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Ischial Bursitis

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Other Names

  • Ischio-gluteal Bursitis
  • Weaver's bottom
  • Tailor's bottom
  • Ischiogluteal Bursitis
  • Ischial Tuberosity Bursitis
  • Lighterman’s bottom

Background

History

  • First described by Frazer in 1932, who performed a surgical resection of a sea captain with 20 years of buttock pain[1]

Epidemiology

  • Ischial bursitis is uncommon and infrequently recognized
  • It is rarely described in the literature

Introduction

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Ischial Bursitis
Illustration of the ischiogluteal bursa[2]

General

  • Likely more common than realized, often overlooked cause of buttock or thigh pain
  • Mimics lumbar back disease, hip arthritis and pelvic masses among others
  • Classically worse with long periods of sitting
  • Most patients will improve with conservative management including activity modification

Etiology

  • Repetitive microtrauma
    • First seen in weavers and tailors who sat for long periods of sitting on hard surface
    • Road equipment machines, tractors, long haul truckers
    • May also be due to repetitive activities, such as running, jumping, kicking, or climbing stairs
    • Chronically ill and seated such as malignancy, paraplegia
  • Less commonly due
    • Acute trauma (hemorrhagic bursitis)
    • Inflammatory diseases such as Rheumatoid Arthritis, Gout
    • Infection such as tuberculosis

Anatomy of the Ischial Bursa

Risk Factors

General

  • Sedentary Lifestyle

Occupational

  • Occupations that require long periods of sitting or vibration
    • Weaving
    • Tractor-driving
    • Road equipment machines

Sports

  • Sports that involve long periods of sitting
    • Canoeing
    • Horseback riding
    • Wheelchair racing for paraplegic patients

Differential Diagnosis

Differential Diagnosis Ischial Bursitis

Differential Diagnosis Hip Pain

Clinical Features

Illustration of typically location of pain in ischial bursitis
AP Pelvic XR shows bilateral calcifying bursitis ischioglutealis[3]
MRI pelvis. Ischial tuberosities demonstrate hyperintense signal with a band of fluid collection at bursae. Fluid is seen extending along the thickened hamstring muscle complex tendons represent bursitis with enthesopathy (white arrow).[4]
Ischial Bursa Ultrasound. Collection with echoes is noted with well-defined wall in the region of interest. It abutts ischial cortex which is intact. Wall thickness is 2 mm. Interal echoes with thin septa are noted. Vascularity is noted in wall and perilesional area. A vessel within septa is noted crossing lumen.[5]

History

  • Pain is typically insidious in onset
  • Located in buttocks or gluteal area, posterior thigh
  • Pain is characterized as a deep ache
  • Worse with prolonged sitting, exercise, standing on toes, bending forward
  • Also worse with running, jumping, kicking, climbing stairs
  • Trouble sleeping at night
  • Patients may endorse trouble sleeping, reduced mobility
  • Often worse with stretching the gluteal muscles
  • Pain with passive hip flexion, active hip extension

Physical Exam: Physical Exam Hip

  • Tenderness to buttock and specifically to the ischial tuberosity
    • Most easily examined with patient in the prone position
    • A soft, smooth, non-mobile mass is most commonly felt
  • May also have pain with passive flexion, inability to actively extend hip
  • They may have an antalgic gait
  • Rectal exam: may find tender area of bulging inflamed tissue on the lateral wall of the affected side
  • Important to examine back and knee to consider referred pain as the etiology

Special Tests

Evaluation

  • Primarily a clinical diagnosis, however imaging useful in mixed or unclear clinical picture

Radiographs

MRI

  • Diagnostic gold standard if imaging is needed
    • Can rule out masses and other causes
  • Findings
    • May demonstrate a cystic mass with pericystic fluid and a thin wall
    • Low or intermediate signal intensity on T1-weighted images
    • High signal intensity on T2-weighted images
    • Mural nodules of the bursa which are enhanced after the IV administration of contrast

Ultrasound

  • Findings
    • Hypoechoic mass with an irregular, thickened wall
    • Compressibility suggests bursitis, while non-compressible structure may suggests other etiology

CT

  • Findings in limited case reports
    • Hypodense cystic mass adjacent to the ischial tuberosity[6]
    • Typically bursitis with central hypodense
    • Peripheral hyperdense areas

Aspiration

  • In cases of suspected infection, aspiration may be indicated
  • This can be done under ultrasound guidance (see: Ischial Bursa Injection)
  • These patients will also require infectious/ inflammatory markers depending on the differential diagnosis

Classification

  • N/A

Management

Ischial Bursitis Cushion

Prevention

  • Horseback Riding
    • Ensure rider has a proper fitting saddle

Nonoperative

  • Primary treatment in the majority of cases
  • Medications including NSAIDS
  • Ice Therapy and Heat Therapy
  • Physical Therapy
    • Goal: correct strength and flexibility deficits
    • Increase strength
    • Stretch hamstrings
  • Avoidance of aggravating activities
    • Avoid activities that elicit pain such as running, climbing stairs
    • Avoid sitting for prolonged periods of time
  • Ischial Bursitis Cushion/ Padded cushion
    • Consider prescribing when patient can not avoid seated activities

Procedures

Operative

  • Indications
    • Non-responsive to conservative therapy
    • Suspect infection, malignancy
  • Technique
    • Bursectomy (?)

Rehab and Return to Play

Rehabilitation

  • There are no evidence based guidelines for rehabilitatoin
  • Consider following a hamstring rehab protocol

Return to Play

  • Activities may be resumed gradually once pain is resolved.
  • Returning prior to resolution of the pain may cause prolonged symptoms.

Prognosis and Complications

Prognosis

  • Needs to be updated, no published literature to guide prognostication

Complications

  • Chronic pain
  • Inability to return to sport

See Also

Internal

External

References

  1. ↑ Fraser I, Belf MC. A very large bursa. Lancet. 1932;219(5658):290–1.
  2. ↑ Lowe Taylor, Anita M., and Eugene Yousik Roh. "Hip: Periarticular Injections." Bedside Pain Management Interventions. Cham: Springer International Publishing, 2022. 675-688.
  3. ↑ Schuh, Alexander, et al. "Calcifying bursitis ischioglutealis: a case report." Journal of Orthopaedic Case Reports 1.1 (2011): 16.
  4. ↑ Sharma, Rajaram, Tapendra Tiwari, and Saurabh Goyal. "Typical MRI findings of bilateral ischial bursitis: bilateral Weaver’s bottom." BMJ Case Reports 14.10 (2021).
  5. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 22914
  6. ↑ Völk M, Gmeinwieser J, Hanika H, Manke C, Strotzer M: Ischiogluteal bursitis mimicking soft-tissue metastasis from a renal cell carcinoma. Eur Radiol 8:1140–1141, 1998.
  7. ↑ Wisniewski, Steve J., et al. "Ultrasound-guided ischial bursa injection: technique and positioning considerations." PM&R 6.1 (2014): 56-60.
  8. ↑ Shen, Zi-wei, et al. "Platelet-rich plasma for treatment of ischiogluteal bursitis Symbol." Journal of Clinical Rehabilitative Tissue Engineering Research 18.47 (2014): 7689-7696.
Created by:
John Kiel on 10 June 2019 17:10:18
Authors:
Last edited:
3 September 2024 13:54:28
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