Ischial bursitis also is known as ischiogluteal bursitis or weaver’s bottom is a condition where the bursa that lies between the ischial tuberosity and the gluteus maximus muscle becomes inflamed. This bursa is present physiologically in order to reduce the amount of frictional force generated between the gluteal muscle and the ischial tuberosity that otherwise might become damaged or irritated by this contact. This inflammation of the bursa is most commonly caused by prolonged pressure on the ischium, as occurs in sitting for extended periods of time or from the repeated movement of the Gluteus Maximus muscle in such activities as bicycling. These activities cause an inflammatory reaction that results in swelling and tenderness over the lower buttock and upper posterior thigh. Many other differential diagnoses have common presentations such as sciatica and tendonitis of hamstring muscles.[rx]
Ischial bursitis or ischiogluteal bursitis is the inflammation of the ischiogluteal bursa due to excessive or inappropriate physical exercise, prolonged sitting, running, repetitive jumping, and kicking. Since ischial bursitis is a rare, infrequently recognized pathology and is difficult to differentiate from the soft tissue disease and tumors (both malignant and benign), herein exemplified is a case with ischiogluteal bursitis whereby the role of magnetic resonance imaging (MRI) in the prompt diagnosis has been highlighted.
Pathophysiology of Ischial Bursitis
Bursa comes in a variety of forms: adventitious, subcutaneous, submuscular, and synovial. An ischial bursa is synovial, meaning it is composed of a fatty connective tissue capsule filled with synovial fluid. When infection or irritation occurs, cells of the synovia proliferate, resulting in increased production of synovial fluid. Inflammatory mediators such as cyclooxygenase, cytokines, and metalloproteases mediate this process. The result is a thick fluid-filled cavity with high amounts of fibrin, resulting in the formation of granulation tissue.[rx] Over time, this tissue will gradually interfere with the normal motion and activity of the surrounding tissues whether they are muscle, bone, or tendon.
Types of Ischial Bursitis
An ischial bursa is located between the hamstring muscle and the ischial tuberosity of the pelvis in the buttock area. This area bears the weight of the body when sitting. The hip joint is one of the largest joints in the body. It is composed of one osseous (contains bone) joint. The hip is built for weight-bearing and movement in several different planes. The stability of the hip joint comes from the capsule, ligaments, muscle and a cartilaginous tissue called the labrum. There are four bursae surrounding the hip joint. A bursa is a fluid-filled sack that reduces friction between tendons, and between tendons and bone. The most commonly injured bursa is the trochanteric bursa. The four major bursae of the hip are:
- Trochanteric Bursa – located on the outside of the hip between the greater trochanter of the femur (leg bone) and the gluteal muscles
- Ischial Bursa – located between the hamstring muscle and the ischial tuberosity of the pelvis in the buttock area. This area bears the weight of the body when sitting.
- Iliopsoas Bursa – located in the groin area between the large psoas muscle and femur bone
- Gluteal Medius Bursa – located between the gluteus medius muscle and the greater trochanter. It is near the trochanteric bursa.
Causes of Ischial Bursitis
- Muscle Tightness – Tightness in the leg muscles and ischial bursitis itself increases the friction on ischial bursitis. Visit the knee stretches section for simple tests to see if your muscles are tight
- Muscle Weakness – Weakness in the buttock muscles (glutes) puts more strain on ischial bursitis increasing your chances of developing ischial bursitis.
- A direct blow to the ischial bursa from falling on the outside of the hip or on the buttocks can produce inflammation and irritation.
- A fall onto the hip or ischial bursa.
- Constant pressure on the ischial bursa from lying on that side.
- Repeated stress or friction injury as the tendon rubs over the ischial bursa during activity. The weakness of the muscles over the ischial bursa.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the ischial bursa.
- The tightness of the structures of the hip like the psoas hip flexor, iliotibial band, and hamstrings.
- The ischial bursa can become swollen as a response to other hip conditions.
