pathology: pes anserinus syndrome

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pes anserinus syndrome

Definition of

Insertion tendinopathy of the pes anserinus superficialis(pes anserinus syndrome at the insertion of the satorius, semitendinosus and gracilis on the inner tibia), usually arising as overuse syndrome, initially without, later often with involvement of the bursa(bursitis). Among track and field athletes, this is the second most common injury after stress fractures. Cross-country skiers in particular are often affected, as the hamstrings contributes significantly to propulsion. In addition to athletes, non-athletes are also affected, especially overweight women with gonarthrosis. A distinction can be made between acute and chronic-relapsing according to duration and course. It is characterized by pain on endorotation of the lower leg in the knee joint with simultaneous flexion.

ICD M76.8

Cause

  1. Overuse: overloading or incorrect loading of the leg
  2. Trauma

Predisposing

– Behavior

  1. Prolonged walking on unstable or sloping ground
  2. Poor running technique
  3. Material defects, inadequate footwear, running shoes without pronation support

– Musculoskeletal system

  1. Gonarthrosis
  2. muscular imbalances
  3. Shortening of the hamstrings
  4. Pelvic instability
  5. Ankle instabilities
  6. Hyperpronation / bowed foot
  7. X-legs
  8. Flatfoot

– Diseases

  1. Metabolic diseases such as diabetes mellitus

– Other factors

  1. Pregnancy (endocrinological)
  2. female gender

Diagnosis

  1. usually clinical
  2. If necessary, MRI to rule out other diseases. This may be unremarkable or there may be tendon edema, possibly bursitis (effusion)
  3. Disappearance of symptoms after local lidocaine infiltration confirms the diagnosis, persistence is equivalent to exclusion

Symptoms

  1. Exercise-induced pain, especially when the hamstrings is stressed, such as walking more vigorously, climbing stairs, running, jumping. Initially it manifests itself as localized pain at the medial tibial plateau, which subsides with prolonged exertion; later permanent pain on exertion.
  2. Possibly palpable swelling
  3. tenderness at the pes anserinus, distal to the joint space
  4. with prolonged presence of crepitations over the tendon insertion
  5. Morning pain after training the day before

Therapy

  1. Suspension of training or reduction/adjustment of training
  2. Inlays if necessary
  3. Technique training, running analysis
  4. PT with leg axis training, core and pelvic stabilization
  5. Stretching exercises for the affected muscles: the hamstrings, the adductors (especially the gracilis) and their important antagonists
  6. Strengthening the quadriceps and adductors
  7. Coordination and proprioception training
  8. Checking and improving the muscle chains
  9. Injection of thrombocyte-rich plasma (ACP)
  10. In acute cases: above all relief
  11. In chronic cases: primarily training of the affected muscles
  12. if necessary: weight reduction
  13. If necessary, optimization of the material (footwear, surface)
  14. If necessary, improvement of the setting for diabetes or RA
  15. As with most insertional tendinopathies: avoid triggering pain in everyday life and training
  16. extracorporeal shock wave therapy
  17. Caution with cortisone infiltrations due to the risk to tendons (necrosis, rupture)
  18. With consistent conservative therapy, the prognosis is good: spontaneous healing usually occurs if there are few risk factors.
  19. Temporary switch to other sports if necessary

DD

  1. Irritation of the medial collateral ligament
  2. Complaints of the medial meniscus

Asana practice

This is an insertional tendinopathy of one of the muscles that attach to the superficial or profund pes anserinus:

  1. superficial: Semitendinosus, Gracilis and Sartorius
  2. profund: semimembranosus

It is necessary to find out which of these four muscle insertions is affected, as the functions of the muscles differ:

  1. the gracilis is the knee flexor, adductor and turns the leg out a little
  2. the Sartorius is also a knee joint, rotates significantly in the hip joint and flexes it
  3. The semimembrannosus and semitendinosus are both knee flexors and hip extensors, and they also turn the lower leg significantly.

If the gracilis is the main cause of the symptoms, wide abductions with the knee joint extended will mainly have a stretching effect and thus reduce the tension on the attachment area. This can lead to significant relief of the symptoms, as all adductions are supported by other adductors. In the respective position, the leg should only be turned out as far as necessary, but not to the maximum, in order to enable the best possible stretching of the gracilis.

This must be practiced with the knee joint extended. The typical pain should be avoided as far as possible. In addition to stretching, the resilience of the muscles should be increased; all strengthening exercises that are not jerky or jerky, but rather sustained(isometric) or calmly dynamic, are helpful here. Again, the typical pain should not be triggered. As with stretching, various rotation situations and flexion anglesshould also be practiced here. It is not possible to strengthen the gracilis in isolation, as other adductor muscles are always involved. However, the degree of flexion in the knee joint changes the length of the sarcomere in which the gracilis works.

