the prevalence rate in the general population ranges between 10% and 12% , making this disease one of the most common causes of pain , activity limitation , and restrictions in participation .
knee osteoarthritis ( gonarthrosis ) is one of the most frequent forms of degenerative osteoarthritis . in knee osteoarthritis
, pain is the primary symptom and probably the most important factor related to activity limitation and disability .
although the pain in knee oa is multifactorial , acute exacerbations are usually closely related to synovial inflammation . various studies performed by using arthroscopy have shown synovitis in painful knees of patients with knee oa . on the basis of these reports ,
many investigators focused on noninvasive imaging techniques , such as magnetic resonance imaging and diagnostic ultrasonography .
the term  pes anserinus  refers to the conjoined insertion of the sartorius , gracilis , and semitendinosus muscles along the proximal medial aspect of the tibia .
these three muscles are primarily flexors of the knee ; they also influence internal rotation of the tibia and protect the knee against rotatory and valgus stress . in pes
anserine bursitis , the fluid - filled bursa in the conjoined insertion of the three hamstring muscles becomes inflamed and causes pain .
patients with this clinical picture may report vague medial knee pain or may present with tenderness and swelling along the proximal medial tibia .
a diagnosis of pes anserine bursitis should be considered when there is spontaneous pain inferomedial to the knee joint and a history of trauma or diabetes .
conditions associated with pes anserine bursitis include degenerative joint disease of the knee , obesity , valgus knee deformity , pes planus , and sporting activities .
pes anserine bursitis affects the quality of life of patients with osteoarthritis , and the treatment methods are different .
treatment includes nonsteroidal anti - inflammatory drugs ( nsaids ) , physiotherapy , and injections of corticosteroid , with highly variable responses ; recovery can take 10 days to 36 months .
mesotherapy was introduced 50 years ago by michel pistor , a french physician who used this technique as a novel analgesic therapy for a variety of rheumatologic disorders .
mesotherapy is a minimally invasive technique that consists of subcutaneous injections of drugs and , occasionally , plant extracts , homeopathic agents , or other bioactive substances ; for this reason , it has been often considered a form of complementary and alternative medicine rather than a conventional medical therapy .
the objective of this type of administration is to modulate the pharmacokinetics of the injected substance and to prolong the pharmacologic effects at a local level .
one of the main advantages of mesotherapy is that a local pharmacologic effect can be obtained without the need for high systemic concentrations .
intradermal injections of small amounts of active substance where the injection site corresponds to the area of the pathologic condition  for example , in low back pain  may provide clinical benefits when other therapies are not available , are not effective , or can not be used for whatever reason .
in addition , intradermal administration of active substances in combination with other systemic therapies can produce synergistic effects , and as a result mesotherapy may have dose - sparing effects . since its introduction , the use of mesotherapy has been expanded , and therapeutic indications have increased .
although mesotherapy is primarily used for osteoarticular conditions , this technique has recently become popular in cosmetic medicine for treatment of edematous fibrosclerotic panniculopathy and local adiposity .
the aim of the current study was to evaluate the effects of mesotherapy with diclofenac for anserine bursitis in knee osteoarthritis .
the multicenter study was conducted at the d'annunzio university in chieti , italy , and at an affiliated rehabilitation center in florence .
it was approved by the local ethics committee and was performed in accordance with the 1964 declaration of helsinki .
one hundred and seventeen patients ( 59 men and 58 women ) age 1856 years ( average age , 36 years ) were evaluated and treated .
all them had anserine bursitis , ascertained clinically and by ultrasonography , in association with grade ii kellgren - lawrence knee osteoarthritis ( fig .
inclusion criteria were age between 10 and 60 years , grade ii kellgren - lawrence knee osteoarthritis , re - acutization of pain , and synovial inflammation .
exclusion criteria were pregnancy , known hypersensitivity to products , infiltrative therapy with hyaluronic acid , polynucleotides or corticosteroids in progress , drug abuse or alcohol abuse , significant comorbidities ( such as the presence of neurologic abnormalities , concomitant severe rheumatic disease , and systemic abnormalities , such as diabetes ) , a surgical intervention within 3 months before the study , psychiatric conditions , or psychotherapy or physical therapy within 5 weeks before the study .
the patients were randomly divided into two groups ( a , mesotherapy ; b , control ) after giving written consent and agreeing to the possible treatment ( local or oral ) .
group a ( 60 patients ; 30 men and 30 women ) received nine sessions of mesotherapy with sodium diclofenac ( 25  mg/1  ml ; akis , ibsa , lugano , switzerland ) , 1  ml for each session , three times per week .
