Pes Anserinus

[hopa860]

Hi all - my first post - just after some advice.

I will try to tell you my history comprehensively and then ask my questions towards the end so forgive the length of this post!

I started to experience knee pain about a year ago, especially when exercising and playing table tennis which I was starting to play at an increasingly higher level.  The pain started off very sharp in a concentrated area on the inside of my leg just below the knee.  This pain, although still sharp, quickly became permanent to the point that I could certainly not play sport as just walking hurt badly. I went to see a Physio whilst still at University who diagnosed a torn medial meniscus tear almost immediately by performing McMurray's test amongst other things. He referred me to my Hospital at home.

I then had an appointment with a physio at my Hospital at home who agreed with his diagnosis.  Although she was competent she seemed a little lacking in confidence so asked a knee specialist to come and have a look at me.  He agreed with the diagnosis of torn meniscus and so having the specialist pop in to see me obviously put my mind at ease.

I had an MRI scan in January 2009 which I was told showed a torn mensiscus and so agreed with the previous diagnosis. I was told my only option was to have a knee arthroscopy in which the cartilage would be trimmed or removed.  I chose to have the operation as soon as I finished University as that would give me 6 weeks to recover before going traveling (which I was told would be fine).

So I had the arthroscopy in mid-June. As soon as I woke up from the operation I was convinced it had not worked as I still had exactly the same pain in exactly the same place. Obviously I was told to give it the required 6 weeks to settle down but I knew it had not worked. The most frustrating thing was that after the operation the nurse informed me that all my cartilage was fine! The surgeon had however removed the plica and 'washed my knee out.'  I was fully load-bearing after the operation.

I attended physio to build my muscles back up and started to do my own research into my problem.  Whilst going to the gym I had discussions with two personal trainers who worryingly both asked me why I had had an operation on my knee when it appeared my pain was at the top of my tibia!!  I quickly came to the conclusion that my problem was either a stress fracture or Pes Anserinus.  I saw the Surgeon's Registrar 6 weeks after the operation and when I asked how my cartilage was fine when the MRI showed a tear he said; "The radiographer read the scan wrong." I quickly picked up on the word "wrong" and he back tracked to say that the shadows on the scan were confusing and showed something which was not there. It puzzled me that by his wording it sounded like the surgeon who actually carried out the surgery had not looked at the scan, just relied on the radiographers opinion.  I then continued to tell the Doctor about my own research. He ruled out a stress fracture straight away as this would be clear on the MRI. He agreed with my diagnosis of Pes Anserinus (swelling and discomfort of three tendons attaching to the tibia) but could only offer me ultrasound once a week or a cortisone injection.  I turned down the injection for the fact I know footballers that have been troubled in later life due to having them.

So at this point I was totally loosing my faith in the Surgeon and his team that had treated me. My traveling ambitions had gone totally out of the window.  The pain was intense in a specific point of my knee and far from returning to sport I sometimes find it difficult to even walk. Due to my frustration and willingness to try anything I decided to pay to see a Sports Doctor who is very well regarded in the football world. He was brilliant and also agreed with Pes Anserinus but informed me it was probably caused by me severe foot angle (due to breaking my leg at the age of 9) placing pressure on the inside of my leg. He recommended me to a Physio friend of his and talked about using trigger points etc. to try to right the problem.  When I asked him whether I had ever needed the knee arthroscospy he frowned and said he would be very interested to see the MRI scan, so I am in the process of applying to get the disk to send on to him.

As of today I have had one session with the physio and although feel no difference as of yet, I am hopefully now on the right road to recovery.

So, my questions are as follows: Does anybody think I have a case for clinical negligence due to incorrect diagnosis of my problem?  To myself (certainly not medically trained!) and the Doctor I paid to see it was painfully obvious my problem was not so much the knee but the top of my leg! I am not after money or any of that, I would simply want to know if I had been done wrong by and get my point across if that was the case. My traveling plans are long gone and I am worried I will be severely affected when I start work in late September as I will be walking round a building site for 10 hours a day and at the moment can manage 20 minutes!  Another annoying point is the fact that the operation it turns out I did not need has caused general niggles around my knee and painful clicking on the other side (was there any need to take out the plica??)

