence of fluid within the anserine bursae in patients with presumed medial meniscopathy lent indirect support to the validity of AB as a bursal condition.2,3 However, recent studies have cast doubt on the anatomic validity of AB as either a bursal or a tendinous condition. Thus, Uson et al,4 in a controlled ultrasonographic study of 37 consecutive patients with clinically diagnosed AB, found bursal enlargement in only 2 instances and pes anserinus tendinopathy in 1. Interestingly, none of these abnormalities was found in an affected knee but in asymptomatic contralateral knees. More recently, Unlu et al,5 in a study of 48 type 2 diabetic patients with clinically diagnosed “anserine tendinitis or bursitis syndrome,” found that only 8.3% had ultrasonographic evidence of pes anserinus tendinopathy and none had bursal swelling. Furthermore, mean pes anserinus tendon thickness was similar in asymptomatic and affected knees in unilateral disease and also in patients as compared with healthy controls. On the other hand, medial meniscopathy, medial compartment osteoarthritis, popliteal cysts, and suprapatellar recess effusions were more prevalent in “pes anserine tendinitis or bursitis” patients than in controls.5 Recently, Hill et al6 reported on the knee RMI findings in 451 subjects older than 45 years. An overall prevalence of anserine bursae effusion of 3.7% was found. However, in 59 subjects with any RMI findings that underwent physical examination, a lack of correlation between RMI findings and physical examination was noted. It can be concluded that in most “AB” patients the anserine bursae and the pes anserinus are normal. Thus, the faulty structure(s) in AB syndrome remains to be identified.

There are no controlled studies assessing risk factors in AB. Nevertheless, several case reports suggest that the syndrome is frequent in overweight female patients with knee osteoarthritis. In one such report, a 93% prevalence of radiographic knee osteoarthritis in 37 consecutive AB patients was found,4 whereas another retrospective report claimed that 46% of knee osteoarthritis patients had a concomitant AB.7 Diabetes mellitus appears to be uniquely associated with the condition. Cohen et al8 found a 34% prevalence of clinically diagnosed AB in 96 consecutive noninsulin-dependent diabetes mellitus patients, while no cases were found in nondiabetic controls. Also, in the report by Unlu et al,5 a 29% prevalence of clinically diagnosed “anserine tendonitis or bursitis syndrome” in 48 type 2 diabetes mellitus patients was found.5

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Given the lack of evidence regarding the actual structure(s) involved in this syndrome plus its straightforward clinical picture, AB is diagnosed on clinical grounds alone and imaging studies are not required. The key element for diagnosis is tenderness on the upper medial tibia at a point 3 to 5 cm distal to the medial knee joint line. There are no validated diagnostic criteria for AB, and the very efficacy of the actual clinical maneuver (palpation) used to establish diagnosis has not been assessed.

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It is often held that physiotherapy, nonsteroidal anti-inflammatory drugs, and the correction of alleged predisposing factors (ie, overweight) are useful therapies in AB. Concurrently, or in cases not responding to these measures, a local glucocorticoid injection is administered.1 Of these treatment modalities, only glucocorticoid injections have been validly assessed. Thus, Calvo-Alén et al9 reported on 44 consecutive AB patients that were alternatively assigned to naproxen 500 mg bid or a glucocorticoid injection. Main outcome measure was pain as assessed by using a verbal scale of intensity, at 1-month follow up. Fifty-eight percent of the naproxen-treated patients were “significantly improved,” and in 5% the condition had resolved. In the glucocorticoid-injected patients, 70% were “significantly improved,” and the condition had resolved in 30% (P≤ 0.05). Also, in a retrospective review of 29 AB patients,7 clinical remission was observed in 11 of 12 who received a glucocorticoid injection as compared with 7 of 17 who did not.

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The faulty structure in AB has not been identified. In particular, the anserine bursae and the pes anserinus have been found to be normal in AB patients, and no alternative lesion has so far been shown. Diabetes mellitus is the only predisposing factor identified; the role of additional factors such as overweight and knee osteoarthritis remains to be shown. AB is diagnosed clinically based on medial knee pain and inferomedial knee tenderness. Nonsteroidal anti-inflammatory drugs and physiotherapy have been proposed as initial therapeutic measures. Local glucocorticoid injections are reserved for those who fail to improve or may be given initially. Local glucocorticoid injections have been shown efficacious as compared with a nonsteroidal antiinflammatory drug in a controlled clinical trial. Given its frequency, it is surprising how little factual information is available on AB. Additional research on epidemiology, pathology, etiopathogeny, and therapy for AB is definitely warranted.

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1. Arromdee E, Matteson EL. Bursitis: common condition, uncommon challenge. J Musculoskel Med. 2001;18:214–224.

2. Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology. 1995;194:5265–5267.

3. Gray SD, Kaplan PA. Muskuloskeletal imaging update, part I: imaging of the knee. Orthop Clin North Am. 1997;28:643–658.

4. Uson J, Aguado P, Bernad M, et al. Pes anserinus tendino-bursisis: what are we talking about? Scand J Rheumatol. 2000;29:184–186.

5. Unlu Z, Ozmen B, Tarhan S, et al. Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus. J Rheumatol. 2003;30:352–354.

6. Hill CL, Gale DR, Chaisson CE, et al. Periarticular lesions detected on magnetic resonance imaging: prevalence in knees with and without symptoms. Arthritis Rheum. 2003;48:2836–2844.

7. Kang I. Anserine bursitis in patients with osteoarthritis of the knee. South Med J. 2000;93:207–209.

8. Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. 1997;24:2162–2165.

9. Calvo-Alén J, Rua-Figueroa I, Erausquin C. Tratamiento de la bursitis anserina: infiltración local con corticoides frente a AINE: estudio prospectivo [Anserine bursitis treatment: local corticosteroid injection against NSAID: a prospective study] [Spanish]. Rev Esp Reumatol. 1993;20:13–15.

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anserine bursitis; pes anserinus; knee pain

© 2004 Lippincott Williams & Wilkins, Inc.

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