Back Pain Doctor
Pes Anserine Bursitis
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Pes anserine bursitis is inflammation of the bursa on the inner side of the knee, just below the joint line, where three hamstring tendons attach to the shinbone. It is a common cause of inner knee pain, particularly in runners, cyclists and swimmers, and in people who already have knee osteoarthritis.
Assessment focuses on confirming the source of the pain by its location and pattern, and considering other causes of inner knee pain: meniscal tear, stress fracture, medial ligament injury and osteoarthritis. Contributing factors such as training load, hamstring tightness, footwear, foot and leg alignment, and body weight are also reviewed, because these often drive the problem and its recurrence.
First-line care is usually relative rest and load modification, ice, simple analgesia or a short course of anti-inflammatory medication where appropriate, and a physiotherapy program targeting hamstring flexibility and lower-limb strength. A corticosteroid injection may help settle a persistent flare in some cases. Where symptoms are ongoing despite conservative care, selected treatments such as focused shockwave may be considered as an adjunct to an active rehabilitation plan.
Common symptoms
- Pain and tenderness on the inner side of the knee, a few centimetres below the joint
- Pain that increases with exercise or climbing stairs
- Puffiness or tenderness to touch in that area
- Stiffness or pain after sitting for a long time with the knees bent
Commonly seen in
Evidence for twelve treatment options in pes anserine bursitis
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).
Pairing reviewed 2026-09-02.
Where it fits
Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. No trials at this bursa
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Searching dry needling, trigger point work, needling and lignocaine against the pes anserine returned a single record, and it is a survey of what sports physicians choose to inject rather than a trial (Cushman, PM R 2021). Nothing has tested needling or trigger point injection at this bursa. What has been mapped is that the medial knee is a common site for tender points: across 483 people with knee pain at four centres, 76 with medial-side diagnoses including pes anserine bursitis had tender points clustered on the medial knee with referred pain into the adductor group and medial calf (Qin, Zhen Ci Yan Jiu 2020) - an observational mapping study, not a treatment trial. The injection literature at this bursa tests corticosteroid, dextrose and ozone placed into the bursa itself, which belongs to the guided injection and prolotherapy rows rather than to this one.
Pairing reviewed 2026-09-19.
Where it fits
Considered where examination finds a tender band in the medial thigh or calf reproducing part of your pain, rather than tenderness over the bursa itself.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Good support
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).
Pairing reviewed 2026-08-30.
Where it fits
Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. No radial-device trial
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Searched 18 October 2026 (shockwave, shock wave or ESWT with anserine, anserinus or pes anserinus; 5 records, all read): no trial of radial shockwave in this condition. The sham-controlled trial and the cortisone-comparison trial both used a focused probe (Khosrawi, Adv Biomed Res 2017; Gouda, Adv Orthop 2023), and a third trial did not state its device (Majidi, Med J Islam Repub Iran 2023). For this condition the old statement that the trials used focused devices is correct.
Pairing reviewed 2026-10-18.
Where it fits
The pes anserine lies close to the skin, so radial is plausible here and can be discussed alongside a strengthening program, but patients are told the trials used a focused device.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Beat sham in one 40-person trial
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Searched 18 October 2026: shockwave, shock wave or ESWT with anserine, anserinus or pes anserinus (5 records, all read; the 180-person trial read in full). In 40 people with pes anserine bursitis of more than three months that had not settled with other care, three weekly sessions of focused shockwave lowered pain more than sham at three weeks and again eight weeks after treatment (Khosrawi, Adv Biomed Res 2017; the abstract gives p-values, not effect sizes). Against a cortisone injection it did worse in the short term: in 180 people randomised to cortisone, PRP or four sessions of focused shockwave, cortisone gave the most relief at one and eight weeks (pain at eight weeks 2.2 out of 10 with cortisone, 4.4 with shockwave), though the paper's tables contain inconsistencies (Gouda, Adv Orthop 2023). In 53 people a guided cortisone injection did better at one month and shockwave better at three months, the device type not stated (Majidi, Med J Islam Repub Iran 2023). All three are single-centre, with follow-up of three months or less, and none reports harms in figures.
Pairing reviewed 2026-10-18.
