Ischial Bursitis

Other Names

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

---

Background

• This page refers to ischial bursitis, or inflammation of the ischial bursa between the Ischial Tuberosity and Gluteus Maximus

History

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

Epidemiology

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

---

Introduction

Illustration of the ischiogluteal bursa

• See: Bursopathies (Main)

Etiology

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

Anatomy of the Ischial Bursa

• Located deep to the Gluteus Maximus muscle over the Ischial Tuberosity
• Muscle origination: semimembranosus, semitendinosus, long head of the biceps femoris
• Synovial bursa composed of a fatty connective tissue capsule filled with synovial fluid

---

Risk Factors

• Occupations that require long periods of sitting or vibration
  • Weaving
  • Tractor-driving
  • Road equipment machines
• Sports that involve long periods of sitting
  • Canoeing
  • Horseback riding
  • Wheelchair racing for paraplegic patients

---

Differential Diagnosis

Differential Diagnosis Hip Pain

• Fractures And Dislocations
  • Pelvic Fracture
  • Hip Fracture
  • Acetabular Fracture
  • Femoral Neck Stress Fracture
  • Pelvic Stress Fracture
  • Hip Dislocation

• Arthropathies
  • Osteitis Pubis
  • Avascular Necrosis of the Hip
  • Hip Osteoarthritis
  • Femoroacetabular Impingement
  • Transient Osteoporosis of the Hip

• Muscle and Tendon Injuries
  • Hip Flexor Tendonitis
  • Piriformis Syndrome
  • Hamstring Strain
  • Proximal Hamstring Tendinopathy
  • Adductor Strain
  • Greater Trochanteric Pain Syndrome

• Bursopathies
  • Iliopsoas Bursitis
  • Ischial Bursitis

• Ligament Injuries
  • Acetabular Labrum Tear

• Neuropathies
  • Meralgia Paresthetica

• Other
  • Snapping Hip Syndrome
  • Septic Arthritis
  • Gout
  • Leg Length Discrepancy
• Pediatric Pathology
  • Transient Synovitis of the Hip
  • Developmental Dysplasia of the Hip (DDH)
  • Legg-Calve-Perthes Disease
  • Slipped Capital Femoral Epiphysis (SCFE)
  • Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
  • Ischial Tuberostiy Avulsion Fracture
  • Avulsion Fractures of the Trochanters (Greater, Lesser)
  • Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)

---

Clinical Features

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
• Trouble sleeping at night
• Patients may endorse trouble sleeping, reduced mobility

Physical Exam: Physical Exam Hip

• Tenderness to buttock and specifically to the ischial tuberosity
• 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

Special Tests

• Straight Leg Raise Test: may elicit symptoms, not specific
• FABER Test: may elicit symptoms, not specific

---

Evaluation

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

Radiographs

• Standard Radiographs Hip, Standard Radiographs Pelvis
  • Screening tool, often normal
  • May show soft tissue swelling, calcifications

MRI

• 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
  • Typically bursitis with central hypodense
  • Peripheral hyperdense areas

---

Classification

• N/A

---

Management

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

• Ischial Bursa Injection
  • Best performed under ultrasound where soft tissue structures are easily visualized
• Platelet Rich Plasma
  • A small study by Shen et al found PRP inferior to local anesthetic

Operative

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

---

Rehab and Return to Play

Rehabilitation

• Needs to be updated

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

• Hip Anatomy (Main)
• Physical Exam Hip
• Hip Pain (Main)

External

• Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/

---