Pes anserine bursitis (PAB) is a common cause of pain on the inside of the knee, often affecting individuals who engage in repetitive knee movements or have risk factors like obesity or knee osteoarthritis. The condition involves inflammation of the pes anserine bursa, a small, fluid-filled sac located on the medial side of the shinbone (tibia), two to three inches below the knee joint. This bursa cushions the tibia and the three hamstring tendons (sartorius, gracilis, and semitendinosus) that join at this site. When irritated, the bursa swells, causing localized tenderness and pain that worsens with activities like climbing stairs or standing up.
Acute Pain Relief and At-Home Management
Initial management of acute pes anserine bursitis focuses on reducing inflammation and pain through accessible, at-home methods. The R.I.C.E. protocol—Rest, Ice, Compression, and Elevation—is the standard first line of defense for a flare-up. Rest is achieved by immediately modifying activities that aggravate the pain, allowing the inflamed bursa and surrounding tendons to settle and preventing further mechanical irritation.
Ice should be applied for 15 to 20 minutes, three or more times daily, using a thin barrier to protect the skin. Compression with an elastic bandage or sleeve helps limit fluid accumulation and provides light support. Elevating the affected leg above heart level, particularly when resting, uses gravity to assist in draining excess fluid, which further reduces swelling.
Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can be used alongside the R.I.C.E. method to target both pain and inflammation. These medications inhibit enzymes that produce inflammatory chemicals in the body. Follow dosing instructions and consult a healthcare professional if there are underlying health conditions or if OTC options are used for an extended period. If pain and swelling do not improve within a few days, or if symptoms worsen, professional medical advice should be sought.
Clinical Treatments and Medical Procedures
When conservative home management fails to provide adequate relief, a healthcare professional can offer more targeted clinical interventions. Seeking a professional diagnosis is important to confirm the pain is due to pes anserine bursitis and not another medial knee condition, such as a meniscal tear or stress fracture. The first step may involve the prescription of a stronger, prescription-strength NSAID if OTC options proved insufficient.
A therapeutic procedure for persistent bursitis is a corticosteroid injection, often combined with a local anesthetic. The corticosteroid (e.g., triamcinolone or methylprednisolone) is a powerful anti-inflammatory agent delivered directly into the bursal sac. This localized application rapidly diminishes the inflammation, providing relief that can last for several months to a year.
To maximize efficacy and safety, many clinicians use ultrasound guidance, which significantly increases the accuracy of needle placement (up to 92% accuracy compared to 17% without guidance). Precision ensures the medication reaches the inflamed bursa while avoiding accidental injection into nearby hamstring tendons, which could potentially weaken these structures. In rare cases where conservative measures and injections have not succeeded, advanced therapies, such as platelet-rich plasma (PRP) or extracorporeal shock wave therapy (ESWT), may be considered.
Rehabilitation Exercises and Preventing Recurrence
Long-term recovery relies on a structured rehabilitation program designed to correct underlying biomechanical issues and prevent future flare-ups. Physical therapy focuses on improving flexibility in tight structures and strengthening muscles that stabilize the knee and hip. Tightness in the hamstring and quadriceps muscles increases tension across the pes anserine tendons, making targeted stretching a primary goal.
Hamstring stretching can be performed by lying on the back and pulling the leg straight up toward the chest using a towel or strap, holding the stretch for about 30 seconds. Quadriceps flexibility is addressed with stretches like the prone knee bend, where the heel is drawn toward the buttocks while lying on the stomach. Strengthening exercises are equally important, focusing on the muscles that control hip and knee alignment, particularly the inner thigh muscles (adductors) and the hip abductors (outer glutes).
Exercises such as side-lying leg lifts for the hip abductors and hip adductor stretches help address muscle imbalances that place undue stress on the inner knee. Core strengthening exercises also contribute to better overall posture and alignment, reducing strain on the lower extremities. Beyond specific exercises, lifestyle adjustments are necessary to mitigate recurrence risk.
Maintaining a healthy body weight is a preventative measure, as excess weight significantly increases the load and pressure on the knee joint. Proper footwear is also important; a physical therapist may assess gait and recommend corrective orthotics, especially for individuals with flat feet (pes planus) or a knock-kneed alignment (valgus). A gradual return-to-activity protocol, avoiding sudden increases in exercise intensity or duration, is necessary to prevent training errors that could re-irritate the bursa.