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The syndrome of anserina bursitisAn overlooked diagnosis.

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1062
BRIEF REPORT
THE SYNDROME OF ANSERINA BURSITIS: AN OVERLOOKED
DIAGNOSIS
LARS-GORAN LARSSON and JOHN BAUM
In 1937, Moschcowitz (1) described the syndrome of anserina bursitis (Nomina Anatomica) and its
clinical expression. He stated that it was fairly common and that it may simulate chronic arthritis. The
patients were described as having pain in their knees
when ascending or descending stairs. Walking on even
ground did not usually present a problem. Physical
examination revealed no pain in the knee on extension
or flexion, and the joint itself was not tender, but the
area over the anserina bursa was tender, and sometimes a moderate swelling was noted. The disease was
then described in 1973 by Brookler and Mongan (2),
who reported similar findings. They were the first to
note the strong association between degenerative joint
disease and the appearance of this syndrome. Since
then, instances of this disorder have not been reported,
and knowledge of the syndrome seems restricted to
rheurnatologists and orthopedists. Apparently, few
primary care physicians are aware of the condition.
This study describes our experience with the epidemiology and treatment of this all too frequently unrecognized disorder.
Patients and methods. In a retrospective study,
we reviewed patients referred to a rheumatologist in a
tertiary care center. In a 7-year period we saw 68
patients with a primary diagnosis of degenerative joint
disease (DJD) and with a major complaint of knee
-_______
From the Department of Medicine, University of Rochester, School of Medicine and Dentistry, Geriatric Arthritis Clinic,
Rochester, New York.
Lars-Goran Larsson, MD; John Baum, MD.
Address reprint requests to Lars-Goran Larsson, MD,
Monroe Community Hospital, 435 E. Henrietta Road, Rochester,
NY 14603.
Submitted for publication October 15, 1984; accepted in
revised form March 7, 1985.
Arthritis and Rheumatism, Vol. 28, No. 9 (September 1985)
pain. Diagnosis was based on the patients’ history,
physical examination results, and radiographic findings. A detailed description of the degree of angulation
or contracture at the knee joint was not obtained from
all patients; therefore, this information was not used in
our study. Most patients, however, did show some
angulation typical of degenerative joint disease of the
knee. We did not reexamine the patients’ joints radiographically. All patients had been treated with nonsteroidal antiinflammatory drugs (NSAIDs) by their
physicians for varying periods of time, and 4 had intrasynovial instillations of corticosteroids. One patient
had undergone a patellectomy because of the knee
pain.
Of 68 patients referred with knee pain presumed
to be secondary to degenerative joint disease, 21%
were men and 79% were women (Table 1). Remarkably, 60% of them were found to have symptoms and
signs of anserina bursitis. The diagnostic criteria we
used included pain in the knee on walking stairs,
particularly upwards, morning pain and stiffness up to
an hour duration, night pain, “giving way of the legs,”
difficulty getting out of a chair or out of a car, and
difficulty in bending the knee. The sign consistent with
this diagnosis in all patients was marked tenderness
over the pes anserinus (located approximately 2 inches
below the medial joint margin). The right knee was
involved in 36% of patients, with 39% of them having
bilateral involvement. In the latter group, two-thirds
had more severe pain on the right side.
The mean ( t S D ) age of patients with the syndrome was 58 t 13.3 years. They were younger, but
not significantly so, than the group as a whole (mean t
SD 60.4 -+ 13.7). The mean (kSD) age at onset-was
53.5 k 13.2 in the women, and in the men it was 46.3 t
BRIEF REPORTS
1063
Table 1. Dkstribution of 41 anserina bursitis patients by disease,
sex, and invoIved joint
-
Number
Total referrals
with DJD (%)*
Anserina bursitis (%)
Age (mean 2 SD)
Left knee
Riglht knee
Bilateral
-
68
41 (60.3)
10 (24.4)
15 (36.6)
16 (39)
Male
Female
14 (20.6)
54 (79.4)
3 (7.3)
46.3 t 5.0
0
38 (92.7)
53.5 ? 13.2
10
14
14
1
2
* DJD = degenerative joint disease.
5.0. In general, this condition is more frequently seen
in individuals in the 50-80-year age bracket (Figure 1).