In principle, all standing postures that involve moving or holding the adductor group in all possible sarcomere areas are indicated here. However, postures other than standing postures can also have a strengthening effect on the gracilis, e.g. the lower leg in jathara parivartanasana is held in position by the adductors. Another example is maricyasana 1, in which the upright leg stabilizes the position of the pelvis.

It is well known that every muscle must be considered with its group of antagonists. Among the abductors, the most powerful, the gluteus maximus, which is also an exorotator, plays a particularly important role. This should also be in good condition in terms of stretching ability and strength.

As the gracilis, even if it is not counted as a classic hip flexor, still has a hip flexing effect, the extension ability of the hip joint should also be tested and improved if necessary, especially as this direction of movement occurs very little in everyday life. Because of its knee-bending effect, hip extensions with stretched or widely extended legs, such as urdhva dhanurasana, are suitable.

To strengthen the gracilis, its hip-flexing effect can be used in addition to the adduction, even if the hip flexors will certainly provide the majority of the strength there. This can be practiced in jathara parivartanasana as well as in tolasana or supta dandasana and similar poses.

In addition to the gracilis, the muscles of the inner hamstrings attach to the pes anserinus: Semimembrannosus and semitendinosus. These muscles are stretched by all forward bends, whether sitting or standing, as well as by many standing postures. Standing forward bends should be preferred due to the significantly more favorable effect of gravity, especially in less mobile people, and the far fewer side effects in the lumbar spine area. The greater force exerted by standing forward bends also has a slightly strengthening effect, which is very welcome in this case, but the insertion pain must not be triggered. In the area of strengthening there are also some very useful postures that allow the hamstrings to work at different sarcomere lengths. If the range of motion is too small to trigger insertion pain, the knee joints can be flexed a little. The range here extends from the right-angled uttanasana and the 3rd warrior pose backwards against the wall to the quite angle-neutral (close to neutral zero in the hip joint and knee joint) purvottanasana with extended legs, performed on one or both legs. The hamstrings is also often used powerfully for extensions of the hip joint, so many backbends are also suitable.

The last muscle that attaches to the pes anserinus is the sartorius. It is used and strengthened in all postures that perform the movement required to assume the lotus or cross-legged position. In the asanas, this movement is typically not performed using the strength of the sartorius, but the arms are used to create a good situation for the medial meniscus through the best possible exorotation of the thigh in the hip joint. There don’t seem to be any movements or postures that cover all directions of movement of the sartorius and are also good for the medial meniscus. Even lifting the lower leg towards the horizontal in a seated position in line with gravity with the thigh turned out creates valgus stress in the knee joint, which not everyone can tolerate and which is of no benefit to anyone. The sartorius can therefore only be activated synergistically with other muscles that contribute more strength to the respective movement. These are

  1. Exorotation of the thigh in the hip joint: many standing postures with the leg turned outwards
  2. Flexion of the hip joint: postures in which the hip joint is flexed against the tension of the hip extensors (all seated or standing forward bends) or against the effect of gravity ( tolasana)
  3. Flexion of the knee joint or without recognizable flexion Stabilization of the knee joint against hyperextensive moments: there are few possibilities to strengthen the sartoriuswith this, as the muscles on both sides of the hamstrings are always involved and carry the greater part of the load. Asanas do not address this, but functional exercises can be designed to do so.

The shortening of the hamstrings, which is one of the risk factors, has already been covered in the above. Hyperpronation as a risk factor can be countered by strengthening the supinators of the ankle. This includes balancing postures and many standing postures in which the lower leg muscles must be used to create a stable stance and counteract small rocking movements around the longitudinal axis of the foot. Not only the standing postures on one leg such as vrksasana or 3rd warrior pose are suitable for this, but also all postures with a narrow physical base of support in which the pelvis points towards one foot such as in parsvottanasana or parivrtta trikonasana. These poses also train the muscles that support the longitudinal arch of the foot.

Finally, there is the strengthening and stretching of the quadriceps, which play an important role as the antagonist of the hamstrings.

Asanas

Since the etiology of the disorder is not uniform and different muscle insertions can be affected, the following list must be given in no particular order.

  1. Asanas in 721: Stretching the hamstrings
  2. Asanas in 722: Strengthening the hamstrings
  3. Asanas in 811: Stretching the quadriceps
  4. Asanas in 812: Strengthening the quadriceps
  5. Asanas in 756: Stretching the gracilis
  6. Asanas in 757: Strengthening the gracilis
  7. Asanas in 831: Stretching the Sartorius
  8. Asanas in 832: Strengthening the sartorius muscles
  9. Asanas in 862: Strengthening the supinators