M76.41 Tibial collateral bursitis [Pellegrini-Stieda], right leg

Name of the Condition

Tibial collateral bursitis [Pellegrini-Stieda], right leg

Summary

Tibial collateral bursitis, also known as Pellegrini-Stieda disease, is an inflammatory condition affecting the bursa near the medial collateral ligament (MCL) of the knee. This condition typically causes localized pain and swelling in the medial knee region, often resulting from trauma or overuse. It may be associated with MCL injury or chronic stress to the area.

Causes

Tibial collateral bursitis commonly arises from direct trauma to the medial knee, such as a blow or fall, or from repetitive stress on the MCL. It can also develop secondary to MCL sprains, where inflammation extends to the adjacent bursa. Overuse activities involving knee flexion or valgus stress may contribute to irritation of the bursal tissue.

Risk Factors

• Participation in sports or activities with high knee stress, such as soccer, basketball, or skiing.
• History of knee injuries, particularly MCL sprains or medial meniscal tears.
• Age-related degeneration of the knee joint, reducing tissue resilience.
• Poor biomechanics or muscle imbalances affecting knee alignment.

Symptoms

• Localized pain and tenderness over the medial knee, often worsening with activity.
• Swelling or palpable mass in the medial knee region.
• Stiffness or reduced range of motion, particularly with knee flexion.
• Pain that may radiate to the inner thigh or calf.

Diagnosis

Diagnosis is based on a physical examination to assess tenderness, swelling, and movement. Imaging, such as ultrasound or MRI, may be used to evaluate tissue damage or inflammation at the bursa. Clinical history, including trauma or overuse, supports the diagnosis.

Treatment Options

• Rest and activity modification to reduce stress on the knee.
• Ice application to alleviate swelling and pain.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation.
• Physical therapy to improve strength and flexibility.
• Corticosteroid injections for severe or persistent symptoms.
• Surgical intervention in rare cases of chronic or refractory bursitis.

Prognosis and Follow-Up

Most cases resolve with conservative treatment within weeks to months. Follow-up may involve monitoring pain and function, with adjustments to treatment as needed. Chronic cases may require longer management or specialist referral.

Complications

• Chronic pain or persistent swelling if untreated.
• Reduced knee mobility or function.
• Recurrence with repeated stress or injury.
• Rarely, infection of the bursa (septic bursitis).

Lifestyle & Prevention

• Use proper footwear and supportive gear during activities.
• Maintain strength and flexibility in knee muscles.
• Avoid sudden increases in activity intensity.
• Apply protective padding if at risk of direct trauma.

When to Seek Professional Help

Seek care if pain is severe, worsening, or unresponsive to rest. Prompt evaluation is needed for suspected infection, significant swelling, or inability to bear weight.

Tips for Medical Coders

Document the laterality (right leg) and specify "Pellegrini-Stieda" if applicable. Ensure clinical correlation with symptoms, trauma history, or imaging to support the diagnosis.