Anserina bursitis is unusual in young women, but it
must be considered in the obese younger woman with
knee pain.
The majority of patients (85.4%) were diagnosed after 1980. At that time, we started looking more
actively for the presence of the syndrome. Since then,
about 75% of the individuals referred with DJD and
knee pain have been found to have the anserina
bursitis syndrome.
In 25 individuals (61%), anserina bursitis and
DJjD were the only diagnoses. Three patients (7.3%)
had simultaneous trochanteric bursitis; 3 (7.3%) had
rheumatoid arthritis, but knee radiographs showed a
mixed picture of rheumatoid and degenerative
''
1'4
g
s
3
2
1
MEAN AGE 53.1 t 13.0
6
5
AGE
Figure 1. The onset age of anserina bursitis in patients who were
referred with degenerative joint disease and knee pain.
Table 2. Duratioe of symptoms in 41 anserina bursitis patients
Years
n
%
25
15
3
6
36.6
7.3
14.6
9.8
7.3
24.4
4
3
2
1
(1
4
3
10
changes. One patient had possible rheumatoid arthritis.
Symptoms had been present for more than a
year in over 76% of patients, and in one-third they had
been present for more than 5 years, making this a
chronic problem for the majority of our patients (Table
2). No patient had a history of significant trauma to the
knees, and the diagnosis of DJD, described as moderate to marked, was primarily based on radiographic
examination prior to our consultation. All patients but
1 were overweight, and they were often described
clinically as obese or extremely obese, indicating that
this is, for the most part, a disease of the middle-aged,
obese woman.
Treatment consisted of injections of local anesthetics or a mixture of local anesthetics and steroids
into the area of marked tenderness, depending on the
severity of the symptoms and the number of spots
injected. We used 3-5 ml of 1% lidocaine, This was
followed on some occasions, by the instillation of 40
mg of methylprednisolone or 20-40 mg of triarncinolone acetonide. Usually we found 1 tender spot in the
area over the pes anserinus, but sometimes there were
2 other tender spots corresponding to the subtendinea
muscular sartorius bursa and the so-called No-Name
bursa (3). These patients were also treated by injection. Relief was usually immediate.
Results. We found no significant difference initially between use of lidocaine alone or use of a
mixture of lidocaine and depo-steroids in the overall
group. However, up to 1 month after the injections,
there was a significantly better result when steroids
were used ( P < 0.01, Wilcoxon rank sum test). Six of
14 anserina bursae injected initially with lidocaine had
only a few hours relief of symptoms. IR contrast, 3
patients with severe knee pain for 1 month, 6 years,
and 8 years have been without symptoms for 61, 16,
and 31 months, respectively, after a single lidocaine
injection. If the improvement was not long-lasting, the
injections were repeated. All patients were also encouraged to join a commercial organization to attempt
to reduce their weight. (We have found their results to
be better than our efforts at dietary control.)
1064
Of 41 individuals diagnosed as having anserina
bursitis, we injected 3 1 (duration of symptoms 5 1.2 rf:
43.9 months, mean & SD). In 4 patients we left the
decision to use injections up to their family physicians.
A followup showed that just 1 of those individuals was
treated with injections, which produced a good result
(the physician had been trained in our clinic), but the
others who were not injected are still in pain. Three
patients refused injections, and further investigation
was suggested in 3 others.
When contacted for followup, 71.4% of patients
injected had improved significantly (mean improvement time 13 f 17.4 months; range 2-61 months). The
range of the results originates from the variable followup time and may not be related to the effectiveness of
treatment. The result was described by 28.6% of the
patients as poor, but only 1 of those patients had had
another injection and she had rheumatoid arthritis.
Anserina bursitis is not a major factor in rheumatoid
arthritis, and it is obvious that the results of treatment
by injections are not as consistently beneficial as with
rheumatoid arthritis patients.
Case report. A 53-year-old widow, weighing 262
pounds, was referred to our clinic because of knee
pain. She had lived an active life with much traveling.
For the past couple of years she had had occasional
knee pain. In November 1982, she bought a house
which had to be renovated. To paint the 8-foot high
ceiling and the walls, she had to climb a 6-foot ladder
several times a day for a month. After a week’s work
she began to have discomfort in her knees, which
continued to worsen. This caused her to sleep poorly
and she would wake several times each night with
pain. Finally, she had to have a pillow placed between
her knees to get some rest. In the morning her knees
were stiff and painful. Walking stairs, particularly
upstairs, was also painful. Walking on level grouhd
didn’t bother her. She also had difficulty getting out of
a chair after prolonged sitting. She had taken several
kinds of NSAIDs but none had helped.