Does anyone have experience of Pes Anserinus and/or a cortisone injection to solve the problem? I am currently doing stretches (mainly hamstring) and icing it four times a day and receiving ultrasound. Is there anything else I can try?

And finally is there anything else anyone thinks it could be!? A lot of people I have spoken to express surprise at the amount of pain it cause me. Sometime it really is agony and I struggle to walk.

As you can appreciate I am very frustrated by my situation at the moment and it has been quite therapeutic to write it all down!  So if you have read this far I thank you for your time and any advice / opinions you can give me.

I will copy this into a couple of the other relevant forums (is that ok!?) as I would like as many opinions / answers as possible.

Thanks Again

[tsznut]

Hello

I was just diagnosed with this same problem, pes anserine bursitis.  I had never heard of this before.  I had knee surgery about 5 months ago and thought the pain was from the surgery, which it could be a complication of the surgery.  My OS put me on Mobic (NSAID), limit activities until the inflammation settles down, ice massage, work on hamstring stretches and quad strengthening.  He did offer me the licocaine/steroid injection, but I chose to wait for a couple weeks to see if it will settle down on it's own.

I have been on the meds for about 1 week now and the pain is less.  So I am hopeful I will not need the injection.

Tori

[ArielF]

Hey there,

I was diagnosed with pes anserine bursitis just a couple of weeks ago by my physical therapist.  I had surgery on the tibia and had increadible bone pain medially just under the knee cap.  This was expected because I had open bone.  Five months later however I still had the same intense pain. I had a delayed union so it continued to make sense that if I had open bone, I would still have the intense bone pain.  After x-rays showed that the bone was mostly healed I kept after the PT.  Finally I was diagnosed with bursitis.  The area is exactly the same as the bone cut and the pain was as intense. 
I have been treated for 4 sessions and the pain is much improved.  I have ultra sound treatment, massage on top of the bursa (OUCH!), and stretching and massage of the IT band. I ice at home, stretch hamstrings, ITB (can't stand and stretch it is very painful) and the standard strenthening routine.  I can finally walk for a short time without a lot of pain.  It comes back and I need to rest but for months it was consistant with every step.  So it is working for me.
I will be seeing the doc in September and he may offer lidocaine/steroid injection but I don't want to count on it. 

So the question is, is the pain different than it was before the surgery? It is possible that the bursitis is a result of the surgery.  Things get streched, moved and things tighten up.  I had no issues with tendons or bursa before surgery but that is the way it goes.  I wouldn't even consider it a complication it is more like a recovery issue.  And yes it is very very painful. 

Best of luck hopa

[hopa860]

Tori / Ariel,

Sorry I did not reply when you left your posts - but I did read them and they did help. They helped my frame of mind at least!  My original consultant told me he had done everything he could do for me and so I basically told him to discharge me as I lost my faith in him.  Luckily I started my job having graduated from University and it came with private medical insurance so I did my best to find 'the best' OS in my area.

He did not think it was Pes Anserine but thought that the other guy had simple missed a torn cartilage! He insisted on doing another MRI scan and said he could clearly see a torn medial meniscus cartilage and so he has done a partial meniscectomy 12 days ago.

I have so far recovered a lot better than the last op. I have by no mean a full range of motion but I can drive etc. which I couldn't do for weeks last time! He has stitched the cartilage back in.  However, worryingly I do have exactly the same pain in exactly the same place as before which is obviously to be expected, but I thought it would be settling down by now?

So.... my questions to you are; how are you both doing? Did either of you end up having the injection and if so what effect did it have??  I have been icing my knee a little to help with swelling, but do you think I should be using heat over ice??

Thanks for your help

Andrew

[ArielF]

Hey Andrew,

Congratulations on your graduation!

I am glad to hear that you are continuing to have your knee issues addressed.  As far as recovering from an arthroscopy, it is very individual.  It all depends on what the doctor does when he is "in there".  They are just tiny little holes but a lot can be manipulated through those holes.  As far as heat or cold, after the first few days heat or cold are acceptable.  Cold constricts blood vessles and decreases swelling and pain.  Heat dialates blood vessles, speeds healing and eases pain.  What ever feels best.  I tend to cycle back and forth.  More ice in the summer more heat in the winter. 

