Pes Anserine Bursitis (Ireland) | A Week Later

It has been a week since I walked out of the Bluestack Mountains. I had covered some 14 miles (23 km) of steep boggy climbs and descents the day prior. I felt fantastic that day! The feet felt wonderful, and gone were the hotspots. I remember feeling like I could have done 20+ (33 km) that day, were it not for my late 11 am start. The trek into Donegal Town was around 8-9 miles. An opportunity to make haste on a long, steep descent that was mostly gravel with old remnants of pavement. After all, it made sense, right. The previous day’s trek from Glenties into the Bluestack was a breeze. I felt great at the end of that day!

So what happened? Where did I go wrong? Simple, bad mechanics and form. With the steep descent and taking too long of steps, I shifted the impact of every step from my heel to my shins and knees, while relying on my hamstrings to support me. Want to experience it? Find an incline, ramp, driveway, etc. Now take a step with your right leg, as you match the incline with the sole of your feet and lean back slightly. As you step down, you ought to feel pressure, if done correctly, at the top of your shin bone below your knee. That’s funny, “done correctly,” here I am describing bad mechanics and how to get hurt. Haha. You will probably feel your foot slide forward in your shoe too. No need to take more than one step. You get the idea. Imagine walking this way for 6 or 7 miles (10 km). Then increase the slope to 10-15%, add 30 lbs (13.5 kg) to your back, and you begin to understand the stress I put on my legs.

My goal here is not to injure any of you. I promise you that. Instead it is to help you understand, so you can appreciate what has become my daily struggle. I also want to share what I know of this injury so that you can avoid it while hiking. I also want to share how this injury has affected me and what I am doing to rehab. 

Before we tackle how the injury has affected me, let’s dig a little deeper into the injury. Below is a picture of where the pain is located. See right where the Pes Anserine bursa is located in the picture. The arrow points to it. As you can see below, it is not associated with the structural parts of the knee (e.g., MCL, PCL, ACL, and Patella's tendon). I can flex just fine without pain. Good news, right? Kinda. The bursa is a small fluid sac that insulates the tendons from bone.

Pes Anserine means ‘goose’s foot. It is where the three tendons on the inside of your knee attach to the lower leg. These three tendon attachment looks like a ‘goose’s foot. The three tendons are the sartorius (a quad muscle), gracilis (a hamstring / inner thigh muscle), and semitendinosus (a large hamstring muscle). Bursitis is just another term for inflammation of the bursa. Below is a view looking at the inside of the left knee.

The more I dig into this injury, the more I realize I'm in for a slow recovery. The strangest part of this injury is I have ZERO swelling. From what I've read thus far, like all tendon injuries, recovery time is slow. Usually about 1-6 months, with 2-3 months being average. I need to be serious about my rehab!

Now that you understand a bit more about the injury, and what it consists of, let’s tackle how it has affected me. After reaching Donegal Town last week, I struggled to stand under my weight. When I put the full weight off my body on my right leg, I buckled involuntarily from the sharp jolt of pain. Stretching that evening at least allowed me to walk into town for dinner. 

As you've read Omagh was a difficult day for me and my injury. The next morning when I was ready to leave my Airbnb, my right leg again buckled under the weight of just my body. My left leg also hurt in the same place now, though it is more manageable. This buckling happens daily and is now part of my morning routine. I carefully rise out of bed and resist the urge of my right leg wanting to collapse as I test the ground and my weight. Fortunately, my left leg just hurts. This happens regardless of how good I feel when I wake up. It is a reminder that I have work to do. 

How about walking? That's a challenge too. Once I start walking, I can manage alright. However, those first couple of steps is a real struggle. The body has a fantastic way of compensating for injuries. It tenses up to support the injury. I hear Dan, my former physical therapist, "Everything gets Angry. We learn to calm things down through PT." As soon as I lift my right foot in preparation for that first step, my entire right leg tenses up. I can feel the involuntary muscle contractions. First, my foot and toes curl up in my shoe. Next, my ankle locks up. Followed by a tensing up in my shin and knee as it braces for impact. I understand what my body is doing here. It wants to isolate and protect me from further injury. In this case, though, it is not helping me. It is the exact wrong approach. If I walk stiff-legged like this, it puts even more stress on the bursa. I remind myself, that I need to stay flexible and pliable or I will be limping forever.

I came across this little note yesterday (above) it made me smile. A good reminder to make time each day for rehab.

As I take my first step, I am consciously walking myself through the mechanics of each step. I deliberately think about every tiny movement and what parts of my right leg need to articulate. I tell myself, relax your foot. Good, now heel down first, ball of the foot, then toes. Next, flex your ankle after your step. Ok. Bend your knee as you step forward. Alright, that's better. After 2-3 steps, I can move with normal mechanics. I am sure I look like I am walking normally to everyone around me, but I assure you it feels awkward and extremely slow. It is like learning to walk all over again, but worse. I need to think about every single muscle and articulation point. I focus on not moving too fast. Honestly, I am not sure I can move fast right now without any pain. I am focused on the simple things, maintaining good form and articulation.

How has this injury affected my psyche? Things I once took for granted that I never had to think through, such as walking, require all of my attention. I have accepted the injury as part of my experience and daily routine. It's not all bad news, though. This new way of navigating through my day, meaning walking slowly and intentionally, is a blessing. First, I find that I enjoy being very intentional about where I exert my efforts in my travels and sightseeing. Second, this injury allows me to constantly be in the present moment. I can't afford to let my attention drift and engage thoughts while I walk. I am focused on not falling and ensuring every part of my leg articulates correctly. It has been difficult, though, I must confess. The first couple of mornings in particular. You bet I considered shutting my trip down and heading home. My heart is not in it. It tells me it has zero desire to head home because of this injury. So, I lean into the experience and shift my focus on learning to find ways to enjoy myself while rehabbing. 

This injury can be rehabbed with proper stretching and reducing the stress that caused the injury. Not necessarily eliminating the stress. I've switched off Vitamin I, a.k.a Ibuprofen, for the moment. I purchased a topical non-steroid gel from a local pharmacy with similar ingredients to ibuprofen or NSAIDs. It is better in treating localized inflammation. As I gain flexibility, I am expanding my strength, and stretching routine. In the last couple of days, I've progressed beyond simple hamstring, calf, and quad stretches. I learned with Dan that it's essential to address the big muscles first in PT. Once those are loose, then you can focus on the smaller muscles. I also enjoy diving into the anatomy of the injury, it’s like unlocking a puzzle. I spend a solid 15-20 min every morning progressing through a range of exercises. Many are from my prior yoga classes, such as Warrior 3, Butterfly, Yogi Squat, and Half Pigeon which are also mixed with traditional exercises like squats, hamstring, and quad stretch. How am I doing? I can tell it IS helping. I do, however, have a long way to go.