Ischial Tuberosity Pain: Causes, Symptoms, Treatment

The ischial tuberosity, also known as tuber ischiadicum or tuberosity of the ischium or sitz bones is a large swelling present on the superior ramus of the ischium and it also marks the lateral boundary of the pelvic outlet. When a person is in a sitting position, then the maximum weight of that person is placed on the ischial tuberosities. The ischial tuberosity is covered by the gluteus maximus muscle when a person is in an upright posture; however, the ischial tuberosity is free in a seated position and often bears most of the weight of the body when sitting.

As mentioned before, ischial tuberosity supports the weight of the body during the sitting posture and it also adjoins with various major muscles that are associated with legs. Ischial tuberosity pain is commonly seen in athletes as they partake in physical activities, such as running, jumping, cycling, skating, soccer, etc. All these activities put constant strain on the muscles of the legs. Persistent overload results in injury, muscle pull and inflammation which in turn get worsened by weight lifting, prolonged sitting position, and sitting on rough surfaces. There can also be ligament tearing and muscle detachment in severe cases. Ischial Tuberosity pain is also experienced in those individuals who adopt a wrong posture when sitting or working for prolonged duration of time in front of the computer.

The Ischial Tuberosity is divided into two regions:

• The lower portion of ischial tuberosity is rough and somewhat triangular in shape. It is further subdivided by a prominent longitudinal ridge, which travels from base to apex, into two further portions: the outer part provides attachment to the adductor magnus. The inner part provides attachment to the sacrotuberous ligament.
• The upper portion of ischial tuberosity is quadrilateral in shape and is smooth. It is further subdivided into two parts by a ridge, which runs obliquely downward and outward. The semimembranosus arises from its outer and upper area. The semitendinosus and the long head of the biceps femoris arise from its inner and lower parts.

The following adjoining muscles, ligaments and bones are attached with ischial tuberosity: Gluteus maximus, hamstrings, adductor magnus and sacrotuberous ligament.

Ischial tuberosity is the site for Pudendal anesthesia which is a local anesthesia and is used during child birth to reduce the severity of pain during delivery.

Athletes more commonly suffer from ischial tuberosity pain due to extended overload and continuous strain on the leg muscles and the sacrotuberous ligaments resulting in severe strain. As these parts adjoin with ischial tuberosity, there is pain felt in the ischial tuberosity. The pain is felt in lower region of the buttock and is commonly experienced upon sitting or running or brisk walking. There can also be swelling and pressure at the site of the ischial tuberosity and the patient experiences significant pain at the location of ischial tuberosity. Causes of ischial tuberosity pain due to certain injuries which involve this area are:

• Fractional tear of the hamstring muscle.
• Tendonitis where the hamstring muscle originates.
• Development of a bruise where the hamstring attaches.

In some cases, rigorous activities can cause swelling of the apophysis resulting in apophysitis. Prolonged overuse leads to damage of the tissue surrounding the ischial tuberosity and results in ischial tuberosity pain. The pain in the ischial tuberosity is commonly known as “pain in the butt.”

The symptoms of Ischial Tuberosity Pain can be best described as “pain in the butt,” as the patient experiences pain in the base of the buttock, which is worsened with prolonged sitting and running. The area of the Ischial Tuberosity can also become tender, swollen and sensitive to touch.

Rest: Patient is usually told to rest; however, this can also worsen the ischial tuberosity pain, as prolonged resting causes diminished blood supply to the damaged tissues of the ischial tuberosity and delays healing. This then leads to stiffening of tissues. Ischial tuberosity pain is often confused and misdiagnosed as ischial bursitis. It is important to get the right diagnosis for correct treatment of the pain.

R.I.C.E. Technique: Conservative treatment, such as the R.I.C.E. technique comprising of rest, ice, compression and elevation is done for managing the ischial tuberosity pain. However, this technique is not always effective, as this method is not helpful in restoring the tissue injury. R.I.C.E. technique helps in alleviating the pain for short term, but it is not quite effective in chronic cases of ischial tuberosity pain. If the patient takes prolonged rest or ice application, then there is decrease in the blood supply which delays in the healing process.

Exercise & Physiotherapy: Mild physical exercises also help in controlling and reducing the ischial tuberosity pain. Physiotherapy does not provide permanent solution, as it does not repair the damage in the muscular tissues and ligaments, but only helps in providing temporary relief from the ischial tuberosity pain.

Analgesic Medicines: Various analgesic medicines are also prescribed for treating the ischial tuberosity pain; however, these medicines will only relieve the pain and will not heal the damaged tissues. Hence, analgesic medicines should only be used for short term duration, as using them long term produces significant side effects. Common analgesic medicines prescribed include: Non Steroidal Anti-Inflammatory Drugs (NSAIDs)^[1] such as diclofenac and aspirin, steroids such as hydrocortisone and COX-2 inhibitors such as celecoxib and etoricoxib.

Prolotherapy:^[2] Prolotherapy is a favorable and advanced treatment method for pain in the ischial tuberosity. In this treatment, a dextrose solution is injected in the areas of the damaged tissues thus allowing increased fluid flow to those particular tissues and produces inflammation, which helps in increasing the blood flow and fixing the damaged area through boosting the immune system. This treatment also helps in depositing new collagen and repairing the injured joint ligaments. There is strengthening of the soft tissues, which leads to gradual improvement of hamstring tearing and sacrotuberous ligaments where they become powerful and firm. This process helps in resolving the ischial tuberosity pain.

Stem Cell Therapy:^[3] This treatment is an innovative method for treating ischial tuberosity pain where through this procedure there is generation of inflammation of the affected ligaments which helps in boosting self-restoration of the affected tissues and alleviating the associated ischial tuberosity pain. Stem cell procedure helps with tissue healing by using the regenerative cells that are taken from patient’s own stem cells thus making this treatment a natural process of a human being’s own physiological system.

Platelet Rich Plasma Technique:^[4] This is an assisting therapy which has been produced with stem cell therapy. There is large amount of cytokinin present in the Platelet Rich Plasma, which reinforces and helps in coordinating the physical involvement required for healing of the bones and soft tissues.

The above mentioned therapies i.e. prolotherapy, platelet rich plasma and stem cell therapy are very advanced treatment methods and require very skilled and experienced physicians and health care staffs to conduct them. These advanced techniques are not commonly used and are not usually found in hospitals. It is important that the patient gets these procedures done in a reputed healthcare facility and by experienced doctors to avoid permanent damage that can interfere with the quality of life of the patient.

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