Introduction To Ischial Bursitis

Ischial bursitis, also known as ischiogluteal bursitis, Weaver’s bottom, or Tailor’s bottom, is a relatively uncommon yet clinically significant inflammation of the ischial bursa located in the buttock region. As one of the four types of hip bursitis, it often goes underdiagnosed due to its subtle presentation and the tendency to attribute symptoms to other conditions. The bursa, a fluid-filled sac that reduces friction between tissues, becomes inflamed primarily due to chronic pressure or mechanical stress. 

This condition is most prevalent among individuals with sedentary lifestyles or those engaging in activities that place repetitive strain on the ischium, such as prolonged running or cycling. It is important to note that ischial bursitis rarely occurs in isolation; it is typically secondary to underlying pathologies, including hamstring injuries, trauma, or overuse syndromes. Proper identification and management of the root cause are essential for effective treatment and prevention of recurrence.

Anatomy of The Bursae Around The Ischium

The ischial bursa is a small, fluid-filled sac located deep in the buttock area, right over a bony part of the pelvis called the ischial tuberosity. It cushions between the large gluteus maximus muscle and the bone to prevent friction when you move.

The bursa is positioned below the gluteus maximus muscle and just behind the ischial tuberosity. On one side, it’s close to where the hamstring muscles attach to the bone. If the bursa gets irritated or swollen, it can sometimes spread into the nearby fatty tissue in the buttock area, especially if it gets swollen or inflamed. This inflammation often happens when there’s too much pressure or stress on that part of the body, like sitting for long periods or overworking the hamstrings.

How Common Is Ischial Bursitis?

Ischial bursitis is a relatively uncommon condition, often overlooked in clinical settings. It can affect individuals of any age, though it accounts for less than 1% of primary care visits related to bursitis. Historically referred to as “weaver’s bottom,” the condition has been associated with sedentary occupations, particularly prolonged sitting on hard surfaces. This has been a recognised issue since weaving became a common vocation, dating back to around 6000 BCE. Despite its long history, ischial bursitis remains underdiagnosed due to its subtle presentation and overlap with other musculoskeletal conditions.

What Causes Ischial Bursitis?

The origin of ischial bursitis is reflected in its historical name, “weaver’s bottom,” referring to workers who spent prolonged periods sitting on hard surfaces, leading to inflammation of the ischial bursa. Similarly, “tailor’s bottom” describes another common cause related to extended sitting. While pressure from prolonged sitting remains a primary cause, other factors contribute to ischial bursitis development. Here are some common causes: 

• Trauma, such as direct impact or injury, can lead to hemorrhagic bursitis. 
• Inflammatory conditions like rheumatoid arthritis and spondyloarthropathies can also trigger bursitis, as the body’s immune response targets the bursa. 
• Though rare, infection can result in septic bursitis, often following septicemia or septic arthritis. 
• Additionally, crystal deposition diseases, including gout and pseudogout, can provoke inflammation in the bursa.
• Activities involving repetitive gluteus maximus motion, such as cycling, can aggravate the ischial bursa due to the continuous stress on the muscle, further contributing to bursitis development.

What Are The Symptoms of Ischial Bursitis?

The symptoms of ischial bursitis are primarily characterised by localised pain and discomfort, often worsening with specific activities or prolonged pressure on the affected area. The presentation can vary in severity, but common symptoms include:

• Pain localised to the ischial tuberosity may radiate down the lower leg.
• Increased pain with prolonged sitting, particularly on hard surfaces.
• Pain with passive hip flexion and inability to extend the hip fully, especially when stretching.
• Tenderness upon palpation over the ischial tuberosity.
• Difficulty sleeping on the affected side due to pressure on the inflamed bursa.
• Regional muscle dysfunction, often resulting in limited mobility and swelling.
• Overlying erythema (skin redness) in more severe cases may indicate underlying cellulitis or septic joint, particularly if redness is a prominent feature.

How Is Ischial Bursitis Diagnosed?

Diagnosing ischial bursitis involves checking for certain signs and symptoms and some imaging tests to confirm inflammation in the bursa when needed.

One important test is the straight leg raise, which often causes pain if ischial bursitis is present. Another way to check is by having the patient resist leg movements; if extending the affected hip reproduces the pain, it further suggests bursitis. In rare circumstances, using X-rays to look for any calcification in the bursa and nearby areas can indicate long-term inflammation.

During the physical exam, patients often have a noticeable soft tissue lump in the buttock area of the affected hip. This lump is usually well-defined, doesn’t move around much, and feels tender when touched. Together, these signs and tests help our practitioners accurately diagnose ischial bursitis.

