Pes Anserine Knee Pain That Won't Go Away: Look Beyond the Knee

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, thanks for joining us again. This is Dr. Sebastian Gonzales with the Performance Place Sports Care Podcast. Before we start, I'll tell you first what you're going to get out of this podcast. And we're going to go over knees or peasant serine tendinitis, which is around the knee on the inside part. And I'm going to go over a couple of conditions which are oftentimes confused as being peasant serine bursitis.

So this is actually a question that we've gotten off one of the YouTube videos and is, is the video on peasant serine bursitis or tendinitis? And this is a long one. I really like it when people send long ones because you get a sense of what they're dealing with. And I'm going to read this out to you all and we'll digest it from there. So this is verbatim. I think I've had peasant serine tendinitis ongoing for probably 10 years and also have back pain. So a few things going on with me. I've been to a doctor and physiotherapist a few times, no help at all. They had never heard of it. I do get tight muscles in the thigh, adductors, and hamstrings.

Ben told this when she's had massages. I have two fat pads that have developed over the years, both or over both Pez and serine. And I'm very tender when palpated there. A doctor told me it was just fat, but the massage therapist thought it had developed because of continual strain that had been on the muscles and tendons in that area, which is more likely. I read that you can make your thigh muscles go tight if crouching and squatting a lot, which I've done in the past, and it's difficult to get them right again, especially the adductors. I do stretch and have had massages in the past, and I put ice on it sometimes.

The knee support helps, but was told you shouldn't use them much. I have to take painkillers for my back, then they ease the knees. What will help? Would the strict regimen of stretching and massage help? Has this gone on, or has it gone on too long? Maybe over 10 years now. It's been too long, and she's sick of it. I used to be very active. It's difficult to walk any distance now. When I'm resting, there's a tingling sensation in the Pez and serine area. Getting arthritis in the knees now. I'm thinking of going to a sports massage, to get a sports massage and see if it'll help. Heard of someone doing it, which is good.

I wish I knew therapists in England, who are as good as you Americans are. The NHS ones I've seen here have been no help at all, and I bought some kinesio tape. Waiting for any advice. That is a long one, isn't it? I hope you didn't get lost in it. Let's just go over the major points in it. She thinks she has Pez and serine tendinitis. She's had it for quite a few years. She also has back pain. She's tried a lot of things like massage. She's been told she has, quote-unquote, fat pads. She's using painkillers and seems very frustrated. The first thing I'll talk about on this is that, actually, you know what, let's go down to the major part in the bottom.

Because she's talking about tingling sensation over the Pez and serine area. Typically, tingling is a nerve-related condition. And anytime someone comes in and starts talking about tingling or loss of sensation in an area, I automatically ask them. If we're talking about the leg, I start asking them about the back. And I know a lot of times it gets frustrating for people when we kind of jump around and question them because it seems like we're not taking their problem into consideration. But really, we're trying to find the root cause. And she's already said she's had back issues, and we don't even know what the back issues are.

And back issues or pinched nerves or stenosis, which is a narrowing of certain holes in the spine, which can be the foramen, which is where the nerve root comes out. Or it can be central, where the spinal cord is. It can all create loss of sensation. Also, too, external or peripheral nerve entrapments can create loss of sensation as well. An example of this in the arm and the hand that you're probably familiar with is carpal tunnel syndrome. But that can also be from a nerve root, which in this case would be C6. So I think that is the first thing, at least, that is coming to my attention in this.

And it seems that everyone's looking like they're ignoring it or she's not doing anything about the back. And I use this example of patients at my office a lot with referred pain. Or there's actually a reference you can look up online. There was some studies they did back in, I believe, in the 50s or 60s by Trevelle, where they injected like irritants into, say, let's say if it's the biceps, muscle belly. They'll inject it in there and they just sat back and asked the patient, what do you feel? And the patients would just tell them subjectively, I feel pain here. I feel it here. And it's just a widespread dot chart on a body that basically we're looking at.

And if you do the same thing for multiple muscles, they'll change this presentation pattern. So I always tell people that we need to figure out what the root cause is because everyone's in agreeance with heart attacks. I know the arm hurts and it goes up to the face and they get sweaty and everything, but everyone's in agreeance that we're not chasing the arm pain down. It's not the biggest issue. And in this case, this could be a referred pain. And we have to consider that everyone's really spending a lot of time down at the knee. But what if it's not even really the knee? What if it's a referred pain like a heart attack is down the arm?

