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Ischial Bursitis

Ischial bursitis describes the inflammation of the ischiogluteal bursa that separates the hamstring tendon from the ischial tuberosity.


Presentation

It is important first to distinguish between two forms of bursitis. The first form is acute and results from direct trauma to the bursa and subsequent bleeding. The second form, which is also the most common, occurs after performing a series of repetitive movements that increase pressure on the bursa and ultimately lead to friction and inflammation.

Patients with ischial bursitis can have a wide range of complaints but most will show one or several of the symptoms described below:

  • Pain in the affected region near the ischial tuberosity that is more severe during specific activities such as bending forward, running uphill, standing on the tips of the toes and sprinting. The pain also tends to radiate to the thigh and the lower part of the leg.
  • Pain that is associated with ischial bursitis worsens with rest (sitting, lying) and is relieved with standing [7].
  • Patients may have trouble sleeping on the affected side. After waking up, there's is usually a very sharp pain when the hip is flexed or extended.
  • There might be prominent swelling.
  • Muscle dysfunction in the affected region might also occur and might be accompanied by a decrease in mobility.
  • There can be point tenderness in the region of the ischial tuberosity or tenderness over the ischial prominence. The latter is increased during resistance strength tests targeting the hamstrings.
Relapsing Polychondritis
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Hip Pain
  • But as we’ll see, age, injury, and normal wear and tear are just some of the factors which can contribute to hip pain.[brooklynreflexology.com]
  • Hip pain usually arises from a degenerated or osteoarthritic hip.[painmd.tv]
  • Video of the Day The primary outstanding symptom experienced is buttock and/or hip pain.[livestrong.com]
Buttock Pain
  • This is a very common problem with cycling and I've seen it overlooked by pretty decent PTs when there was no initial obvious mid to upper buttock pain.[forum.slowtwitch.com]
  • This is an often-overlooked cause of buttock pain. Prolotherapy to both attachments can resolve the buttock pain and often the lower back pain that is associated with it.[getprolo.com]

Workup

Myxoid tumors can present similar signs and must be differentiated from ischial bursitis. Examples of myxoid tumors include neurofibromas, myxomas and schwannomas. The performance of an incisional or an excisional biopsy may be necessary to rule out myxoid tumors [7]. The process entails taking a sample of the tissue affected and sending it for histopathological analysis. The latter can distinguish between the characteristics of neoplasms and ischial bursitis.

An X-ray may also need to be performed to make sure symptoms are not the result of a stress fracture or a thickening of cartilage. Other imaging procedures that may be useful include T1 and T2 weighed MRI. T1 weighed MRI scanning can show intermediate intensity at the site of injury. T2 weighed MRI on the other hand will show high intensity for the space occupied with fluid, subsequent to inflammation.

The physical exam is helpful in establishing the diagnosis [7] [8]. A straight leg test is usually positive and manifests with pain. There is a resistance to hip extension and concomitant pain. A mass can sometimes be palpated in the region of the gluteus in the affected hip. The mass is normally slightly tender, does not move and is well-defined.

Treatment

Treatment of ischial bursitis comprises two main forms: medical treatment and physical therapy.

Medical management is instituted through the administration of non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitors. In case of poor or no response, anesthetic and corticosteroid injections within the ischial bursa follows.

The initial phase of physical therapy consists of rest, in the sense of limiting physical movements to a lower intensity and within a reasonable pain threshold. Cold therapy follows through the application of cold packs or placement of ice on the surface of the buttocks. Cold packs are generally wrapped in humid towels and ice should be used no more than 20 to 30 minutes [9]. This leads to a decrease in the temperature of the skin, the subcutaneous tissue as well as muscles, bones and joints but to a significantly lower degree. Chemical agents such as ethyl chloride can also be used to decrease the temperature. Another possibility is the use of heat treatment, which should be applied for 30 minutes, two times a day within a temperature range of 38C to 50C [10]. Heat therapy helps in increasing blood flow to the area.

Stretching and strengthening exercises are critical components of physical therapy [11]. Patients should stretch relevant muscles everyday, 30 seconds for each exercise. Stretching helps decrease the tension in the hamstring muscles, reducing in the process the pressure on the ischial bursa. It also reduces the amount of energy per time unit absorbed by the muscles, helps resolve muscle soreness and does not involve reflex contractions [12] [13]. Strengthening exercises, on the other hand, can help in maintaining muscle stability and reduce symptoms.

