Ischial tuberosity pain syndrome treatment
Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
In our many years of helping people with chronic pain conditions, we have seen many patients with Ischial tuberosity pain syndrome. We have also seen the many causes of this problem.
- My chiropractor suggests that my hips are out of alignment and my “sit bones” are not properly aligned.
- My doctor thinks that I have Sacroiliac Joint Dysfunction. This is causing a “load imbalance” on my Ischial Tuberosity and this is causing the inflammation responsible for my bursitis and tendinopathy. I had a cortisone injection and it has helped quite a bit, but it is wearing off.
- My physical therapist suggest that my problem is from too much cycling. I have made adjustments to my technique and my saddle height, that has helped but I am still feeling pain when I sit.
- My doctor says I am putting too much stress on my hamstrings.
- I have bad hip pain, it has lasted for months, my leg feels weak, almost as if it is giving out. My doctor says I have ischiofemoral impingement syndrome. Something is pinching.
- My athletic son or daughter has an apophyseal (growth plate) avulsion fracture.
When a person has severe buttock pain along with tenderness on the ischial tuberosity, often the diagnosis of ischial tuberosity pain syndrome or ischial bursitis is made. Bursitis can be ruled out when the area is not significantly red and swollen.
When MRIs are performed of this area, occasionally they show tendinosis or degenerated tendon (it is actually the hamstring muscle origin) but more often than not, the MRI is negative. Why is this? MRIs can never show weakness in a tissue. When you can stand and your butt no longer hurts, but then it significantly irritates you the more you sit, then clearly the structures you are sitting on do not have the strength to withstand the pressure of sitting.
What are the structures?
The ischial tuberosity is a strong, widening of the bone on either side of the frontal portion of the ischium, the lowest of the three major bones that make up each half of the pelvis.
As the point of fusion of the ischium and the pubis, it is attached to various muscles and supports the weight of the body when one is sitting. The Ischial tuberosity is commonly referred to as the “sit bones.”
The ischial tuberosity is where the adductor and hamstring muscles of the thigh, as well as the sacrotuberus ligaments attach. The forceful pull of these muscles, may result in avulsion fracture, where a piece of the bone is pulled off during a trauma/impact injury (see below for our discussion on avulsion fractures).
- Danielle R. Steilen-Matias, MMS, PA-C, describes the pelvic anatomy and how these various structures in the pelvis can cause Ischial tuberosity pain.
- The Ischial tuberosity, the bony prominences at the base of the pelvis, or commonly, the “sit bones” or the “seat bones,” are just that. The bones you sit on. This is a suspected pain origin when a patient complains of “pain in the butt.”
- A patient will often complain of a problems with tight hamstrings as well. They report that they do a lot of stretching, they “foam roll,” they have had cortisone shots, the pain returns.
- There are varying reasons for pain in this area.
- The patient’s pain is in fact related to the hamstring attachment at the Ischial tuberosity.
- (Image of Ischial tuberosity) If this hamstring tendon attachment is damaged, the patient will suffer pain when they put their whole body weight on it to sit.
- Sometimes a patient will come in with a chronic Ischial tuberosity pain that doesn’t get better with anything they’ve tried because the pain is coming from elsewhere. It could be from the sacroiliac joints. When there is sacroiliac joint instability, this can tug on the hamstrings. This is why hamstring treatments may fail. The hamstrings are under constant stress from the sacroiliac joint. To fix the hamstring problems, the sacroiliac joint instability must be addressed. We have seen this more commonly in runners. This is why patients will tell us that they “pull their hamstring all the time, then I rest. Then I pull it again.” If hamstring treatments are not helping, an evaluation of the hip may reveal a labral tear or hip instability that is also pulling on the hamstring tendon attachment and injuring it.
- Part of the work up of when you come to Caring Medical with complaints of butt pain or a diagnosis of Ischial tuberosity pain syndrome or impingement is an examination of all these areas, the hip, the sacroiliac joint, the low back, the groin area.
- Treatment: Ischial tuberosity pain syndrome is a degenerative condition. We have to first stop the causes of the damage and then we can begin to repair the area and get these tissues to regenerate and be strong. We use Prolotherapy injections, this is an injection of simple dextrose or sugar. Sometimes we may use the platelets in your own blood, this is better known as Platelet Rich Plasma Therapy or PRP. It usually takes 4 to 6 treatments. These treatments are described in more detail below.
Demonstration of the treatment
The Prolotherapy treatment begins at 1:37
In this video Ross Hauser, MD. demonstrates an Ischial tuberosity Prolotherapy treatment.
- The patient in this video has been given a Topical analgesic and is comfortable during the treatment. The treatment is done quickly.
- It is a long needle because the injections has to reach the Ischial tuberosity bone.
- This treats the attachments of the semitendinosus, semimembranosus, biceps femoris muscles of the hamstring and the sacrotuberous ligaments.
- In a typical treatment all these attachments are treated.
Doctors in Spain published their findings on Ischiofemoral impingement syndrome in the medical journal Skeletal radiology. (1). They describe it as:
- An under-recognized hip impingement problem defined by hip pain related to narrowing of the space between the ischial tuberosity and the femur which causes a pinching of the soft tissue between the bones.
- The causes of ischiofemoral impingement is multifactorial (note in the original research how many times the word instability is used – clearly the problem is joint instability). Here is their list:
- hip instability
- pelvic/spinal instability,
- abductor/adductor imbalance,
- ischial tuberosity enthesopathies (stress and wear on the ligament and tendon attachment to the bone).
