Ischial Bursa Injection

Other Names

• Ischio-gluteal Bursa Injection
• Ischial Bursa Peritendinous Injection
• Ultrasound-guided Ischial Bursa Injection

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Background

Illustration of the ischiogluteal bursa

• This page refers to injections of the ischial bursa

Key Points

• Use either high-frequency linear or curvilinear probe depending on body habitus
• Ischial bursa can be difficult to find at times and is not always obvious
• Optimize patient positioning to ensure success

Anatomy of the Ischiogluteal Bursa

• Located deep to the gluteus maximus muscle over the ischial tuberosity
• Muscle origination: semimembranosus, semitendinosus, long head of the biceps femoris

Palpation vs Ultrasound Guidance

• To date, there no studies comparing ultrasound, fluoroscopic and palpation guided approaches
• One study showed ultrasound guidance provided relief at 1 and 6 months

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Indications

• Ischial Bursitis

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
  • Septic Bursitis
• Relative
  • Can be treated with less invasive means
  • Muscle tear or rupture
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Patient in lateral decubitus position for long-axis, in plane approach

Probe position for long-axis approach

Ultrasound image of long axis approach. Arrow represents needle approach from distal to proximal

Patient (A) and probe position (B) for short axis approach

Ultrasoud image of short axis approach with needle tractory (arrow). Glute Max (GM), Hamstring (HS)

Equipment

• Sterile including chloraprep, chlorhexadine, iodine
• Ultrasound with sterile probe cover
• Gloves
• Needle
  • 25 gauge, 1.5 inch for local anesthetic
  • 21-22 gauge, 3.5 inch needle for injection
• Syringe: 5-10 mL
• Gauze
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid/ injectate

Ultrasound Findings

• Ischial tuberosity is best visualized in long axis
  • Use a high frequency linear or curvilinear transducer
  • Depth is between 3 and 6 cm
• Common ultrasound findings include:
  • Thickened proximal hamstring tendon
  • Lose of normal fibrillar architecture
  • Peritendinous fluid collection
  • Cortical irregularity of the ischial tuberosity

Technique: Long Axis

• Patient Position
  • The patient is in lateral decibitus position
  • Ipsilateral leg is up with hip and knee flexed
• Transducer position
  • Sagittal, long axis to hamstring tendon complex and bursa
• Needle orientation/ approach
  • In plane
  • Distal to proximal
• Target
  • Peritendon and ischial bursa
• Pearls and Pitfalls
  • Identify sciatic nerve prior to injection
  • If injecting the peritendon, look for tracking up and down the tendon sheath
  • If not visualized, reposition needle until flow is seen
  • The bursa should also distend or enlarge when injecting

Technique: Short Axis

• Patient Position
  • Prone
• Transducer position
  • Short axis to hamstring tendon complex and bursa
• Needle orientation/ approach
  • In plane
  • Lateral to Medial
• Target
  • Peritendon and ischial bursa
• Pearls and Pitfalls
  • See Technique: Long Axis

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Aftercare

• No major restrictions in most cases
• Can augment with ice, NSAIDS

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Complications

• Sciatic Nerve Injury
  • May inadvertently regionally block the sciatic nerve which will resolve as anesthetic wears off
  • Can also fenestrate sciatic nerve if not careful during procedure
  • Very important to identify during pre-procedure sonogram

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See Also

• Procedures Main
• Ultrasound Main
• Hip Pain Main

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