By Lauren Opatrny, PT, DPT, PHRC San Francisco, CA
Ischial bursitis, or ischiogluteal bursitis, is a condition where the bursa that lies between the ischial tuberosity and the gluteus maximus muscle becomes inflamed.(1) Ischial tuberosities are the bones that we sit on and are commonly referred to as your “sits bones.” They provide support for the body while sitting and serve as an attachment site for several muscles and tendons. When this bursa becomes inflamed, it can cause pain, stiffness, and limited mobility in the affected area.
Image credit to Sports Injury Clinic
What is a Bursa and why does it get inflamed?
A bursa is a fluid-filled sac that serves to provide cushion and reduce the amount of friction between ligaments, tendons, and bones so our tissues can glide and slide past one another during movement. “Bursitis” refers to inflammation of the bursa. Bursitis is usually a temporary condition, and ischial bursitis is relatively uncommon. The bursa can become inflamed from injury or overuse. Typically, ischial bursitis is caused by prolonged sitting on a hard surface and is most common in individuals who have a sedentary lifestyle(1), but it can also be caused by trauma to the area such as a fall, or from injury to the hamstring muscle or tendon from activities like running or biking.
These activities can cause an inflammatory reaction in the bursa and surrounding tissues resulting in swelling and tenderness over the lower buttock and upper posterior thigh.(1) Symptoms can include:
- Pain with prolonged sitting (especially on a hard surface)
- Pain when stretching the gluteal and/or hamstring muscles (pain with hip flexion and/or straight leg raise)
- Tenderness on ischial tuberosity
- Pain that my radiate into back of the thigh
- Swelling and limited mobility
- Pain with gluteal and/or hamstring muscle activation
- Sleep disturbances due to pain
- Difficulty or pain with walking and running
Differential Diagnosis
Many muscles attach on or near the ischial tuberosities including the hamstrings, adductor muscles, gluteal muscles, and the superficial transverse perineal muscle, which is part of the pelvic floor. Because there are several different tendons, muscles, ligaments, and nerves in this region of the pelvis, it makes diagnosing pain in this area difficult. Besides ischial bursitis, differential diagnosis can include but is not limited to sciatica, hamstring tendonitis or tendinopathy, proximal hamstring or adductor muscle strain, pudendal neuralgia, and pelvic floor dysfunction. Your doctor may recommend imaging such as an x-ray or MRI to rule in or out certain diagnoses.(1)
How can physical therapy help?
Physical therapist will perform an evaluation to determine the most likely cause of your pain, which will determine the types of interventions that are appropriate. If it seems like ischial bursitis is the most likely source of pain, the treatment will depend on that individual’s specific presentation. Everyone is different! And it is possible there is more than one thing going on. Treatment may include but is not limited to patient education and activity modification, manual therapy to surrounding tissues to improve mobility and blood flow, gentle stretches to reduce compression of the bursa and restore mobility, postural and neuromuscular re-education, and strengthening.
Activity modification may include taking a look at sitting posture and habits, as well as possibly making ergonomic adjustments to someone’s work station set up. Nowadays, people spend a lot of time sitting at work, so it’s important to make sure you are implementing proper ergonomics. If you have access to a standing desk, this can be a great way to break up sitting throughout the day. While sitting, it may be helpful to use a cushion; below is a great video describing different types of cushions for pain with sitting:
If the injury is more acute, using ice to the affected area can be helpful to reduce pain and inflammation. Rest and modifying activities that cause pain are also very helpful, because this allows the tissues time to heal more effectively.
References:
- Johnson, Donovan B., and Matthew Varacallo. “Ischial Bursitis.” National Center for Biotechnology Information, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/29493912/.
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.