Where it fits
Worth discussing alongside strengthening and load management for inner-knee pain over the pes anserine that has not settled. A cortisone injection works faster; in one trial shockwave held up better by three months.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Case series; cortisone better early
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Studied here, mostly without a comparison group. In 33 people with long-standing pain at the pes anserinus given one injection of PRP into the painful area, 28 (85%) had complete or near-complete relief within six months, with a poorer response where knee arthritis was advanced (Rowicki, Ortop Traumatol Rehabil 2014). In a randomised trial of 60 people comparing one ultrasound-guided PRP injection with two a week apart, both groups improved in pain, function and walking distance at four and twelve weeks with nothing between them. At twelve weeks 78% reported complete or significant relief and 7% were worse, but there was no group without PRP (Karabaş, Transfus Apher Sci 2021). The one comparison with another treatment went against it in the short term: in 180 people randomised to cortisone, PRP or shockwave, cortisone gave better pain and function scores than PRP at one and eight weeks. The groups were not well matched for pain at the start, and nobody was followed beyond eight weeks (Gouda, Adv Orthop 2023). There is no placebo-controlled trial. A systematic review of the bursae around the knee describes PRP as a promising alternative for cases that have not settled, while calling for better trials (Hasan, Cartilage 2025).
Pairing reviewed 2026-10-10.
Where it fits
Can be discussed for pain at the inner knee that has not settled with load management and strengthening, particularly where a cortisone injection has worn off or is best avoided. Cortisone works faster, and Patients are told so. If used, PRP is placed at the tender area under ultrasound guidance to make the strengthening program more tolerable, and the knee joint itself is assessed, because arthritis there predicts a poorer response.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Outlasted cortisone in one trial
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Tested in one randomised trial. Seventy-two people with pes anserine bursitis, most of them women and with an average age of 61, were randomised at several centres to an ultrasound-guided injection into the bursa of cortisone, oxygen-ozone or 20% dextrose. All three groups improved. Cortisone and ozone were ahead on pain and function at one week, and by eight weeks ozone and dextrose were ahead of cortisone (Babaei-Ghazani, Am J Phys Med Rehabil 2024). The limits: 72 people split across three groups, eight weeks of follow-up, and no placebo group, so it shows dextrose lasting longer than cortisone rather than dextrose beating no treatment. A search for dextrose or prolotherapy at the pes anserine returned four records and no other trial. The one other clinical report is a single badminton player treated with weaker 5% dextrose at the tendon attachments (Yang, Int Med Case Rep J 2026).
Pairing reviewed 2026-10-10.
Where it fits
Can be discussed for pain at the inner knee that has not settled with load management and strengthening, particularly where a cortisone injection has given only short relief. It rests on one small trial, and Patients are told so. If used, it sits alongside the strengthening program and does not replace it.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used here
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Not offered here, and not studied. PubMed searches pairing hyaluronic acid with pes anserine terms found no study of any kind; the only record describing injection at this site uses cortisone (Cardone, Am Fam Physician 2003). In the one randomised trial of hyaluronic acid into a bursa, at the shoulder rather than the knee, it was only marginally better than saline (Hsieh, Clin Rehabil 2021). This is an absence of evidence at this site, not evidence that it fails.
Pairing reviewed 2026-11-09.
Where it fits
Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this bursa and its tendons sit outside the knee joint. Where knee osteoarthritis coexists, the joint itself is assessed separately.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No trial of perineural injection at this site. The randomised evidence here tested a different injection: 72 people had ultrasound-guided 20% dextrose, corticosteroid or oxygen-ozone placed into the bursa itself, with dextrose and ozone still ahead of corticosteroid at eight weeks (Babaei-Ghazani, Am J Phys Med Rehabil 2023). That is prolotherapy into the bursa, not dilute dextrose around a nerve. The only report using the perineural technique nearby is a single case, in which 5% dextrose at the sartorius, gracilis and semitendinosus tendon traction points settled medial knee pain from 8 to 1 out of 10 (Yang, Int Med Case Rep J 2026).
Pairing reviewed 2026-09-09.
Where it fits
Considered only where the medial knee is tender over the skin and superficial nerve territory rather than over the bursa. If the bursa is the problem, the injection that has been tested is the one placed into it.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Searching hydrodissection and hydrorelease against pes anserine and pes anserinus returns no records at all, so this technique has not been reported at this bursa. What has been reported nearby is treatment of the infrapatellar branch of the saphenous nerve, which crosses exactly this part of the inner knee and can cause pain here: 16 people with persistent medial knee pain after knee replacement had the nerve hydrodissected and freed from the surrounding tissue planes, nine of them dropping to a pain score of 0 or 1 (Clendenen, Clin Orthop Relat Res 2015), with a later series of 29 holding its gain at nearly five years (Shi, Cureus 2020). Both authors call for a placebo-controlled trial, which has not been done.
Pairing reviewed 2026-09-15.
Where it fits
Only where the inner knee pain has a nerve quality (burning, numbness or an area that feels oversensitive to touch) and the examination points to the infrapatellar branch of the saphenous nerve rather than to the bursa. The bursitis itself is treated by the options higher up this page.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other knee conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How is pes anserine bursitis diagnosed?
What does treatment involve?
What else can cause pain in the same area?
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