Ischial tuberosity pain syndrome treatment
Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C
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. The most common cause of pain at the cheek line in the buttock area is weakness in the structures that attach to the ischial tuberosity. The condition that is manifested by buttock pain and tenderness over the ischial tuberosity is known in traditional medical lingo as ischial bursitis. A bursa is a fluid-filled sac that allows tendons and muscles to glide over the bones. Bursitis means inflammation of the bursa. True bursitis pain is so painful that any pressure to the bursa would elicit a positive “hit the ceiling” sign. True bursitis is extremely rare.
- 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 suggests that my problem is from too much cycling. I have made adjustments to my technique and my saddle height, which 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 sacrotuberous 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 problem 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.
What are we seeing in this image?
The complexity of Ischial tuberosity pain syndrome or Ischial tuberosity impingement can be seen in this view of the pelvic floor. Injured sacroiliac ligaments and sacrotuberous ligaments will contribute and cause Ischial tuberosity pain syndrome and possibly entire pelvic floor dysfunction.
Part of the workup 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.
Entheses (plural) is the point at which a structure attaches to the bone. One of the enthesis of the hamstring muscles and sacrotuberous ligament is the ischial tuberosity. Disease, degeneration, or weakness of an attachment of a muscle, ligament, or tendon to the bone is called an enthesopathy. Ligaments and tendons typically first become weakened, degenerated, and injured at their fibro-osseous junctions. Fibro signifies connective tissue and –osseous stands for bone, so the fibro-osseous junction is the enthesis. Thus, buttock pain from weakness at the ischial tuberosity muscle and ligament attachments should really be called ischial tuberosity enthesopathy.
- 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.
Ischiofemoral impingement and ischial tuberosity pain syndrome
The complexity of ischial tuberosity pain syndrome can be seen in patient case histories and their stories of treatments. Ischial tuberosity pain syndrome is an umbrella term that describes pain in the lower buttocks area. Let’s listen to people and researchers describe not only a diagnosis of ischiofemoral impingement but multiple diagnoses
I use to run, over the years I developed a lot of hip pain and pain in my glutes. My whole upper buttock area and hips became very painful. I went for the MRI and I had a CT scan and I was diagnosed with ischial tuberosity pain syndrome, groin pain, deep gluteal pain, ischiofemoral impingement and I also had a torn hip labrum. I was immediately told to shut down, no running. I had weeks of physical therapy. After three months I tried to gently run again. It was as if I had done nothing to recover. All the pain was still there. In desperation, I got a cortisone injection. I am here because I am really starting from square one again.
First, my doctors thought I had Ischial tuberosity pain syndrome. I rested a lot and I stopping most of my activities to have time to heal. When resting did not help I went and had two PRP injections. They did not work. I then had physical therapy. That did not help. I was finally diagnosed with a hip labral tear and had arthroscopic surgery. Following the surgery, I still have the pain in my butt and now experience sciatica-like symptoms.
Doctors in Spain published their findings on the concurrent problems patients face with Ischiofemoral impingement syndrome. The study appeared in the medical journal Skeletal Radiology. (1). Here is what they described:
- 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 are 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 enthesopathy (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 perspective 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.”
Ischial tuberosity pain syndrome and Piriformis syndrome – sciatic nerve entrapment at the level of the ischial tuberosity
In our article Piriformis Syndrome and Sciatica Pain we wrote that we see many patients who are not really sure what is wrong with them, or, they are diagnosed with a problem that they do not really understand. Such is the case with Piriformis syndrome. For some, since lower back pain is a problem, a trip to the chiropractor was made. It is here that some of these patients were first made aware of Piriformis syndrome. In the chiropractor’s office, the patient may have been given an explanation that their problem is not one of a bulging or herniated disc pressing on a sciatic nerve, but it is the piriformis muscle that has entrapped the sciatic nerve and causing “herniated disc like symptoms.”
Most recently in the 2020 medical publication Stat Pearls (3), piriformis syndrome is described as a clinical condition of sciatic nerve entrapment at the level of the ischial tuberosity. While there are multiple factors potentially contributing to piriformis syndrome, the clinical presentation is fairly consistent, with patients often reporting pain in the gluteal/buttock region that may “shoot”, burn, or ache down the back of the leg (i.e. “sciatic”-like pain). In addition, numbness in the buttocks and tingling sensations along the distribution of the sciatic nerve is not uncommon. . . whenever the piriformis muscle is irritated or inflamed, it also affects the sciatic nerve, which then results in sciatica-like pain.
