A 35-year-old man comes to the office due to right knee pain over the last 2 weeks. The patient recently started running to lose weight and runs approximately 15 miles a week. He has since developed inner right knee pain, making it difficult to climb stairs. The pain is most intense at night when he is trying to fall asleep. Medical history is unremarkable, and he takes no medications. The patient does not use alcohol, tobacco, or illicit drugs.
The patient's temperature is 36.5 C (97.7 F) , blood pressure is 120/70 mm Hg, and pulse is 75/min. His BMI is 31 kg/m². There is no knee swelling. Localized tenderness is noted at the medial aspect of the right knee, 1 inch below the joint line. While stabilizing the right thigh, lateral movement of the lower right leg elicits no knee pain or medial joint space movement. His gait is normal. The remainder of the physical examination is within normal limits.
Which of the following is the most appropriate next step in management?

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11ec193a_9916_370a_853d_3965f79bc21c_MD0002_00 This patient with medial knee pain and focal tenderness has pes anserinus pain syndrome (PAPS). This condition is often referred to as anserine bursitis, but most patients do not have true inflammation in the bursa, and multiple regional structures can contribute to the pain. The pes anserinus is formed by the conjoined tendons of gracilis, sartorius, and semitendinosus. The anserine bursa is located anteromedially over the tibial plateau, just below the joint line of the knee and deep to the pes anserinus. PAPS can arise due to medial compartment knee osteoarthritis, trauma, or increased mechanical stress on the knee (eg, running, obesity). Localized pain is typical over the anteromedial tibia and is often exacerbated by pressure from the opposite knee while lying on the side. Examination shows a well-defined area of tenderness over the medial tibial plateau just below the joint line. The diagnosis is primarily based on clinical features. Acute therapy includes avoidance of leg crossing, limiting repetitive knee bending, decreasing pressure on the area by placing a pillow between the knees at night, and applying ice to reduce pain. Nonsteroidal anti-inflammatory drugs are often given for pain relief but may not be beneficial as oral medications do not concentrate well in the isolated anserine bursa. (Choice B) The erythrocyte sedimentation rate and rheumatoid factor would be elevated in rheumatoid arthritis, which usually presents as polyarthritis rather than monoarthritis. (Choice E) Glucocorticoid injections into the bursa are reserved for patients who fail conservative measures and have persistent symptoms for 6-8 weeks. (Choice D) An MRI is often performed to assess the integrity of the medial collateral and associated ligaments when injury is suspected. However, this patient's negative valgus stress test makes this unlikely. valgus stress test (Choice E) X-rays are not required to diagnose PAPS. They may identify medial compartment osteoarthritis, which can also contribute to medial knee pain; however, osteoarthritis is unlikely in this young patient without previous symptoms. Educational objective: Pes anserinus pain syndrome presents with point tenderness along the medial knee. Acute therapy includes restricting activity, placing a pillow between the knees at night, applying ice, and possibly using nonsteroidal anti-inflammatory drugs. Patients who are refractory to conservative measures may benefit from a glucocorticoid injection. __________ References: Anserine syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21125167)

A 35-Year-Old Man Comes to the Office Due to Right