In this installment of our “injury of the week” series we’re going to be talking about pes anserine. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system so that you’ll have a “sample treatment session”.

So where is the pes anserine?

Any time you have multiple muscles attaching at one point, you have the potential for problems. The pes anserine is one of these areas and involves three separate muscles that cross the inner knee joint to insert on the tibia (lower leg bone). They are the sartorious (blue line), gracilis (red line) and the semitendinosus (purple line and part of the inner hamstring muscles). Together these muscles act as an important stabilizer for the inner knee.

#1 Gracilis.

Of all the inner thigh muscles, the gracilis is the easiest to find. Unlike the other adductor muscles which work their way in towards the femur (long thigh bone), the gracilis remains on the outside and works it’s way straight down towards the knee and it’s insertion into the pes anserine. Click here to review the anatomy and for palpation tips to find the muscle.

# 2 Sartorious

This muscle is a small rope like muscle that originates on the anterior illiac (hip) bone and wraps across the thigh to insert just below the inside of the knee. To find this muscle, bend your knee and flex your hip (bring the knee up towards the ceiling). Rotate your whole leg OUT (like you’re trying to prop your ankle up on your other knee). You will feel the Sartorious move under your hand. Click here to review the anatomy and for palpation tips to find the muscle.

#3 Semitendinosus

The semitendinosus is one of two medial (inner) hamstring muscles. It is a small, thin muscle that has a long tendon and wraps around the inside of the knee to insert into the front of the tibia. When bending/straightening your knee, you will feel two ropes moving behind the knee. The innermost rope is the semitendinosus and can be traced to its insertion on the pes anserine. Click here to review the anatomy and for palpation tips to find the muscle.

Those are three powerful muscles that can generate A LOT of force on one area. To help alleviate that a bursa is located under the tendon to reduce friction. What does that mean?  It means that you can have a variety of injuries at this area. The bursa could get inflamed. The tendon could get irritated or any of the three muscles running into that insertion point can get injured.

Why do these injuries occur?

In the past we’ve talked about injuries that occur because of other problems in the legs. The pes anserine is definitely one of these injuries and typically pops up while compensating for something else. Here’s a video to help explain some of these mechanisms of injury.

The inside of my knee hurts? NOW WHAT?

The first step is determining if it is truly a pes anserine injury or something else. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. It can start as a gradual ache/pain during workouts or even after. It can also be one of those injuries where nothing is wrong until you sit down and stiffen up. Then all of the sudden- ouch!

Typical symptoms with pes anserine injuries include pain or tightness on the inside of the knee. They can move all the way up into the inner thigh as well Symptoms are typically worse with activity and better with rest, and swelling can occur at the lower tendon (where all three muscles attach onto the tibia) if the inflammation is severe enough or the bursa is irritated.

Here are some guidelines for when seeing a doc should be your top priority: 1) If you see any bruising and/or swelling, and 2) numbness/tingling along the front/inner part of the thigh or calf). An injury to the pes anserine is a symptom of a bigger problem. Think of it like a link in the chain. Something stopped working and that chain got snapped due to the increased strain on it.

Be smart. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:

• Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Pes anserine injuries respond well to hands on/massage work. Because this injury is typically a sign of other restrictions in the legs, exercise alone won’t cut it as the whole leg has learned to compensate and multiple muscle groups will require attention.
• Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.

How to treat it.

 **download PDF with links, sets, reps, progressions, etc here**

( Click here for a walk through of how to use our PDF pages! )

Step 1- Traditional R.I.C.E. treatment:

When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage.

Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.

Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.

Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them or calf sleeves). In the case of a pes injury, compression shorts or tights (versus the calf sleeve or sock) are best.

Step 2- Kinesiology taping:

By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Make sure to read the application instructions first! This stuff should last 3+ days, not fall off in an hour. That means you need to prep the skin so that it is hair free and clean. 

1) Pes anserine application. Click here.

Step 3 – Getting mobility back

The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a post tib injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.

1) R.I.C.E. + gentle stretching. There should be no pain with stretching.

2) Begin using the foam roller to work around the injury first. The goal here is to start getting slack into pes anserine without aggravating the injury itself. To do that we need to work up into the thigh to loosen up the inner hamstrings and adductors. At this stage in the healing, lets hold off on the tennis ball work and active/joint mobilizations. The order should be foam roll the muscles around the area of pain -> stretch -> RICE. (** Remember- with pes anserine injuries you need to fix two things: 1) the muscle injury itself and 2) the muscles/restrictions that led to the injury. Fix just one and the other will be back to stir up problems again.)

3) Begin using the foam roller over the painful area to tolerance. The order should be foam roll the muscles around the injury-> over the injury -> stretch -> RICE.

4) As the tendon/muscle heals, we can really start to go after the muscles using the deeper cross friction and trigger point techniques.

5) Lastly, to really loosen up the post tib, we’re going to add muscle mobilizations as well as joint mobilizations at the hip and down at the ankle. The order should be foam roll around the injury -> over the injury -> cross friction/trigger point -> mobilizations -> stretch -> RICE.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

Here’s what it looks like (remember, we move left to right on the chart):

Step 4- Strengthening

We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.

Why these exercises? The whole goal of this progression is restore muscle balance so that the large muscles in the back of the hip (glutes) are doing more of heavy lifting than the quads/hamstrings. When you start to lose that big muscle control and power, that’s when things start to get out of whack, and you start pulling the leg around.

What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.

Optional equipment: 1) a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20. 2) suspension trainer. These are starting to get really popular in gyms and very affordable to get for home. Great all around strength training aid.

Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.

Level One

Level Two

Level Three

To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts.

Hope that helps, and fire away with any questions in the comments.

References

1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.

5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.

6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.