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 other standard recommendations. 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 the 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 a 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 and published in the medical journal Pain Practice, (4) 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 a 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.”
Summary learning points:
- The most common cause of pain at the cheek line in the buttock area is a weakness in the structures that attach to the ischial tuberosity.
- The condition that is manifested by buttock pain and tenderness over the ischial tuberosity is known in traditional medical lingo as ischial bursitis. A bursa is a fluid-filled sac that allows tendons and muscles to glide over the bones. Bursitis means inflammation of the bursa. True bursitis pain is so painful that any pressure to the bursa would elicit a positive “hit the ceiling” sign. True bursitis is extremely rare. If a physician diagnoses bursitis and recommends a cortisone shot to relieve the inflammation, a second opinion should be sought.
Prolotherapy injections for buttock pain are given all along the ischial tuberosity, where the hamstring muscles and sacrotuberous ligaments attach. Prolotherapy will strengthen this area. After four sessions of Prolotherapy, the buttock pain is usually eliminated. Unfortunately, the ischial tuberosity is an area that is rarely examined by traditional physicians.
Special note on Dysfunction after malunion or non-union of ischial tuberosity apophyseal avulsion fractures
In this section, we will discuss the realistic options in treating ischial tuberosity apophyseal avulsion fractures.
Often someone will contact us with a story that is very familiar. This person’s story goes something like this:
After several months of severe pain in my right side glute, I went to the doctor and had an MRI. The MRI revealed a chronic avulsion injury of the ischial tuberosity on the right side and that a portion of my hamstring tendon attaches to the bone fragment. I have tight hamstrings when sitting, stretching does not help, I had a cortisone injection for bursitis I evidently never had and would explain why the injection did not help my pain. Nothing has really helped me and now I am being told to have a surgery that I am not sure will help.
Doctors at the Mayo Clinic (5) examined ten patients (ages 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 are 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 in the 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 to strengthen the tendon and ligament attachments that may cause instability.
Platelet-rich plasma injection as a bone graft?
Platelet Rich Plasma or PRP therapy is an injection treatment. There is a lot of research on PRP that suggests when administered correctly by a doctor experienced in the treatment, PRP can work well for many different orthopedic conditions.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)
Although the application of Platelet Rich Plasma has been around for decades, the treatment has become a more recent option for doctors and patients.
Here is a May 2019 case history reported by the Emory University School of Medicine reported in the journal Regenerative medicine. (6)
- (The case doctors) present a case of an 18-year-old with a 2-year history of buttock pain who failed extensive treatment for a perceived hamstring strain. Upon evaluation, he was diagnosed with an ischial tuberosity nonunion avulsion fracture. The patient underwent bone grafting via an ultrasound-guided leukocyte (white blood cell) rich platelet-rich plasma injection followed by the use of a bone stimulator to enhance bone healing. At 3 months, he was asymptomatic and had radiographic evidence of excellent bone healing. He remained asymptomatic at 1 year and had resumed full activities. This case report is the first in the literature to describe the treatment of a chronic ischial tuberosity nonunion avulsion fracture with the use of platelet-rich plasma as a bone graft.”
This case is unique, it is not standard of care, however, it does illustrate the potential healing strength of Platelet Rich Plasma.
Summary and contact us. Can we help you?
The ischial tuberosity is part of the innominate bone and it attaches to the other side of the innominate bone via the pubic symphysis and its ligaments; and in the back attaches to the sacrum via the sacroiliac ligaments and the lower lumbar vertebrae by way of the iliolumbar ligaments. These areas need to be evaluated, as injuries to these structures would put additional strain on the structures of the ischial tuberosity and would also need to be treated to obtain long-term pain relief. The person who had complete relief of his/her buttock pain with Prolotherapy to the ischial tuberosity only to have it recur, should make sure to eliminate excessive static sitting and consider whether or not joint instability in the lower back or pubic area is associated with the condition.
Prolotherapy injections for buttock pain are given all along the ischial tuberosity, where the hamstring muscles and sacrotuberous ligaments attach.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your ischial tuberosity pain syndrome. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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 Hicks BL, Varacallo M. Piriformis Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. [Google Scholar]
4 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]
5 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. [Google Scholar]
6 Stafford CD, Colberg RE, Nourse AL. Chronic ischial tuberosity avulsion nonunion fracture treated with a platelet-rich plasma injection as a bone graft. Regenerative medicine. 2019 May 9;14(5). [Google Scholar]
This article was updated January 14, 2021