Ischial Bursitis

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Keywords:Ischial bursitis, ischiogluteal bursitis, bursitis Exercise therapy, strengthening exercise, treatment, cold therapy, symptoms, ultrasound therapy, stretching exercise, rehabilitation program

Definition/Description

Ischial bursitis, also known as Ischiogluteal bursitis or Weaver’s bottom [1,7], is a rare, infrequently recognized bursitis of the buttock region. [8] It’s one of the four types of hip bursitis. The bursitis is mainly due to chronic and continuous irritation of the bursa and occurs most often in individuals who have a sedentary life.[7,17]

A bursitis always develops in response to another pathology. Therefore, the diagnosis of bursitis must be considered as a secondary happening, the primary condition being another pathology. [22]

Clinically Relevant Anatomy

The Ischial bursa is a deep located bursa over the bony prominence of the Ischium [18] and lies between the M. Gluteus Maximus and the Ischial tuberosity. [10, 17]

More specific is the bursa located deep:
- On the sagitale section: between the inferior part of the M. Gluteus maximus and posteroinferiorly part of the Ischial tuberosity.
- On the transverse and coronal sections: the superior end of the bursa abutted to the inferomedial surface of the Ischial turberosity, and it lies medial to the common tendon of the hamstrings muscles that has his insertion from the inferolateral surface of the Ischial tuberosity. [17]


When the bursa is larger, it is possible that it is located in the subcutaneous fat at the ischiorectal fossa, beyond the imaginary line that can be drawn between the medial ends of the gluteus maximus and adductor magnum muscles on the transverse sections. [17]

Epidemiology /Etiology

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Characteristics/Clinical Presentation

First of all we have to mention that bursitis can be caused in two different ways. First we have the acute bursitis, caused by a direct trauma, which causes bleeding into the bursal
space. However, the most common cause is repetitive joint motion with excessive pressure or too much friction which also leads to inflammation of the bursa. [15]

It is noteworthy that not all patients with Ischial Bursitis have the same complaints. But some of the known symptoms are:
- Pain or warmth in the region of the ischial tuberosity. The pain will become more intense in hill running, sprinting, bending forwards and standing on tiptoes. (And sometimes it radiates to the thigh or lower leg). [1,3]
- The pain is worse when sitting or lying on the back than standing [14]
- Tenderness of the Ischial prominence, which increases when you do resisted hamstrings strength test. [3]
- The patient may be unable to sleep on the affected hip. When he gets up, he’ll feel a sharp pain when flexing and extending the hip. [5]
- Local point tenderness may occur over the ischial tuberosity. [5]
- Possible regional muscle dysfunction. [3]
- Bursitis is accompanied with swelling and limited mobility. [15]

Differential Diagnosis

Ischial Bursitis can be confused with myoxoid tumors. These are a group of rare tumors showing myoxoid change, including neurofibroma, schwannoma and myoxoma. Therefore it may be necessary to do an incisional or excisional biopsy. [14] By using this technique the doctors take cells out of the injured place and they can histologically differentiate cells from a myoxoid tumor or from Ischial Bursitis.

To be sure it isn’t a stress fracture or roughening of the cartilage in the hip joint go to the doctor to have an X-ray. [10]

Diagnostic Procedures

- MRI: T1 weighted scans show an injury with intermediate
intensity [8,14]. T2 weighted scans show a higher intensity of this lesion, suggesting a space filled with fluid.
- X-Ray [16]

Outcome Measures

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Examination

- Pain with straight leg raise test is often present.[5,10,14]
- Active resisted extension of the affected hip reproduces the pain.[5]
- Plain radiographs may reveal calcification of the bursa and associated structures that is consistent with chronic inflammation. [5]
- Examination of patients with ischial bursitis reveals a soft tissue mass in the gluteal region of the affected hip. This soft tissue mass is described as well defined, non-mobile and slightly tender. [8,14]

Medical Management

Combination of nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors and physical therapy. When these modalities have no influence on the patient’s injury, the next step is injection of local anesthetic and steroid into the ischial bursa. [5]


Physical Therapy Management

The combination of nonsteroidal anti-inflammatory drugs (NSAIDs) or clycooxygenase-2 inhibitors and physical therapy should be include in the initial treatment. [5]

The treatment begins with rest. Rest in the meaning of keep on doing your daily activities and sporting but at a lower intensity. The recommendation is to stay within your pain threshold.

The preliminary treatment starts with non-operative options such as ultrasound therapy and cold therapy.
1. Ultrasound therapy [4,6]
2. Cold therapy: Cold therapy contains ice application with cold packs. The surface of the buttock can be refrigerated by applying ice. This application of cold leads to lowering of the temperature of the skin, subcutaneous tissues and to a lesser degree, deeper tissues like muscle, bone and joint. Cold water, cold gel packs and ethyl chloride or other sprays can be used, depending on the clinical situation.[2]


Wrap cold packs in a towel, ice’s temperature is below 0! Usually ice is used for about 20-30 minutes.[23]

Cold packs have to be wrapped in moist towels because the temperature is -0°C. Treatment time is generally 20-30 minutes.[23]

Heat treatment is also possible, with hot packs. It increases blood flow and oxygen tension. The treatment is used twice a day for 30 minutes. Target temperatures range from approximately 38°C to 50°C. [25]

The therapeutic rehabilitation program should contain stretching exercises, to increase flexibility of tight hamstrings muscle and reducing pressure on the bursa and achieving painless motion and strengthening exercises, to correct muscle imbalances, ease symptoms. [1,15,20]

Static stretching is believed to be the safest method because it would have the lowest injury risk. It is most effective when you stretch once a day, 30 seconds for each stretch. [19,21]
The benefits of slower stretching are:
- It prevents the tissue from absorbing great amounts of energy per unit time
- It won’t elicit a forceful reflex contraction
- It is good against muscle soreness. [19]


Examples of static stretching exercises: [1]
- Gluteus stretch:
lie on your back, with your head on a cushion. Bent your affected knee upward. Grab the back of your knee with both hands and slowly pull the knee toward your chest. Hold this position for 5 to 10 seconds and repeat 6 to 10 times.
- Piriformis stretch:
while sitting on the floor, cross the leg on your affected side over the other leg, placing your foot alongside the knee. Use the opposite hand to pull the upright knee across the midline of your body. You should feel a stretch in the affected buttock and in your outer thigh. Hold this position for 10-30 seconds.