group b ( 57 patients ; 29 men and 28 women ) received 21 oral administrations of sodium diclofenac ( 50  mg ; voltaren , novartis , parsippany , nj ) , once every day for 3 weeks .
all patients reported pain during sleep and after a long period of rest , as well as reduction of pain after about a 200-m walk .
all patients were asked to provide standard radiographs ( anterior - posterior and lateral ) of the lumbosacral tract and knee joints .
primary outcome measures were pain intensity , quantified by using a 10-cm millimetric visual analogue scale ( vas ) , on which the patient is asked to mark the degree of pain intensity , ranging from 0 ( absence of pain ) to 10 ( the worst pain imaginable ) , along with abilities in activities of daily living ( adls ) , ability to participate in sports , level of pain , symptoms , and quality of life , as assessed by the knee injury and osteoarthritis outcome score ( koos ) .
all these assessments , along with ultrasonography , were performed before ( t0 ) and after ( t1 ) the treatment period and at 30 days ' ( t2 ) and 90 days ' ( t3 ) follow - up in all patients .
differences between mean values before and after the rehabilitation period were tested for significance by using two - way analysis of variance for repeated measures .
graphpad prism ( version 6 ) software ( abacus concepts graphpad software , san diego , ca ) .
in group a , the subjective pain levels assessed by vas were 71.05 at t0,20.35 at t1 , 3.80.85 at t2 , and 4.00.85 at t3 ( fig .
disability during sports activity at t1 decreased significantly ( p<0.05 ) : t0 score , 7010.7 ; t1 score , 557.9 ; t2 score , 608.5 ; t3 score , 608.7 ( fig .
perceived symptoms also were significantly reduced ( p<0.05 ) at t1 and at both follow - up times : t0 score , 71.411.9 ; t1 score , 46.49.4 ; t2 score , 509.7 ; t3 , score 53.69.0 ( fig .
was seen in the effect of osteoarthritis on quality of life at t1 and at both follow - up times : t0 score , 68.813.2 ; t1 score , 43.810.9 ; t2 score , 509.7 ; t3 score , 509.8 ( fig .
disability with regard to adls also decreased significantly ( p<0.05 ) at t1 and at both follow - up times : t0 score , 7214.2 ; t1 score , 478.7 ; t2 score , 478.7 ; t3 score , 509.2 ( fig .
finally , pain perception was significantly reduced ( p<0.01 ) at t1 and at both follow - up times : t0 score , 7510.3 ; t1 score , 30.55.5 ; t2 score , 365.2 ; t3 score , 415.8 ( fig .
error bars represent the standard deviation . a , group a ( mesotherapy treatment ) ; b , group b ( oral treatment ) .
trend of disability during sports activity ( knee injury and osteoarthritis outcome score [ koos ] ) .
trend of disabilities with regard to activities of daily living ( adls ) ( koos ) .
b , the subjective pain levels assessed by vas were 7.51.85 at t0 , 31.10 at t1 , and 5 at t2 and t3 ( fig .
the koos findings were as follows : disability during sports activity did not significantly decrease : t0 score , 7515.8 ; t1 score , 6515.5 ; t2 score , 6515.7 ; t3 score , 7017.2 ( fig .
3 ) . a significant reduction occurred ( p<0.05 ) in perceived symptoms at t1 : t0 score , 71.413.1 ; t1 score , 60.78.3 ; t2 score , 64.38.7 ; t3 score , 64.39.1 ( fig .
the effect of osteoarthritis on quality of life decreased significantly ( p<0.05 ) at t1 : t0 score , 7513.2 ; t1 score , 5011.0 ; t2 score , 68.814.5 ; t3 score , 68.814.7 ( fig .
disability with regard to adls was reduced significantly ( p<0.05 ) at t1 : t0 score , 70.612.7 ; t1 score , 61.79.4 ; t2 score , 66.210.9 ; t3 score , 67.612.5 ( fig .
finally , a significant reduction ( p<0.05 ) was seen in pain perception at t1 and at both follow - up times : t0 score , 7510.4 ; t1 score , 52.78.3 ; t2 score , 55.68.8 ; t3 score , 58.39.5 ( fig .
in particular , group a had pain remission after a 120-m walk at t1 and after a 160-m walk at t2 and t3 .
ultrasonography showed a reduction of the hypoechoic area related to anserine bursitis only in group a ( ie , the mesotherapy group ) .
the aim of this study was to evaluate the effectiveness of anti - inflammatory drugs administered via mesotherapy in patients with local inflammation in grade ii kellgren - lawrence knee osteoarthritis .