On physical examination she had a markedly
tender area approximately 2 inches below the joint
margin on the medial aspect of her right knee. Radiographs showed degenerative joint disease. The tender
spot was injected with 3 ml of 1% lidocaine and 1 ml of
a depo-steroid (triamcinolone acetonide, 40 mg/ml).
She had immediate relief and did well for about 2
months but then, after moderate recurrence of symptoms, she was reinjected with lidocaine and deposteroids. She was asymptomatic for the next 4 months
despite lack of weight reduction. Slowly her knee pain
BRIEF REPORTS
returned and so she was reinjected with lidocaine
alone. She has had no symptoms for a subsequent 12
months.
Discussion. Twelve bursae in the area of the
knee have been previously described (3). It has been
presumed, as with other bursae in the body, that they
could become inflamed and cause pain and discomfort.
Based on experience with our patients, one of
the most frequently involved sites of knee pain is in the
vicinity of the anserina bursa, which is located about 2
inches (5 cm) below the medial aspect of the joint
space. It lies under and about the pes anserinus, the
insertion tendon of the sartorius, gracilis, and semitendinosus muscles. About 0.5-1 cm cranial to the anserina bursa there is another bursa, the subtendinea
musculi sartotii bursa, and occasional communication
between these 2 bursa has been reported (1). Therefore, involvement of one may be associated with
inflammation in the other. The site of the No-Name
bursa mentioned earlier is “exactly at the front edge of
the superficial and parallel anterior fibers of the mediotibial collateral ligament” (3). A great deal of physical
stress is placed on these areas when these muscles are
used going up and down stairs, particularly when a
person is overweight and has osteoarthritis with a
resultant anatomic deformity of the knee. With this
stress the bursa could become inflamed and develop
pain and tenderness. This stress could also produce
tendon tears resulting in a localized tendinitis. The
patient experiences pain referred to the knee. Because
of their broad pelvic area with the resultant angulation
at the knee joint presumably putting more stress on
these attachments, women seem predisposed to development of this problem.
In our retrospective study we have found that
the anserina bursitis syndrome is a common disease,
particularly in the obese middle-aged or elderly female
with refractory knee pain and a diagnosis of degenerative joint disease. Apparently, few physicians are
aware of this condition. Since degenerative changes,
per se, can cause pain or can be blamed for the pain,
the syndrome of anserina bursitis is easily overlooked.
It is important that every patient with knee pain,
especially those with clear-cut degenerative changes
on radiographs, also be checked for this syndrome
since the condition is readily treated with local anesthetics alone or with depo-steroids. The patient usually experiences prompt relief which is maintained for
several months and years. If the patient, during this
time, can reduce his or her weight, we believe there is
a good possibility that the knee pain and the aching
BRIEF REPORTS
will not return. However, none of our patients have
succeeded in any significant weight reduction. Treatment with ultrasound (2) has also been reported to be
effective, although in the 1 patient to whom we administered this therapy, we found no benefit.
An important question is why, in most patients,
injections of a local anesthetic to the region of the
bursa gives relief of the chronic pain, which lasts for
months or years. We apparently break the pain cycle-why the effect is long-lasting has not been determineld.
Although this syndrome is called anserina bursitis, on the basis of any of the reports or descriptions
of this lesion in the literature, we cannot rule out
pannjiculitis or a tendinitis of one of the tendons of the
1065
pes anserinus. In any event, the recognition of this
condition is important and will save patients much
distress and may avoid incorrect treatment including
intrasynovial steroid instillations and possibly patellectomy.
REFERENCES
1. Moschcowitz E: Bursitis of sartorius bursa, an unde-
scribed malady simulating chronic arthritis. JAMA
109:1362, 1937
2. Brookler MI, Mongan ES: Anserina bursitis, a treatable
cause of knee pain in patients with degenerative arthritis.
California Medicine 11923-10, 1973
3. Stuttle FL: The No-Name and No-Fame bursa. Clin
Orthop 15~197-199,1959
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