- Flat Feet – If you have flat feet (dropped foot arches) it slightly changes the angle of the leg, putting more friction through Ischial bursitis
- Excessive long-distance or hill running – Overuse can also lead to ischial bursitis due to repetitive friction. Hill running puts even more tension through ischial bursitis.
- Running on a sloped surface – Lots of running surfaces e.g. roads and running tracks are slightly banked. The foot position on the lower leg causes ischial bursitis to be stretched
- The sudden increase in activity – Someone who rapidly increases their training is at risk of developing due to the sudden increase in friction at the hip
- Leg Length Discrepancy – If one leg is slightly shorter than the other it puts more strain on the hip.
- Bowlegs – The curved nature of bow legs means there is a larger than normal space between the knees. This puts an extra stretch on the bursa
Symptoms of Ischial Bursitis
- Pain, tenderness, swelling, warmth, or redness may travel up or down the thigh or leg
- Initially, pain at the beginning of an exercise that lessens once warmed up; eventually, pain throughout the activity, worsening as the activity continues; may cause the athlete to stop in the middle of training or competing
- Pain that is worse when running down hills or stairs, on banked tracks, or next to the curb on the street
- Pain that is felt most when the foot of the affected leg hits the ground
- Possibly, crepitation (a crackling sound) when the tendon or bursa is moved or touched
- Stabbing or stinging pain along the outside of the knee
- A feeling of the snapping over the knee as it bends and straightens
- Swelling near the outside of your knee
- Occasionally, tightness and pain at the outside of the hip
- Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to a standing position
- Pain that is worse when running down hills or stairs.
- Pain that is felt most when the foot of the affected leg hits the ground.
- Possibly, a crackling sound when the bursa is moved or touched.
Diagnosis of Ischial Bursitis
A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose ischiogluteal bursitis. Further investigations such as an Ultrasound, X-ray, CT or MRI scan are often required to assist with diagnosis and assess the severity of the condition.
Treatments of Ischial Bursitis
Treatment of ischial bursitis is relatively symptom driven. Primary treatment is lifestyle modification by stopping the activity that caused bursitis in the first place, whether it was a physical activity or sitting for long periods of time on hard surfaces.
- Rest – People with ischial bursitis may need to cut back on the intensity, duration and frequency of activity that leads to ischial bursitis pain (for example, reduce running or cycling mileage). People with moderate to severe ischial bursitis and pain may need to take time off from their sport and works. It can be frustrating and difficult for active people to cut back on their training schedules; however, rest is necessary for the injury to heal.
- Ice – Apply ice to the affected area for 5-10 minutes at a time three to five times per day to help reduce inflammation. Make sure you wrap the ice in a thin towel to prevent an ice burn from occurring. You may need to ice the area every day for around 6-12 weeks.
- Warm-up – Five to 10 minutes of gentle exercise and stretching can literally increase the body’s temperature, helping muscles become more elastic and responsive and reducing the chance of ischial bursitis or other injuries.
- Change footwear – Switching out shoes and/or getting orthotic inserts can alter a person’s biomechanics and reduce the risk of ischial bursitis pain.
- Massage – Much like the foam roller exercise, massage may help relieve tension and improve blood flow in-band thereby reducing pain.
- Avoid Sitting on Hard Seats – Avoiding hard seats or stools is one of the best ways to reduce the pain from bursitis. If you do need to sit down for long periods, use a pillow or a doughnut cushion. Also sit upright and maintain a good posture while sitting.
- Stretching – A doctor may recommend stretching or yoga to promote flexible muscles and other soft tissue.
- Change running biomechanics – Runners may consider shortening their stride and running on soft, flat surfaces, such as tracks and even, grassy trails.
- Change cycling biomechanics – Cyclists may consider adjusting saddle position and pedal clips. Even a small adjustment can alter the biomechanics of their pedaling and reduce ischial bursitis pain.
- Ultrasound – Efforts to heal ischial bursitis and reduce pain may get a small boost from ultrasound and electrical muscle stimulation.
