Physical Therapy Approach for Pes Anserine Tendonitis

First-Line Physical Therapy Interventions

Eccentric strengthening exercises combined with stretching should be the primary physical therapy approach for managing pes anserine tendonitis, as these interventions have demonstrated effectiveness in reducing pain and improving function in tendinopathies 1, 2
Active exercise therapy should be prioritized over passive modalities, as active interventions promote self-management and have shown greater effectiveness in tendinopathies 3
Eccentric strengthening exercises specifically targeting the pes anserine tendons are recommended to reduce symptoms, increase strength, and promote tendon healing 4, 5
Stretching exercises for the involved muscles should be incorporated to improve flexibility and reduce tension on the tendon insertion 6
Rest from aggravating activities is important to prevent ongoing damage while continuing activities that don't worsen pain; complete immobilization should be avoided to prevent muscular atrophy 6

Ice application through a wet towel for 10-minute periods is effective for short-term pain relief by reducing tissue metabolism and blunting inflammatory response 6, 7
Deep transverse friction massage can be used to reduce pain and promote healing in the tendon 4
Correction of biomechanical issues with appropriate orthotics may be beneficial, particularly if excessive foot pronation or pes planus is contributing to the condition 6

Initial phase (1-2 weeks): Relative rest from aggravating activities, ice application, gentle stretching of hamstrings and adductors, and NSAIDs for pain control if appropriate 1, 6
Intermediate phase (2-6 weeks): Progressive eccentric strengthening exercises, continue stretching program, deep transverse friction massage, and address biomechanical issues with orthotics if needed 1, 4, 5, 7
Advanced phase (6+ weeks): Sport or activity-specific exercises, return to normal activities as tolerated, and maintenance program to prevent recurrence 2, 5, 6

Avoid complete immobilization as it leads to muscle atrophy and deconditioning 6
Corticosteroid injections may provide faster short-term relief but don't improve long-term outcomes and could potentially weaken the tendon structure 7
Injections around tendons should be performed with caution; particularly avoid direct injections into the tendon substance due to risk of rupture 3

The British Journal of Sports Medicine recommends biomechanical assessment and running retraining for lower extremity injuries, including pes anserine bursitis, to optimize lower extremity biomechanics during running 8, 9
Addressing core and proximal strength is important to optimize lower extremity biomechanics during running, as recommended by the British Journal of Sports Medicine 8

Running-specific exercises with gradual return to running activities, combined with biomechanical assessment and running retraining, are recommended for the advanced phase of treatment, as suggested by the British Journal of Sports Medicine 8, 9

The American Geriatrics Society recommends performing stretching exercises daily, preferably when pain and stiffness are minimal, such as before bedtime 10
The American Geriatrics Society suggests beginning with a warm shower or application of superficial moist heat to prepare the muscles for stretching 10
The American Geriatrics Society advises ensuring relaxation before beginning the stretching routine 10

The American Geriatrics Society recommends a hamstring stretch, sitting with the affected leg extended straight in front, slowly reaching forward toward the toes until a gentle stretch is felt, holding for 10-30 seconds 10
The American Geriatrics Society recommends an adductor stretch, sitting with the soles of the feet together and knees bent outward, gently pressing the knees toward the floor until a stretch is felt in the inner thigh, holding for 10-30 seconds 10
The American Geriatrics Society recommends a sartorius stretch, sitting with the legs crossed, gently leaning forward until a stretch is felt along the inner thigh, holding for 10-30 seconds 10

The American Geriatrics Society suggests performing movements slowly and extending the range of motion to a point that is both comfortable and produces a slight sensation of resistance 10
The American Geriatrics Society advises remembering to breathe normally during each stretch 10
The American Geriatrics Society recommends holding the terminal stretch position for 10-30 seconds before slowly returning to the starting position 10
The American Geriatrics Society suggests modifying stretching exercises to avoid pain when the area is inflamed, decreasing the range of motion or duration 10

The American Geriatrics Society recommends structuring each exercise session with three essential phases: warm-up, training period, and cool-down 10

The American Geriatrics Society warns against stretching too aggressively, which can worsen symptoms 10
The American Geriatrics Society advises against neglecting to warm up before stretching 10
The American Geriatrics Society recommends maintaining a consistent daily stretching routine 10