But in this case, it could be from some type of neurological issue up in the spine. Now, what are the other types of neurological conditions? By the way, neurological means nerve. I want to make sure I clarify any terms that I use on these podcasts. So nerve-related conditions up in the spine, they can be oddball ones too, which I know there's a saying in school that we said that when you hear hoofs, you think horses are coming, but every once in a while it's a zebra. And this is the same in regards to conditions is a lot of times they'll be the thing that you think they are, but sometimes they're the oddball one.

MS or multiple sclerosis is something that I've seen come through my office a few times and they just present it in a really odd way, but they have similar findings to what regular conditions have. And I'm not saying that this person has multiple sclerosis, but there's always the potential of an oddball case, which we do have to consider. So I'm hearing that a lot of people are spending time down at her knee and the peasant serrini, let's just say if it is the peasant serrini, what is the typical rehab that we would do for peasant serrini bursitis? Well, first off, I'll clarify what a bursa or a bursitis is.

And a bursa is a fluid-filled sac, it's naturally there, it's there all the time. It's used as a mechanism to decrease friction amongst tendons. Tendons are extensions of a muscle which attach to bone. And I've found in a lot of people, although the bursa may become inflamed and irritated and painful, it's not usually the bursa. And we found actually through some studies in the hip, the hip bursitis or trochanter bursitis on the side of the hip is actually majority of the time it's a glute medius tendonitis. So it's a tendon issue, although there's a bursitis there. And I think it's mainly because of proximity.

It's because if one thing is irritated, the other one's irritated. But that one thing that's irritated, which is the bursa in this case, more, it's just because it's more susceptible to irritation. The tendon really doesn't change in size too much. It just is there and it's pissed off and it's creating a chemical response in everything in the area, which does affect things in proximity as well. And this is why in conditions like, let me think of one, say you hit your arm on a table, it'll swell up because the tissues there are irritated. And fluid and material are coming in there to address the condition.

That's what we call an inflammatory response. So the rehab with Pesansarani is really, I give a lot of trunk stabilization exercises. And I will give things specific for the knee. But mainly it's, I think of the knee as purely in a geometry form. And I think of the tibia and the femur, which are the bones above and below, below and above, as columns. And if you compress them, they're actually really good at doing their job. But if you tilt them or rotate them, they don't like it. And same with the muscles going around the knee. They're not really intended to be continually irritated due to abnormal motions.

And a lot of the improper stacking or landing of the knee is from the hip and trunk. And if they're strong enough or coordinated enough to get these motions right. Now, sure, we can keep addressing the knee. But I think there's a bigger thing here. And the commonality we're finding between the two things that she's mentioning is, well, there's a knee condition. Okay, so we'll strengthen the trunk. Because we found that majority of cases that if you have a knee condition, you strengthen the trunk and the hips and they get better. She has a back condition. What's the remedy for that? A lot of it is trunk stuff.

And so we're finding that these things kind of come into a common ground. And from a rehab perspective, it does take a little bit of time. And this is part of the problem that I've noticed with patients that come in is they want a quick fix. They want someone to rub on something. They want something adjusted. They want something injected. Which will make them feel better. But it doesn't change how you move. And it doesn't change how strong you are. Coordination, strength, and movement patterns don't change overnight. They can improve over the course of a couple hours if you're training them. But a lot of times people forget how to do them.

And they go back into their old habits. Which is perfectly normal. But it does take a lot of time to get these things to respond. And hypertrophy, which is the increase of muscle size due to cross-sectional area or the girth of it, it doesn't even happen until at least three months. Sometimes four. And that's doing something majority of the times of the week. That's four times a week of doing something in that area. So there's a lot of work to be done. And it's going to take a good mental mindset to be able to commit to it. So if there's disbelief in what I'm saying right now with knee conditions, the strongest thing I could recommend is that you need to do your own research.

Because the research is very clear on what has helped in the past. And they're doing new research all the time. So this podcast could be outdated for all we know by next year. But I really doubt it. Because they found in the past that strengthening the hip and the torso and even the ankle are helpful with knee conditions. Now, some conditions of the knee which may mimic Pesanserani bursitis are there could be the ligament around the inside part of the knee, which is the MCL. So there could be an MCL injury or there could be a medial meniscus injury. And I don't even know if I would suggest doing images on this type of case.

Because I don't actually want, I wouldn't want the person in this case to see what is happening in the knee. Because if she's had it for 10 years, there's probably arthritis there. There's probably meniscal tears. There's probably strains. There's probably tendinitis. There's probably everything around there. And I know from a patient perspective, a lot of times you see that and you're like, oh, man, I'm damaged. I don't know if that's coming back. And I've met many people like this. My grandma's one of them. Or I suggested that she come in to work with her back pain. And she's like, no, no, no, you can't help me.