I would recommend taking it slow and don't rush your recovery.  You are fortunate that your surgeon was able to stitch the meniscus back into place. It is always better to have your own cartilage.  I don't think that it is time to consider a cortisone injection.  Cortisone can damage and weaken cartilage over time.  My doctors have avoided it untill just recently.  It didn't work anyway. 

Best of Luck Ariel

[Pertinax]

This is a response to an old post, but it was so similar to my problem that I thought I would.About 24 months ago I started to have medial knee
pain on my right knee. I am a triathlete, so it could have been from running, or biking, or swimming the breaststroke in my masters class. It seemed to be worse after swimming, so I cut out the breaststroke(breaststrokers knee) I went to a PT who told me my gracilis was taught as a bowstring. I stretched it and it got better. Then the left knee started to hurt terribly in the same area. I found out about PAB online and figured it was from my bike cleat positioning. The bike fitter pointed my toes outward to keep my knees going forward. I found out PAB is caused by outward pointed toes on the bike. I pointed my toes more inward. Problem solved? No. I went to another PT who said my left gracilis was tight, tight. He stripped it 3-4 times, OUCH! That helped , but it came back. Another PT thought I had a torn meniscus, even though his tests didnt really confirm it. After resisting an MRI(I had to pay half) they said I had a small tear, and that I needed surgery. I would tell them during exams where it hurts(much lower), but they didnt have much experience with PAB(you could tell)
My PTs office shares space with a knee surgeon(go figure)
The surgery 9 months ago never helped me. I have run approx 60 miles in 9 months, as the pain the next few days is bad, I have kept biking and swimming.. After visiting the PT many times after the surgery, I waited 6 months just to let it heal(it didnt) I just went back the other day, and here is where the guy earned my money. He watched me walk barefoot for awhile, messed with my feet and ankles, and even had a colege come over. He saw that my left ankle was very stiff, probably from rolling on it 2,000,000 times as a serious golfer for 30 yrs. The left ankle was causing my foot to pronate both running, and pedaling. He added wedges to my bike shoes, and put me in a strong stabilty shoe Gel Kayanos, with Dr. Schoals orthotics, and Viola!
I have run 12 miles this week, and biked 95, and no pain! I have tears in my eyes as I write this.
My point is, check your pronation. A stability shoe with orthotics should keep your knee from coming in, putting stress on those ligaments. I had switched from stability shoes 2.5 years prior, and had gone to running in nuetral shoes only. I used to get ITB at times, so I switched, I had forgotten that.
Dont give up.

[investor54]

Dear hopa860,
Your condition sounds very similar to mine.
About 6 months ago I has an Arthroscopic Posterior 1st Horn Medial Meniscectomy and a "surprise" Microfracture Chondroplasty of the Medial Condyle.
Gusee what ... I have the same pain as before the operation. It's on the front inner side, just below my right knee when going up a step that prompted me to see an OS in the first place.
The MRI report indicated a torn medial posterior meniscus and a loss of cartilage about 1 CM deep and 3 MM wide on the posterior medial condyle .
My first OS said he did not see anything wrong and gave me a shot that was ineffective.
My second OS thought differently and operated. After 5 months I was still on crutches and he said the Microfracture takes more time to heal.
My 3rd OS sent me to PT, ordered an unloader brace.
NONE of the surgeons REALLY listened to my original complaint and the operating surgeon executed solely on the MRI report.
FINALLY, after collecting the Operation Report and the Pre & Post MRI Reports I realized that the operation focused on the inner rear side of my knee and NOT the inner FRONT.
Yesterday, I accidentally LIT myself up with pain when I put some weight on a slightly bent knee. I marched into the operating OS office and now he thinks I have an inflammed Anserine Bursa. He proceeded with my 2nd of three shots of Orthovisc and talked about giving me a steroid shot a week later. I intend to discuss Pes Anserinus and the swelling and pain of the three tendons attached to the tibia.
Is anyone familiiar with Pes Anserinus that can help me?