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By Debbie Roberts, LMT

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Pes Anserine Tendonitis vs. Medial Meniscal Tear

What do you think stiff golf shoes, playing with a child, riding a bike, running and swimming breast stroke would all have in common? Well, they each require knee joint involvement. To quote the physical therapist Gary Gray, "the knee is just the dumb guy in the middle." The knee is a devotee to every movement that is made well or poor by either the hip or ankle joint. In this article, I want to give you some examples of how clients can develop Pes Anserine Tendonitis. We will also look at how to differentiate a medial meniscus tear from Pes Anserine Tendonitis and we will also discuss what a treatment plan would look like.

What is It?

The Pes Anserine Bursa is also known as the goose's foot bursitis because the three tendon's that attach at the lower part of the knee and press on this superficial bursa resemble a goose's foot. The semitendinosus muscle, sartorius, and gracilis all attach together onto the tibia at the inner part of the lower knee joint. In this area is a bursa called the anserine bursa which lies between this combined tendon attachment and the tibia bone underneath. This bursa may become inflamed due to repetitive friction in sports such as golf, cycling, running and swimming. This can result in bursitis and/or a tendinopathy otherwise known as a tendonitis.

Pes Anserine Tendonitis is often difficult to distinguish from a medial tendon or ligament injury because the symptoms are similar and both are likely to be painful when stressing the inside of the knee joint. The client will also point to the inside of the knee, particularly the lower part just below the joint line. They will experience pain when getting up out of a chair or when contracting the hamstring muscles against resistance.

Golfing Example

The first case was a golfer who presented with left Pes Anserine symptoms. This client has been with me for the past 18 years as both a training client and a massage therapy client. He is in his mid-seventies and in great physical shape, with the exception of a few minor aches and pains. He had a previous lumbar surgery 20 plus years ago.

Over time, his left hip has lost internal rotation and he has a chronic right SI issue contributed from playing too much golf. I asked him what was different in yesterday's game of 18 holes of golf. He originally said "nothing that I can think of." So as a massage therapist going through the list of how and why did this happen, what would be a good question to ask next? You got it; did he happen to change his stance or shoes? His answer was, "yes at the last minute I decided to change to my other golf shoes." What is different from the golf shoes you were wearing before and the ones you decided to play in yesterday? "Well they are stiffer, not as much give in them." Okay, now as a therapist, what are you thinking might have caused this injury? You got it again; possible more torque at the knee joint was created by a stiffer golf shoe.

Let's take a brief look at what happens in the golf swing. The left leg is the follow through or the finish leg. The right hip extensors and abductors and left adductor magnus initiate left pelvic rotation during the forward swing. For a right-handed golfer, a significant amount of torque and valgus stress is generated at the left knee. Remember also, this golfer had back surgery leading to tight back and tight hip muscles which changes the joint alignment at the knee. In order for a golfer with a tight back and tight hips to generate force, there is more torque and rotation at the knee joint which often leads to injuries to the medial meniscus. Like any shoe (in this case golf shoes) that does not provide enough arch support, it can lead to an over pronated foot position which places the knee in a rotated position.

I highly recommend strengthening the intrinsic foot muscles for better foot position than relying on a device to provide better foot position. If we look at the design of the knee, it is not intended for the rotational forces and side-to-side movements required by the golf swing. We can theorize that his stiffer golf shoes put more rotation force through the knee and recruited semi-tendinosis, gracilis, and sartorius to help stabilize the knee causing more friction at the bursa giving him a Pes Anserinus tendinitis.

I performed massage therapy working with him for one hour using the treatment plan I describe at the end of the article. He was able to play in his tournament the next day without knee pain and went back to using his other golf shoes. There has been no return of pain.

Playing with Children

The second case I wanted to share with you was one of my clients who were trying to help teach a child to do flips. She was crouching down in a flexed knee position and putting a valgus rotational torque on the knee by trying to support the child and turn the child in her flips. This client does have a long standing history of lumbar pain and poor internal and external rotation at the hip joint. Both of these contributing factors combined with the repetitive motion of squatting and valgus rotational stress caused her Pes Anserine Tendonitis. I worked with her for one hour, gave home therapy suggestions such as ice to the bursa and heat to the muscles, taught her the PNF stretches to lengthen the target muscles and she has reported no return of pain.

spin class - Copyright – Stock Photo / Register Mark Spin Classes

The third case was a spin instructor who loved to crouch down as much as possible on the bike and focus on the upstroke of pedaling. Along with medial knee pain, she was also experiencing a quadriceps tendinitis. Her unusual riding position was not allowing the hip, knee, and ankle joint to stay in the proper alignment necessary for cycling. If the foot cannot be at the angle it needs to be in, then the knee becomes the weakest link in the pedaling chain and is loaded improperly.

I worked with her for one hour, explained what her riding position was doing to create the pain, talked about bike set up and gave her home therapy suggestions. She reported no knee pain the next week, but she was still experiencing the quadriceps tendonitis. She was unwilling to take a break from teaching to allow some healing time plus she didn't have the ability to continue therapy on a regular basis. So it took longer for her to have relief from the quadriceps tendonitis. But she did however tell me she began to instantly notice the difference once she changed her positioning on the bike. Just as a side note, also with cycling the pedal/cleat system needs to have enough rotation to allow the riders feet to fall at the angle they need to.

I personally experienced medial knee pain when I changed from a pedal/cleat system I was using for outside riding that allowed more foot rotation to another pedal/cleat system that could easily adapt for indoor cycling but was not allowing me to have the same foot rotation. I did some height and aft adjustments to help accommodate and the pain was eliminated. So always ask a cycling client about their bike set up, ask if anyone has looked at their position on the bike and for indoor cyclists be sure to suggest not adding so much resistance on simulated hill climbing.

Assessment

The McMurray test evaluates for meniscal tears. The client is supine and the therapist grasps the foot with one hand and palpates the knee joint line with the other hand. The therapist flexes the knee and rotates the tibia into medial and lateral rotation. With the tibia held in lateral rotation, the therapist applies a valgus stress and extends the knee. The test is repeated with the knee held in medial rotation and a varus stress is applied while extending the knee. A palpable or audible click, especially with pain, within the joint is considered a sign of meniscal tear.

The other test is the Apley's Compression Test which is performed with the client in a prone position and the knee is flexed to 90 degrees. The therapist will stabilize the client's thigh and leans on the heel, compressing the menisci between the femur and tibia, and then rotates the tibia medially while maintaining this compression. Medial joint pain created by this test suggests a medial meniscal tear, whereas lateral joint pain suggests a lateral meniscal tear.

Treatment

Do a manual muscle test of the semi-tendinosis, gracilis, and satorius to help establish which position creates the most discomfort. This will be used over and over again during the therapy to determine if the therapy is helping take the pressure off of the bursa. Perform a myofascial release to the entire extensor, adductor, flexor, and abductor chain of muscles. The target of course is to use extra attention to release the three tendons specifically. I apply some heat and the use of PNF stretching (Proprioceptive Nerve Facilitated) to the target muscles. My personal formula is MMT, Myofascial release with either hands on or cupping to target muscles, heat, PNF, re-test and repeat this formula up to ten times in one hour or until there is relief of symptoms.

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