Goosefoot tendinitis or tendinopathy

Pain on the inside of the knee that appears when you climb stairs or start running again after winter. This burning or tender sensation just below the knee often indicates pes anserine tendinopathy.

This condition frequently affects runners, cyclists, and people over 50.¹ The good news is that it responds well to conservative treatment, and the vast majority of people recover completely. This guide explains what causes this pain, how to recognize it, and how to treat it effectively.

What is pes anserine tendinopathy?

Pes anserine tendinopathy is an irritation of one or more tendons located on the inside of the knee. It results from repeated overuse of this area, especially during knee bending and straightening activities.

What is the pes anserine?

The pes anserine refers to the spot where three knee tendons attach together on the shinbone (tibia), just on the inside and slightly below the knee. These three tendons come from the following muscles:

The name "pes anserine" comes from the shape of the three tendons' attachment, which resembles a goose's webbed foot. A bursa (a small fluid-filled sac) is located beneath these tendons to reduce friction. When this bursa becomes irritated, it's called pes anserine bursitis.

What is the difference between tendinitis and tendinopathy?

These two terms refer to almost the same condition. Science has discovered that inflammation is not always present in tendon pain.²

When tendon pain occurs without inflammation, it's called tendinopathy. When the pain is accompanied by inflammation, it's called tendinitis. In both cases, the management remains similar.

What causes pes anserine tendinopathy?

Pes anserine tendinopathy occurs when the tendons are repeatedly overloaded beyond their capacity to recover. Repetitive bending and straightening movements of the knee place significant stress on these structures.

The Mechanism of Overuse

Your tendons are like strong ropes. Every time you run, cycle, or climb stairs, these ropes experience significant forces. Normally, your tendons repair themselves during rest.

The problem arises when the demands placed on your tendons exceed their ability to repair. The tendon fibers gradually wear down, and areas of irritation appear where they attach to the shin bone.

Main Risk Factors

Common Scenarios

Certain situations frequently trigger this condition:

• Restarting running after winter without gradual progression
• Going on a mountain hike with many downhill sections
• Suddenly increasing cycling distance
• Resuming sports after a long break

Knee osteoarthritis significantly increases the risk. Up to 75% of people with knee osteoarthritis also have associated pes anserine tendinopathy.³

What are the symptoms of pes anserine tendinopathy?

The main symptom is pain on the inside of the knee, about 5 cm below the joint. This pain can spread along the inside of the shin bone.

Key Signs

• Localized pain on the inside of the knee, just below the joint
• Tender area to the touch on the inner shin bone
• Pain that increases when going up or down stairs
• Pain after running or prolonged walking
• Morning stiffness that improves with movement

• Doing a squat
• Crossing legs while sitting
• Turning the knee inward
• Getting up from a low chair

Typical Presentation

Initially, pain only appears after activity. You might finish your run without a problem, then feel the pain in the evening or the next morning.

If the condition progresses, pain will appear during activity. It can even occur during simple tasks like climbing a few stairs. In advanced cases, the pain persists even at rest.

This suggests something else

Consult quickly if you notice:

• Significant knee swelling
• Redness or warmth in the area
• Constant pain that does not change with activity
• Locking or a feeling of instability in the knee
• Intense nighttime pain that prevents sleep

How is pes anserine tendinopathy diagnosed?

Diagnosis is mainly based on your symptom history and a clinical examination. The physiotherapist or doctor will locate the pain by palpation (touching the area) and reproduce your symptoms with specific tests.

Clinical evaluation

The evaluation includes:

• When did the pain start?
• Have you changed your activities recently?
• Is the pain localized or diffuse?
• What movements make it worse?

• Palpation of the painful area (tenderness to touch?)
• Knee flexion and rotation tests
• Assessment of leg alignment
• Thigh muscle strength tests

The role of imaging

In most cases, no imaging is required. A clinical diagnosis is sufficient to begin treatment.

X-rays do not show tendinopathy, but they can reveal associated osteoarthritis. An ultrasound can confirm tendon thickening or bursitis if the diagnosis remains uncertain.

MRI is rarely necessary. It is mainly used to rule out other problems in complex cases.

How does physiotherapy treat pes anserine tendinopathy?

The main treatment combines managing the load on the tendons with progressive strengthening exercises. The goal is to help the tendons adapt while avoiding overload. Patience is essential, as tendons take time to remodel.