- Iontophoresis – Doctors and physical therapists occasionally recommend iontophoresis, which uses a mild electrical current to administer an anti-inflammatory medicine (e.g. dexamethasone) through healthy skin and into the sore area. This treatment may be appropriate for people who can’t tolerate injections or want to avoid injections.
- Frictional massage – It is recommended to use friction massage additional to the therapy on chronic bursitis because it affects the adhesions in chronic bursal problems. It breaks down scar tissue, increases extensibility and mobility of the structure, promotes normal orientation of collagen fibers, increases blood flow, reduces stress levels, and allows healing to take place. Friction massage is beneficial to the underlying structures. By using the Graston technique of friction massage the patient should be forewarned because it may initially aggravate a chronic subacute inflammation that is present. It is postulated that deep friction, especially with the Graston technique instruments, may initiate a new inflammatory cascade, which is necessary to reach the remodeling stage of the inflammatory process and result in healing of the area.
- Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
- Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your painful area. Steroids make the inflammation go down. The corticosteroid will provide prolonged anti-inflammatory protection by inhibiting the inflammatory mediators. Patients will most likely be symptom-free within days to weeks without treatment.[rx]
- Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time. The lidocaine will help by providing immediate relief from the pain by blocking the sodium channels in the surrounding tissue, inhibiting the transmission of the pain signal.
- Muscle Relaxants – These medications provide relief from muscle spasms.
- Neuropathic Agents: Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- Calcium & vitamin D3 – to improve bone health and healing fracture.
- Glucosamine & diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
- In severe cases, the fluid in the ischial bursa may need to be drained. Fluid can be checked for possible infection.
- Antibiotics if there is an infection of the ischial bursa
Longer-Term Treatment of Ischial Bursitis
- Strengthening Exercises – Strengthening the glutes, quads, and hamstrings improves how the hip and knee function which reduces the friction on bursitis. Visit the knee strengthening section for exercises that will help
- Stretching Exercises – Stretching the quads, hamstrings, and ischial bursitis also helps reduce the friction at the knee. Visit the stretches section to see if tight muscles are likely contributing to your ischial bursitis
- Gluteus stretch – Lie stretched out on your back with your head supported by a cushion. Bend one knee. With both hands around the knee, pull it slowly toward your chest and hold the position for 5 to 10 seconds. Slowly straighten your leg, and do the same with your other knee. Repeat 5 to 10 times.
- Piriformis stretch –
- Sit on the floor with both legs straight. Cross one leg over the other, with your foot along the knee. With the opposite hand, gently pull your bent knee across the middle of your body. Hold this position for 10 to 30 seconds. You should feel a stretch in the muscles of your outer thigh. Repeat with the other leg.
- Taping – Taping can also be used to reduce the forces going through ischial bursitis – see you physical therapist/ sports injury specialist for more information
- Massage – Deep tissue massage to the Iliotibial Band can reduce tightness, but it can be quite painful
- Injections – If other treatments have failed, a cortisone injection can be given to help reduce pain and inflammation. However, it should always be accompanied by strengthening and stretching exercises to ensure the problem doesn’t return
- Orthotics – Special insoles can be worn in your shoes to correct poor foot positions such as flat feet. See an orthopedist for a full assessment and advice
Common Physical Therapy interventions in the treatment of Hip Bursitis (Ischial Bursa) include:
- Manual Therapeutic Technique (MTT) – hands-on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the knee. The use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) – including stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee to support, stabilize, and decrease the stresses placed on the ischial bursa and tendons of the hip joint.
- Neuromuscular Reeducation (NMR) – to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on ischial bursa and tendons in daily activities.
- Modalities including the use of ultrasound – electrical stimulation, ice, cold laser, and others to decrease pain and inflammation of the ischial bursa.
- A home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
- In addition to the home program – it is often necessary to initiate therapy in our office to directly treat the bursa. Our office will usually use therapeutic ultrasound, electrical stimulation, transverse friction, cross friction or active release massage in addition to manual muscle and joint manipulation to treat this painful condition. We will also employ correct stretching and strengthening exercises as well as Kinesio or KT Tape to help stabilize the region between treatment sessions.
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