Not All Hip Pains Are Caused By Ischial Bursitis

The symptoms of ischial bursitis can sometimes look like other conditions, such as myxoid tumours, which are rare growths that can occur in the body. These include types like neurofibromas, schwannomas, and myxomas. Suppose one of our practitioners suspects a tumour. In that case, they might do a referral for a biopsy, which involves taking a small sample of tissue from the area to examine under a microscope. This helps tell the difference between the swelling from bursitis and the cells from a tumour.

In rare circumstances, one of our practitioners may also use X-rays to rule out other causes of pain, like stress fractures or wear and tear on the cartilage in the hip joint. A careful physical examination is essential to distinguish the pain of ischial bursitis from muscle-related issues. This examination typically involves checking specific movements and pressing on the area over the ischial tuberosity (the bony part of the pelvis). This thorough approach helps ensure a correct diagnosis and the right treatment plan.

How Is Ischial Bursitis Bursitis Treated

Chronic ischial bursitis is typically managed by reducing activities that exacerbate the condition, alongside using anti-inflammatory medications such as ibuprofen, Naprosyn, or Celebrex for a few weeks. While these medications help alleviate pain and inflammation, they do not address the underlying issue. Icing the affected area 2-3 times daily for 20-30 minutes can effectively control swelling; however, heat should be avoided, as it can worsen inflammation. 

Corticosteroid injections into the bursa may help reduce swelling but carry risks of side effects, including infection, skin atrophy, or chronic pain. These injections are generally reserved for cases that do not respond to other treatments, and they should be avoided if infection is suspected.

If signs of infection accompany ischial bursitis, immediate medical attention is crucial. Aspiration of the bursa may be necessary to relieve swelling and obtain samples for biopsy, with antibiotics prescribed to eliminate the infection. A significant concern with infected bursitis is the potential for bacteria to spread into the bloodstream. As with other forms of bursitis, rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) are employed to manage inflammation.

In cases of traumatic bursitis, aspiration with a small needle may be required to remove excess fluid or blood from the affected bursa. Icing the area and using NSAIDs can also help reduce swelling. Physical therapy may be beneficial, particularly if the condition is accompanied by muscle tightness or dysfunction.

HPL Therapy (High Power Laser Therapy): HPL therapy is a non-invasive treatment that utilises focused light energy to penetrate tissues deeply. While research specifically targeting ischial bursitis is limited, studies on other musculoskeletal conditions show promising results. HPL therapy enhances blood flow, accelerates the removal of inflammatory substances, and boosts cellular energy production (ATP), promoting tissue repair. In chronic or severe cases of ischial bursitis, it can serve as an effective adjunctive treatment, with some clinical studies reporting a significant reduction in pain, with patients experiencing up to a 40-60% improvement in pain and function after consistent use over several weeks.

ESWT (Extracorporeal Shockwave Therapy): ESWT is well-known for treating chronic tendinopathies but has also shown promise for ischial bursitis. The acoustic waves produced in ESWT stimulate tissue repair by enhancing blood flow and reducing inflammation. Some clinical studies indicate a success rate of 60%-80% in decreasing pain and improving function in patients with musculoskeletal conditions. Additionally, data shows that patients with chronic hip pain who do not respond to conservative measures experience significant improvements after several ESWT sessions.

Conclusion

In summary, ischial bursitis is an often overlooked yet significant condition that can adversely affect individuals’ quality of life, particularly those who lead sedentary lifestyles or participate in activities that impose repetitive strain on the ischial bursa. This inflammation of the bursa can lead to localised pain, discomfort, and restricted mobility, making it essential for individuals to recognise the symptoms and seek proper evaluation.

Understanding the potential causes—such as prolonged sitting, trauma, inflammatory conditions, and repetitive motion—is crucial for effective management. An accurate diagnosis, often achieved through physical examination and imaging is vital in differentiating ischial bursitis from other conditions that may present similarly.

Treatment options vary and may include conservative measures like activity modification, anti-inflammatory medications, and ice application to reduce swelling. In cases where traditional treatments are insufficient, advanced therapies such as High Power Laser Therapy (HPL) and Extracorporeal Shockwave Therapy (ESWT) have shown promise in promoting healing and alleviating pain.

Proactively addressing ischial bursitis improves comfort and enhances overall mobility and quality of life. If you have any questions regarding ischial bursitis or are experiencing hip pain, don’t hesitate to contact Severn Clinics at 04 385 6446. Our dedicated team is here to assist you in navigating your path to recovery and restoring your well-being.