The initial assessment

Your physiotherapist will evaluate several factors:

• Your joint mobility in the knee and hip
• The gliding of your nerves
• The quality of your movements (squatting, walking, climbing stairs)
• Your muscle strength and stability

The fundamental principle: load management

The key to treatment is finding the right amount of activity. Too little load can weaken the tendons, while too much can cause persistent irritation.

Specifically, this means:

• Temporarily reduce activities that worsen pain
• Maintain moderate physical activity (swimming, pain-free cycling)
• Gradually Introduce Therapeutic Exercises

Types of Therapeutic Exercises

Other interventions

Your physiotherapist may also use:

• Knee mobilizations to reduce pain
• Advice on modifying your daily activities
• Recommendations for your footwear or orthotics
• Guidance on the optimal intensity and volume for your sports activities

How long does it take to recover?

Recovery from pes anserine tendinopathy generally takes 4 to 8 weeks with adequate treatment. Chronic cases may require 3 to 6 months. Patience is essential as tendons remodel slowly.⁴

Phases of healing

Factors indicating a good prognosis

• Symptoms for less than 3 months
• Pain only after activity
• Good adherence to the exercise program
• Willingness to temporarily modify activities

Factors indicating a less favorable prognosis

• Symptoms for more than 6 months
• Continuing activities despite pain
• Associated knee osteoarthritis
• Unmodified risk factors

When to consult a physiotherapist?

You should consult a physiotherapist if you have symptoms as described above, or if your doctor has already ruled out any other causes for your pain.

You do not need to see a doctor before consulting a physiotherapist. If your condition requires further medical evaluation, your physiotherapist will be able to inform you.

• Pain persists for more than 2 weeks despite rest
• Pain limits your daily activities
• You notice significant swelling or redness
• Pain keeps you from sleeping

What to do at home to relieve pain?

Temporarily stop movements that cause too much pain, then gradually resume them.

Tips that can help

• Ice: Apply ice for 15-20 minutes after painful activities
• Alternative activities: Swimming, pain-free cycling, walking on flat ground
• Strengthening exercises: Work your glutes with exercises like bridges
• Gentle stretches: Stretch your hamstrings and adductors without forcing

What to Avoid

• Pushing through the pain
• Increasing activity volume too quickly
• Remaining completely inactive (weakens tendons)
• Aggressive stretches that increase pain

Frequently Asked Questions

Can pes anserine tendinopathy heal completely?

Yes, in most cases. With proper treatment and patience, most people recover completely and can return to their sports activities. Persistent cases are often related to inadequate load management or returning to activity too quickly.

Can I continue running with this condition?

It depends on the severity of your symptoms. If the pain remains mild and doesn't increase during or after running, you can continue with modifications (reduce distance, avoid downhill running). If the pain increases, a temporary break is necessary to allow for healing.

What is the difference between pes anserine tendinopathy and bursitis?

Both conditions affect the same region and have similar symptoms. Bursitis involves inflammation of the bursa (a small fluid-filled sac) under the tendons. Tendinopathy affects the tendons themselves. Often, both conditions coexist. The treatment remains similar.

Are anti-inflammatories helpful?

Anti-inflammatory medications can temporarily relieve pain, but they don't address the underlying issue. Since tendinopathy is generally not inflammatory, their usefulness is limited. Therapeutic exercise remains the primary treatment.

How to Prevent a Recurrence?

Prevention involves maintaining a strengthening program, gradually increasing training loads (never more than 10% per week), adequate warm-up before activities, and listening to the first signs of overload.

References

1. Rennie WJ, Saifuddin A. Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal Radiol. 2005;34(7):395-398.

1. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416.

1. Uysal F, Akbal A, Gokmen F, Adam G, Resorlu M. Prevalence of pes anserine bursitis in symptomatic osteoarthritis patients: an ultrasonographic prospective study. Clin Rheumatol. 2015;34(3):529-533.

1. Mohseni M, Graham C. Pes Anserine Bursitis. StatPearls Publishing; 2023.

1. Uson J, Aguado P, Bernad M, et al. Pes anserinus tendino-bursitis: what are we talking about? Scand J Rheumatol. 2000;29(3):184-186.

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Pes anserine tendinopathy causes pain on the inside of the knee, just below the joint. It often affects runners and responds well to physiotherapy treatment.

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