present results showed that the administration of nsaids ( diclofenac ) via mesotherapy can provide the same therapeutic benefit as that induced by conventional ( oral ) drug administration in relation to pain after a 3-week treatment period .
indeed , both treatments significantly reduced pain intensity and disability in daily life activity ; the effect was maintained up to 3 months ( 30 days ' and 90 days ' follow - up ) only in the group that received mesotherapy .
these results are in accordance with previous studies showing that naproxen and diclofenac administered via mesotherapy were more effective than those given orally .
the major finding of this study is the similar effectiveness of mesotherapy and conventional systemic therapy , despite the lower amount of drugs administered to patients undergoing mesotherapy ( 25  mg with mesotherapy vs 50  mg with oral administration ) and the lower short - term risk for adverse reactions in the mesotherapy group ( 3 weeks ) .
the similar efficacy of mesotherapy and conventional therapy , despite different drug dosages , is difficult to explain .
subcutaneous drug administration results in a very slow drug absorption in comparison with other systemic routes , such as oral and intramuscular .
thus , it could be hypothesized that anti - inflammatory drugs administered via mesotherapy achieve a higher drug concentration in the subcutaneous tissue and exert local effects close to inflammatory cells , sensory fibers , and vascular mediators that orchestrate inflammation and pain .
this hypothesis could be confirmed by the evidence of reduction of the anserine bursitis showed by ultrasonography in group a ( the mesotherapy group ) but not in group b ( the oral administration group ) .
although this study did not measure drug plasma levels after the two routes of administration , it is possible to hypothesize that mesotherapy resulted in a lower systemic bioavailability of drugs , with consequent lower incidence of adverse reactions .
this could offer a great therapeutic advantage given the high rates of adverse effects associated with nsaid or corticosteroid use in the elderly population .
although mesotherapeutic techniques used in dermatologic surgery have been associated with many adverse effects at injection sites , including atypical mycobacterial infections , urticaria , lichenoid drug eruptions , and psoriasis , no evidence of local reactions was found in the present study . in conclusion ,
results of this study indicate that combined administration of conventional nsaids ( diclofenac ) by mesotherapy is an effective and well - tolerated method for managing anserine bursitis in ii grade knee osteoarthritis in the short term and mid - term compared with oral administration of the same drug with different concentrations .
however , future studies could have a larger scale and thus also measure plasma bioavailability of the drug .
these observations could be of potential interest for the pharmacologic treatment of anserine bursitis in order to reduce the adverse effects associated with high plasma levels of anti - inflammatory drugs .
 abstractbackground : pes anserine bursitis strongly affects quality of life in patients with osteoarthritis . 
 treatment includes nonsteroidal anti - inflammatory drugs ( nsaids ) , physiotherapy , and injections of corticosteroid , with highly variable responses ; recovery can take 10 days to 36 months . 
 mesotherapy is a minimally invasive technique consisting of subcutaneous injections of bioactive substances . 
 the goal is to modulate the pharmacokinetics of the injected substance and prolong the effects at a local level.objective : to evaluate the effects of mesotherapy with diclofenac for anserine bursitis associated with knee osteoarthritis.methods : one hundred and seventeen patients with anserine bursitis associated with grade ii kellgren - lawrence knee osteoarthritis , assessed by clinical , radiographic , and ultrasonographic examination , were evaluated and treated . 
 they were randomly divided into two groups ( a , mesotherapy ; b , control ) . 
 group a completed nine sessions of mesotherapy with sodium diclofenac ( 25  mg/1  ml ; akis , ibsa , lugano , switzerland ) , 1  ml for each session , three times per week . 
 group b received 21 oral administrations of sodium diclofenac ( 50  mg ; voltaren , novartis , parsippany , nj ) , once a day for 3 weeks . 
 primary outcome measures were pain intensity assessed by visual analogue scale ( vas ) , along with ability to perform activities of daily living , ability to participate in sports , level of pain , symptoms , and quality of life , as assessed by the knee injury and osteoarthritis outcome score . 
 these measures were performed before and after the treatment period and at 30 and 90 days ' follow up.results : in both groups pain level decreased significantly after the treatment period . 
 ultrasonography showed a reduction of the hypoechoic area related to anserine bursitis only in group a.conclusion : administration of conventional nsaids ( diclofenac ) by mesotherapy is effective in managing anserine bursitis in knee osteoarthritis in the short term and mid - term . 
 these observations could be of interest for efforts to reduce the adverse effects of oral administration of anti - inflammatory drugs . 