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Ischial Bursa Injection

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Other Names

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

Background

Illustration of the ischiogluteal bursa[1]

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

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[2]

Indications


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

Procedure

Patient in lateral decubitus position for long-axis, in plane approach[3]
Probe position for long-axis approach[3]
Ultrasound image of long axis approach. Arrow represents needle approach from distal to proximal[3]
Patient (A) and probe position (B) for short axis approach[3]
Ultrasoud image of short axis approach with needle tractory (arrow). Glute Max (GM), Hamstring (HS)[3]

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

Aftercare

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

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

See Also


References

  1. Lowe Taylor, Anita M., and Eugene Yousik Roh. "Hip: Periarticular Injections." Bedside Pain Management Interventions. Cham: Springer International Publishing, 2022. 675-688.
  2. Zissen, Maurice H., et al. "High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection." American Journal of Roentgenology 195.4 (2010): 993-998.
  3. 3.0 3.1 3.2 3.3 3.4 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
Created by:
John Kiel on 28 May 2023 12:00:31
Authors:
Last edited:
28 May 2023 14:33:53
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