Two important stretching exercises are the gluteus and piriformis stretches. The gluteus stretch is performed by lying on a bed with the head firmly placed on a cushion such as a pillow, grabbing the affected knee with both hands and pulling it towards the chest. This position is then held for 5 to 10 seconds and is repeated up to 10 times. The piriformis stretch, on the other hand, is performed by crossing the leg on the affected side over the other one, followed by pulling the affected knee towards the midline. The position is then held for 10 to 30 seconds. Strengthening exams target hip rotators as well as gluteal muscles. They involve stair climbing and reverse curls.

Massage can also help in alleviating symptoms, particularly in chronic problems in the bursa involving adhesions. Friction massage increases blood flow and extensibility, decreases the levels of stress and improves mobility. Nonetheless, it is important for the patient to know that friction massage can initially accentuate subacute inflammation. This early phase is followed by a remodeling stage and progressive healing of the affected area.

Prognosis

Prognosis is good when medical management and adequate physical therapy are administered, though full recovery may take many weeks. Patients who suffer chronically from ischiogluteal bursitis may need more time to achieve full recovery. It is critically important to start physiotherapy very early in the course of the disease.

Etiology

Ischiogluteal bursitis results from inflammation and damage of tissue in the gluteal bursa. A bursa is a space filled with fluid that decreases friction between adjacent structures. The ischiogluteal bursa can be found at the level of the ischial tuberosity, a bony prominence at the base of the pelvis. On the other hand, the hamstring muscles originate from the ischial tuberosity and attach to the lower leg bones. A tendon helps in fixing the hamstring to the pelvis. The ischiogluteal bursa separates the hamstring tendon from the ischial tuberosity.

The hamstring muscle functions by flexing the knee and extending the hip. It is most commonly employed in activities such as running, kicking and jumping. When the hamstring contracts, tension is transmitted to its tendon, which lies in close proximity to the ischiogluteal bursa. The force is then cushioned by the bursa to protect the ischial tuberosity. Sitting can also transmit tension to the bursa. Excessive force resulting from harsh or repetitive movements can ultimately lead to irritation and inflammation. The result is ischiogluteal bursitis.

Epidemiology

Ischial bursitis is not an uncommon disease, especially in individuals who lead a sedentary lifestyle.

Sex distribution
Age distribution

Pathophysiology

The molecular pathophysiological mechanisms underlying bursitis are still not clear. The disease is generally characterized by a thickening of the walls of the bursa and proliferation of the cells that line the synovium. This is accompanied by the presence of formations in the shape of villi, deposits, adhesions and tags. Synovitis ultimately leads to an increase in fluid production and a proliferation of the cells lining the joint. This translates outwardly with swelling and the other prominent signs of local inflammation. In rare cases, the inflammatory reaction can spread to adjacent joints [3] [4] [5] [6].

Relief subsequent to the injection of steroids and anesthesia gives credence to the inflammatory theory of ischial bursitis, although histopathological studies failed to find any markers of inflammation [3] [5].

Prevention

Ischial bursa can be prevented by avoiding repetitive movements that place large amounts of stress and pressure on the bursa. Some patients however may be constrained by their occupation. In this case, using walking aids and pads for protection can be extremely useful.

Summary

Ischial bursitis described the inflammation of the ischiogluteal bursa [1] [2]. The ischiogluteal bursa normally separates the tendon of the hamstring muscle from the ischial tuberosity at the base of the pelvis. Repetitive overuse of the hamstring muscle through activities such as kicking, running, sprinting or sitting can result in excessive tension on the hamstring tendon that is subsequently transmitted to the bursa. The bursa normally functions to cushion the ischial tuberosity, but in the presence of repeated elevated pressure, an inflammatory process can set in and result in bursitis.

The molecular pathophysiological mechanisms are still not entirely clear, but there is in general a thickening of the synovium, excessive fluid production manifesting with swelling as well as microstructural changes within the bursa that result from inflammation. Patients in general can present with a range of symptoms but they mainly complain from pain in the region of the ischial tuberosity that is exacerbated by lying down or sitting and relieved by standing, troubles in sleeping on the affected side and muscular abnormalities that can result in reduced mobility. A physical exam may also show a well defined mass in the gluteal region that is immobile and slightly tender.