Strengthening of the hip rotators is a frequently used rehabilitation program. [3] Another program contains strengthening of the hamstrings and gluteal muscles by climbing stairs and reverse curls. [11]
It is recommended to use friction massage additional to the therapy on chronic bursitis because it affects the adhesions in chronic bursal problems. [12]

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. [24]

By using the Graston technique or 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. [13] 

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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[1] Celeste, R.-N. (2005, October). By the way, doctor. What can I do about ischial bursitis? Harvard Woman's Health Watch , p. 8.
Level of evidence: 5 - Expert opinion
[2] Ernst, E., & Fialka, V. (1994, January 1). Ice Freezes pain? A review of the clinical effectiveness of analgesic cold therapy. Journal of Pain and Symptom Management , pp. 56-59.
Level of evidence: 2c - Outcomes research
[3] Paluska, S. A. (2005). An overview of Hip Injuries in Running. Sport Medicine , pp. 991-1014.
Level of evidence: 2a: systematic review of cohort studies
[4] Swam Downing, D., & Weinstein, A. (1986, February). Ultrasound Therapy of Subacromial Bursitis. Physical Therapy. Journal of the American Physical Therapy Association , pp. 194-199.
Level of evidence: 3a: systematic review of case control studies
[5] Waldman, S. D. (2012). Ischial Bursitis. In Atlas Of Common Pain Syndromes (pp. 288-290). Philadephia: Elsevier Saunders.
Level of evidence: 5 - Expert opinion
[6] Luck J., L. (n.d.). Musculoskeletal Ultrasound Intervention: Principles and Advances. p. 515-533.
Level of evidence: 5: expert opinion
[7] Kim, S., & al., et al., (2002). Imaging features of ischial bursitis with an emphasis on ultrasonography. Skeletal Radiol , pp. 631-636.
Level of evidence: 3a: systematic review of case control studies
[8] Van Mieghem, I. M., & al., et al. (2004). Ischiogluteal bursitis: an uncommon type of bursitis. Skeletal Radiol , pp. 413-416.
Level of evidence: 4: case series
[9] Ege Rasmussen, K.-J., & Fano, N. (1985). Trochanteric Bursitis. Treatment by Corticosteroid Injection. Scand J Rheumatology , pp. 417-420.
Level of evidence: 2C - Outcomes research
[10] Weiss, L., & al, et al. (2007). Ischial Bursa. In Easy Injections (pp. 92-94). Philadelphia: Elsevier.
Level of evidence: 5 - Expert opinion
[11] Subotnic, S. (1991). In Conventional, Homeopathic & alternative treatments. Sport & Exercise injuries. (p. 279). California: North Atlantic Books.
Level of evidence: 5 - Expert opinion
[12] Hammer, W. (1993). The use of transverse friction massage in the management of chronic bursitis of the hip and shoulder. Journal of Manipulative & physiological therapeutics .
Level of evidence: 4 - case-series
[13] Hammer, W. I. (2007). Hip Bursitis. In Functional Soft-Tissue Examination and Treatment by Manual Methods (P. 281). Jones and Bartlett Publishers Inc.
Level of evidence: 2C - outcomes research
[14] Hitora, T., & al, et al. (2008). Ischiogluteal bursitis: a report of three cases with MR findings. Rheumatol Int , 455-458.
Level of evidence: 2a - cohort studie
[15] Pécina, M. M., & Bojanic, I. (2004). Bursitis. In Overuse injuries of the musculoskeletal system (pp. 305-313). Florida: CRC Press.
[16] Ryan, A. J. (1962). Bursitis. In Medical care of the athlete (p. 132). McGraw hill.
[17] Cho, K.-h., et al. (2004, November 13). Non-infectious ischiogluteal bursitis: MRI findings. Korean J Radiol , 208-286.
Evidence level: 2c
[18] Zimmermann III, B., et al. (1995). Spectic Bursitis. Seminars in Arthritis and Rheumatism , 391-410.
[19] Brady, W. D., et al. (1998). The effect of static stretch and dynamic range of motion training on the flexibility of the hamstrings muscles. Journal of Orthopaedic & Sporrts Physical Therapy , 295-300.
Evidence level: 3b
[20] Thacker, S. B., et al. (2004). The impact of stretching on sports injury risk: a systematic review of the literature. Official journal of the American College of sports medicine , 371-378.
Evidence level: 3a
[21] Bandy, W. D. (1997). The effect of time and frequency of static stretching on flexibility of the hamstrings muscles. Physical therapy , 1090-1096.
Evidence level: 1a
[22] Uththoff, D. H. (2010, October). Shoulder injury and disability. Discussion paper prepared for the workplace safety and insurande Appeals Tribunal .
Evidence level: 5
[23] Cuccurullo, S. (2004). Physical Mediine and Rehabilitation Board Review. New York.
Evidence level: 5
[24] Premkumar, K. (2004). The massage connection: anatomy and physiology.
[25] Badgwell Doherty, C. (2009). Thermotherapy in dermatologic infections. Continuing medical education , 909-927.