- trauma/overuse or extreme hip motion,
- iatrogenic conditions (post surgical pain caused by the surgery),
- tumors and other pathologies.
In 2020 Ischiofemoral impingement remains a confusing diagnosis – MRIs can confuse the issue
An editorial in the medical journal Radiologia brasileira (2) from Dr. Marcello H. Nogueira-Barbosa, an Associate Professor of Radiology at Ribeirão Preto Medical School – University of São Paulo suggested in the paper’s title: “The importance of prospective and longitudinal studies on ischiofemoral impingement syndrome.”
Dr. Nogueira-Barbosa writes that “Ischiofemoral impingement may cause pain in the deep posterior gluteal region, the hip, and the groin. Because it is an uncommon condition, its diagnosis is often missed or delayed. When there is compression or irritation of the sciatic nerve, the pain can radiate to the posterior region of the thigh, due to the proximity of the sciatic nerve to the posterior border of the quadratus femoris muscle).”
Dr. Nogueira-Barbosa also writes that MRIs may confuse the issue further. “Measurements of the ischiofemoral and quadratus femoris spaces (to denote Ischiofemoral impingement) on MRI may vary with the positioning of the patient (during the MRI), being influenced by the degree of flexion, adduction, and rotation of the hip, as well as by the patient (position when laying down). Measures performed on routine MRI may not reflect the variations that occur during activities of daily living or sports activities. The measurement of those spaces tends to be smaller during external rotation, with adduction or extension of the hip. Therefore, hip positioning is an important factor to be considered in ischiofemoral impingement evaluation. That is one of several reasons why prospective studies are important.”
Prolotherapy and Conservative Treatments for Impingement
The traditional conservative treatment route prescribes the RICE protocol, which consists of rest, ice, compression and elevation. The problem with this approach is that it does not repair the injured tissue of the hamstring tendons, the tendon attachments and support ligaments.
- Rest and ice are particularly serious culprits when it comes to soft tissue damage because they decrease circulation to the area, which hinders rather than helps the healing process.
- Physical therapy is commonly ordered and has its place for the treatment of ischial tuberosity pain, but once again, does not address the issue of weak or injured ligaments or tendon attachments.
- Steroid injections and anti-inflammatory medications are another standard recommendation. These treatments may provide short term relief, however, in the long run do more damage than good.
Prolotherapy is a regenerative treatment that successfully treats ischial tuberosity pain. Prolotherapy injections to the sacrotuberous ligaments and the hamstring tendon attachment will stimulate repair of these damaged areas. A comprehensive exam by the experienced Prolotherapist is vital for a thorough treatment. Sometimes pain in other areas is also involved. For instance, pain in the ischial tuberosities may be coupled with pain in the pubic symphysis. There may also be pain in the sacroiliac joints. A comprehensive Prolotherapy treatment will include all of the weakened or injured areas.
Prolotherapy for ischial tuberosity pain involves injections of a dextrose solution which causes a mild inflammatory reaction at the weakened areas. This initiates a wound cascade that includes an increase of blood flow and immune cells to the treated area. There will be an influx of reparative cells and a deposition of collagen to repair the injured ligaments and attachments. Once this soft tissue is strengthened, the sacrotuberous ligaments and the hamstring tendon attachment and other involved soft tissue will now be strong and stable, and the ischial tuberosity pain will resolve.
In a case study presented by doctors at the Chung-Ang University College of Medicine in South Korea and published in the medical journal Pain Practice, (3) the doctors of the study showed that they effectively treated two male patients using ultrasound-guided prolotherapy.
- A 24-year-old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle.
- A 23-year-old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle.
After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0-1/10), and follow-up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images.
The researchers concluded: “Prolotherapy was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.”
Special note on Dysfunction after malunion or non-union of ischial tuberosity apophyseal avulsion fractures
- Doctors at the Mayo Clinic (4) examined ten patients (age 14 to 28) who underwent surgery for recurring hip and buttock pain following a prior ischial tuberosity avulsion fracture.
- The malunion or non-union following ischial tuberosity apophyseal (growth plate) fracture can lead to ischiofemoral impingement and hamstring dysfunction. The pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.
- Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal a little more than two years after surgery.
In this situation, where weakness exists after surgery, a Prolotherapy consultation may assist the young athlete or patient following surgery strengthen the tendon and ligament attachments that may cause instability.
If you have questions about Ischial tuberosity pain and ischiofemoral impingement, get help and information from Caring Medical
1 Hernando MF, Cerezal L, Pérez-Carro L, Canga A, González RP. Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis. Skeletal Radiol. 2016 Jun;45(6):771-87. doi: 10.1007/s00256-016-2354-2. Epub 2016 Mar 3. [Google Scholar]
2 Nogueira-Barbosa MH. The importance of prospective and longitudinal studies on ischiofemoral impingement syndrome. Radiologia brasileira. 2019 Oct;52(5):IX. [Google Scholar]
3 Kim WJ, Shin HY, Koo GH, Park HG, Ha YC, Park YH. Ultrasound‐guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome. Pain Practice. 2014 Sep 1;14(7):649-55. [Google Scholar]
4 Spencer-Gardner L, Bedi A, Stuart MJ, Larson CM, Kelly BT, Krych AJ. Ischiofemoral impingement and hamstring dysfunction as a potential pain generator after ischial tuberosity apophyseal fracture non-union/malunion. Knee Surg Sports Traumatol Arthrosc. 2015 Oct 1. [Pubmed] [Google Scholar]