Diagnostic testing may be needed to rule out other causes. Neoplastic diseases such as myxomas and neurofibromas can present similar signs and therefore excisional or incisional biopsies are sometimes necessary. X-ray Imaging is important to rule out stress fractures of the ischial tuberosity. T1 and T2 weighed MRI also show characteristic intermediate or increased intensity over the affected regions. Treatment includes medical and physical therapy. Medical therapy consists of non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors. Physical therapy, on the other hand, includes gluteus and piriformis stretching exercises and strengthing exercises. Ice packs or sometimes heat treatment can both help in reducing the level of inflammation. Avoidance of harmful physical activity is recommended and exercise intensity should not exceed pain threshold.

Prognosis of ischial bursitis is good, with most patients achieving full remission after a few weeks of treatment, although early physical therapy is very important.

Patient Information

Ischiogluteal bursitis describes an inflammatory condition that is usually present in the buttock region in the pelvis. A bursa is a fluid filled sac that helps in cushioning pressure directed from one structure to another. The ischiogluteal bursa separates the tendon of the hamstring muscle from a bony prominence in the pelvis called the ischial tuberosity. The hamstring normally functions to flex the knee and extend the hip and is particularly active in certain sporting activities such as kicking, running or sprinting. Normally, action of the hamstring transmits tension to the tendon of the muscle which is in turn cushioned by the ischiogluteal bursa to protect the ischial tuberosity, the bony region where the tendon attaches. In cases of overuse of the muscle, the tension on the bursa becomes excessive and inflammation takes place.

When the bursa becomes inflamed, the patient may start complaining from a range of symptoms. These include pain when performing certain activities such as climbing a hill, running, sprinting or kicking. The pain is normally exacerbated by lying on a bed and is relieved by standing. Patients usually are not able to sleep on the affected side. The condition presents similar signs observed in other diseases, particularly tumors involving the cells that line the bursa. To differentiate between the two conditions, the physician may perform a procedure to take a sample of the issue and send it for analysis. Imaging with MRI or X-ray can also be helpful in diagnosing the condition or excluding other causes such as stress fractures.

The cornerstone of the treatment is physical therapy with concomitant medical therapy. Medical therapy consists of anti-inflammatory drugs. Physical therapy, on the other hand, is done through the performance of stretching and strengthening exercises of the muscles of the buttocks. Cold or heat appliances can also be used to reduce the level of inflammation. Relative rest is advised and sporting activity is limited to an acceptable range of pain. Patients usually recover after a few weeks, but it is very important to start physical therapy early.

References

Article

  1. Kim SM, Shin MJ, Kim KS, et al. Imaging features of ischial bursitis with an emphasis on ultrasonography. Skeletal Radiol. 2002 Nov;31(11):631-6.
  2. Cho KH1, Lee SM, Lee YH, Suh KJ, Kim SM, Shin MJ, Jang HW. Non-infectious ischiogluteal bursitis: MRI findings. Korean J Radiol. 2004 Oct-Dec;5(4):280-6.
  3. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: trochanteric bursitis. J Clin Rheumatol. 2004;10:123-124.
  4. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology IV: anserine bursitis. J Clin Rheumatol. 2004;10:205-206.
  5. Silva F, Adams T, Feinstein J, et al. Trochanteric bursitis: refuting the myth of inflammation. J Clin Rheumatol. 2008;14:82-86.
  6. Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med. 2006;73:465-471.
  7. Hitora T, Kawaguchi Y, Mori M, et al. Ischiogluteal bursitis: a report of three cases with MR findings. Rheumatol Int. 2009 Feb;29(4):455-8.
  8. Van Mieghem IM, Boets A, Sciot R, Van Breuseghem I. Ischiogluteal bursitis: an uncommon type of bursitis. Skeletal Radiol. 2004 Jul;33(7):413-6.
  9. Cuccurullo S, Brown D, Petagna AM, Platt H, Strax TE. Musculoskeletal injection skills competency in physical medicine and rehabilitation residents: a method for development and assessment. Am J Phys Med Rehabil. 2004 Jun;83(6):479-85.
  10. Badgwell Doherty C, Doherty SD, Rosen T. Thermotherapy in dermatologic infections. J Am Acad Dermatol. 2010 Jun;62(6):909-27; quiz 928.
  11. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc. 2004 Mar;36(3):371-8.
  12. Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther. 1998 Apr;27(4):295-300.
  13. Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Phys Ther. 1997 Oct;77(10):1090-6.

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Last updated: 2018-06-22 08:50