What is the role of injections of local anesthetics or corticosteroids in the management of pes anserine bursitis?

Updated: May 08, 2018
  • Author: P Mark Glencross, MD, MPH, FACOEM, FAAPMR; Chief Editor: Milton J Klein, DO, MBA  more...
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Answer

Intrabursal injection of local anesthetics, corticosteroids, or both represents a second-line treatment option. It should be considered only for refractory cases that have not responded to physical therapy, rest, ice, and NSAIDs. A study found no difference in short-term pain relief between 3-5 mL of 1% lidocaine with methylprednisolone and the same amount of lidocaine without the corticosteroid.

Injection can be directed to the point of maximal tenderness. Care should be taken to avoid injecting any of the 3 tendons converging at the pes anserinus; injection within the tendons themselves can weaken these structures and intensify the patient’s pain. Ultrasound guidance has demonstrated effectiveness in cadaveric studies, increasing accuracy from 17% (unguided) to 92%. [34]

Occasionally, an area 0.5-1 cm higher than the tendons is injected in order to include the medial collateral ligament (MCL) bursa, which also may be a pain generator. Injection of the knee joint itself may be beneficial in recalcitrant cases.

Generally, use a 22-gauge or 23-gauge needle to inject 1-3 mL of 1% lidocaine and corticosteroid (20-40 mg of triamcinolone, 20-40 mg of methylprednisolone, or 6 mg of betamethasone). If infection—which is rarer here than in the bursae of the anterior knee—is suggested, use a larger, 19- or 20-gauge needle and a 20-30 mL syringe for aspiration. Relief is usually immediate but may not be complete.

Repeated lidocaine injections or the use of corticosteroids may result in longer-lasting relief (from 1 to several months). No more than 3 injections should be used over a 1-year period, with intervals of at least 1 month between injections. It should be kept in mind, however, that patients who do not respond to the initial injection rarely respond to repeat treatments. [17] Patients who do not respond to initial injection rarely respond to repeated bursal injections.

A study by Sarifakioglu et al indicated that physical therapy and corticosteroid injection are similarly effective in the treatment of pes anserine tendinobursitis. In the study, 60 patients with a combination of knee osteoarthritis and pes anserine tendinobursitis were divided into physical therapy and corticosteroid injection treatment groups, with significant improvement seen in functional capacity and pain scores in both groups after 8 weeks. [35]


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