I have arthritis. And I think that is the worst way to think of things. Thinking that you won't succeed without trying. And in this case, because of the commonality of the two things, of the two injuries that she mentioned, where they intersect in a rehab standpoint, it's very, it'd be a very basic starting point. And just some things that I would probably have her do, but obviously, I don't know if I gave a disclaimer here, but I can't actually recommend care, by the way. So if you're listening to this and you have these conditions, don't follow these recommendations because I haven't seen you.

Okay, I can't stress that enough. You need a good diagnosis from someone locally first. And then you can probably start learning from these podcasts a little bit more once you know what your condition is. But I'd probably recommend, you know, bird dogs, dead bugs, learning how to squat, probably. Do we know if her posterior chain or backside is strong? How strong are her hamstrings and glutes? How strong is her trunk? When she's in a standing position, can she deadlift? Has she been active for the last 10 years? It sounds like it's really hard for her to walk at any distance at all. Is it easier to sit when she sits down?

Does it go away? If it does, then perhaps there's some claudication, which is a condition that is a little bit more rare, probably, in this situation, since we don't know what her age is. But that's something that could be considered as well, which would be a whole different treatment plan. So there's a lot of things I would probably start with. But I think from a general overview standpoint, I'm seeing a lot of stretching. I'm seeing a lot of massages, ice, painkillers, kinesio tape. I'm seeing a lot of what I call passive therapies. And passive therapies are things which make you feel better but won't make you stronger.

And most people don't like to be recommended active care, what I've found. Some really, really take to it, which is great. But some people don't like it. And I've had actually people walk out of my office because I told them they're going to do X, Y, and Z in the rehab area or weight room. But it's something you just have to consider that if this area is weak and not working well, none of this other stuff will make it stronger. None of it will teach it to work better. Okay? I can't stress that enough. I know it's tough love, but I can't stress it enough. And you'll probably hear me over and over and over again talk about it on podcasts with some of these things that I'm hearing on YouTube.

And I'm finding that's a really common, a big common ground for people is that people try to do the passive care first, and then they hit wit's end, and then they're willing to try something else. And there's no problem with that. And I also do the same thing. When I feel like something hurts, I rest it. I ice it, I stretch it, I elevate it, I compress it. And then once I get my wits about me, I start doing some research and find out that on PubMed and all these research journals that strength training, deep tissue work, stretching, all this stuff is really, really, really helpful. But it takes time.

So I hope this was helpful. And I, as always suggest, if you want your question answered, although I can't give you direct medical information, it's a good talking point for other people. And I want the audience, I want you guys to learn from everybody's cases. I want you to learn about how I would think about it on my side and how I would program for it. But it doesn't mean it doesn't mean I'm suggesting to each people, each person individually, because actually, I don't know. I'll probably do a podcast on this one day is that I actually did a study on self-diagnosis and how accurate people were.

And they were wrong more than half the time. So now I really, really stress, go in and get something checked. Get an image. Go to a professional. Go to a sports injury doctor. And figure out what it is. Because at that point, can you only start going in the right direction and start taking online courses and educating yourself about the topics that are important. So if you're looking for our courses, we do have free courses online. They're informational. Again, they're not intended for medical usage. We have one on shoulders and hips. And we're building new ones every day. And they're on Performance Place HB.

So again, that's Performance Place HB. And there are some paid courses on there. So go on there. And we will give you the best information I possibly can. I record all of them personally. I write them all personally. So if you find typos, it's because I actually hate proofreading. But I do my best to get that out so people can start correcting my verbiage. Because sometimes it's completely skipped words. But I'm starting to use an outsourcer here or an editor. And it saved me a bunch of time and hassle because I want to give the information out there. But man, I hate proofreading. English was my worst subject in school.

I just had no tolerance for it. If you want to leave a message for us to answer on air or to have me answer on air, go on to p2sportscare.com. Again, p2sportscare.com. There is a voicemail button there, which you can speak right into your computer and leave us a message. It's really, really easy. I will have other people on this podcast for... We're going to do live sessions pretty soon. And I'm going to have other experts on. And we're probably going to do them through YouTube live. And I really, really want people to go on there and leave us comments so we can answer them amongst our discussion.

So I think it'll be really helpful to all of you. You'll learn a lot. You'll benefit a ton. And I really want to keep giving back to each and every one of you because you have provided a platform for me to educate the public. Share this, and I will talk to you soon.