M76.40 Tibial collateral bursitis [Pellegrini-Stieda], unspecified leg

Name of the Condition

Tibial Collateral Bursitis [Pellegrini-Stieda], Unspecified Leg

Summary

Tibial collateral bursitis (Pellegrini-Stieda) is an inflammatory condition affecting the bursa near the tibial collateral ligament, typically causing pain and swelling in the medial knee region. It is often associated with trauma or overuse and may limit mobility in the affected leg.

Causes

The condition commonly results from direct trauma to the medial knee, such as a blow or fall, or repetitive stress on the tibial collateral ligament. Inflammatory processes or degenerative changes in the ligament or surrounding tissues can also contribute to bursitis.

Risk Factors

• Participation in activities involving sudden changes in direction or direct knee impact.
• Previous knee injuries or ligamentous instability.
• Age-related degeneration of the medial knee structures.
• Prolonged kneeling or repetitive stress on the medial knee.

Symptoms

• Localized pain and tenderness over the medial knee.
• Swelling or warmth in the affected area.
• Stiffness or reduced range of motion in the knee.
• Pain that worsens with weight-bearing or knee flexion.

Diagnosis

Diagnosis is based on a physical examination to assess tenderness, swelling, and knee mobility. Imaging, such as ultrasound or MRI, may be used to evaluate bursal inflammation or rule out associated ligamentous or meniscal injuries.

Treatment Options

• Rest and activity modification to reduce knee stress.
• Ice application and anti-inflammatory medications to manage pain and swelling.
• Physical therapy to improve knee strength and flexibility.
• Corticosteroid injections for persistent inflammation.
• Surgical intervention in rare cases of chronic or refractory symptoms.

Prognosis and Follow-Up

Most cases resolve with conservative treatment, though recovery may take several weeks. Follow-up care focuses on monitoring symptoms and gradual return to activity. Persistent pain or functional limitations may require further evaluation.

Complications

• Chronic pain or recurrent inflammation.
• Reduced knee mobility or stiffness.
• Potential progression to ligamentous or meniscal damage if untreated.

Lifestyle & Prevention

• Use proper protective gear during high-risk activities.
• Maintain knee strength and flexibility through regular exercise.
• Avoid prolonged kneeling or repetitive knee stress.
• Warm up before physical activity and cool down afterward.

When to Seek Professional Help

Seek medical attention if pain is severe, worsening, or accompanied by significant swelling, instability, or inability to bear weight. Prompt evaluation is recommended for persistent symptoms or suspected trauma.

Tips for Medical Coders

Document the affected leg (unspecified in this code) and specify any trauma or overuse history. Ensure clinical notes support the diagnosis of tibial collateral bursitis, including location and symptom details. Code M76.40 is appropriate when the leg is not specified; use laterality codes if documented.