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Ischial Bursitis
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Ischial Bursitis - September 20, 2005 3:30:00 AM
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tishasutton
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From: Oklahoma City, OK USA
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Has anyone ever treated ischial bursitis?
A little background- I am a USAF PT and I have a patient who is VERY active that came in with what I thought was a hamstring strain- I had her rest, ice, then work up with strengthening. I then had her use compression shorts for activity- and not run for 3-4 weeks, but now it is 4 months later and she is returning with the same problem and the ortho doc has diagnosed it as ischial bursitis. I have not recently checked her SI joint- which I will with her next visit- does anybody have any suggestions to what I can look for? Thank you!
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Re: Ischial Bursitis - September 20, 2005 3:34:00 AM
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FLAOrthoPT
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check SI, but more importantly do some research on "hamstring syndrome". Neural tension probelm, if so, treat accordingly with opening up th espine some, and working out the neuro-myofascial components around the outlet, lots of creative neural gliding, works well in supine because you can adjust back with pelvic tilting, and easily hold hip/knee where you want to, etc..
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Re: Ischial Bursitis - September 20, 2005 3:36:00 AM
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Shill
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Im my experience, Ischial bursitis should only hurt with pressure on the bursa itself, such as with sitting. I would say look to the spine. US is helpful for temporary relief only, it seems.
If you can bring on the sx with spine motions, or relieve them, theres your answer. Try many sets of repeated movements, in standing and in supine and prone. Be sure to have her analyze what she is feeling both during and after the motion.
More info is needed to supply more suggestions. What is her mechanism of injury? What, other than running bothers her?
Steve
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Steve Hill PT
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Re: Ischial Bursitis - September 20, 2005 4:05:00 AM
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tishasutton
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From: Oklahoma City, OK USA
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MOI- She fell when she was rollarblading last year and has had pain ever since.
x-rays negative
She has had a steroid injection to the site- and had relief for 6 weeks. (during those 6 weeks she was moderately active)
She is a dentist and has pain with sitting for long periods of time, biking, and also with hamstring resistance. She has excellent flexibility with hamstrings, quad, piriformis and hip musculature.
She has been seeing another therapist for several months off base- because I just had a baby- but now she is coming back and I am concerned because she did not get better- so I am wanting to look at other causes of her problem.
She says she has been receiving Ultrasound, estim and doing some exercises- including hamstring curls with theraband and squats. She states she is SLIGHTLY better. I am just having a hard time understanding why she is not better after 3-4 months of physical therapy. I have NOT seen her recently for a new evaluation- I see her next Monday.
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Re: Ischial Bursitis - September 20, 2005 4:22:00 AM
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eam
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I had a patient recently with a dx of adductor strain, runner, training for NYC marathon. After running outside up hills, she started to feel her sx's come on.
After the IE, I could not reproduce sx's which were akin to an adductor strain. She had alot of tone at her proximal h/s, posterior inom. rotation at the ilio/sacral joint and a stiff lumbar spine on her achy side. Stiff end feel with h/s stretch (although full range). In addition to the good suggestions above, check lumbar spine directly as well as the pelvis. The fall implicates more than just a hamstring strain , I think. I would not go crazy with strengthening at first.
Good luck!
Erica
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Re: Ischial Bursitis - September 20, 2005 4:33:00 AM
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Yogi
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From: San Antonio, Tx., USA
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FOB (fall on butt) flags clear SI for me. Esp. w/ no or little improvement over long period.
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Re: Ischial Bursitis - September 20, 2005 11:29:00 AM
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FLAOrthoPT
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agreed
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Re: Ischial Bursitis - September 20, 2005 11:31:00 AM
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FLAOrthoPT
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or SI biomechabical alterations causing new forces applied to the hamstring over the bursae, etc, i'd say if it is flared up, get one more cort or anasthetic injection even as a Diff Dx and be aggressive from there on in, checking for upslip etc..good luck, don't rule out possibility of neural impingement of sciatic nerve as it rides through the fascial boney opening there...
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Re: Ischial Bursitis - September 21, 2005 4:15:00 AM
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ehanso
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I agree with Yogi on this one. A history fall with buttock, hip or lower back pain points me to the SI as a cause of chronic Sx. A very reputable back surgeon I recently saw told me that at least 20% of the people he sees with chronic back pain and radicular Sx can be traced back to SIJ dysfunction and usually clear within 3-4 months with proper treatment and compliance.
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Re: Ischial Bursitis - September 21, 2005 4:30:00 AM
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MickeyPT
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I must agree with the consensus, SI involvement seems to be likely. Check her leg length in supine and then have her come up to long leg sitting to see if there is any innominate displacement. If the SI clears then I would check the sacrotuberous ligament and make sure it hasn't been sprained in the incident.
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Re: Ischial Bursitis - September 21, 2005 9:54:00 AM
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Alex Brenner PT MPT OCS
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If the lumbar spine is clear you may want to consider a possible stress fracture to the femoral neck. I have seen this several times in young short female soldiers who have a big increase in running (basic training). The increase in physical activity coupled with trying to use a larger stride length to keep up during formation runs causes this "military unique" type of injury. I can't tell you how many times a soldier has been referred to PT with a diganosis of "hip adductor strain" and end up having a femoral neck stress reaction or fracture. These can be disatrous if missed. When I was at Fort Knox (large basic training population) we would see probably 3 or 4 kids per year that would end up getting their hip pinned. Pretty sad to see a young 18 year old kid getting his/her hip pinned.
What happens when you scour her hip? The fact that you mention she is military and "VERY" active kind of throws this flag up for me. She may benefit from a bone scan if you have that test at your disposal. I wouldn't hesitate to order that in our military system. Cheap, quick, and will answer that question easily.
Erica, same goes for your "hip adductor" strain patient. Especially since she was training for a marathon. You dont want to miss a femoral neck stress fracture. Can be REAL bad (AVN of femoral head)!
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Alex Brenner, PT, MPT, OCS
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Re: Ischial Bursitis - September 21, 2005 5:19:00 PM
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eam
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From: New York, NY 10028
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Good thoughts Alex, thanks!
Erica
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Re: Ischial Bursitis - September 22, 2005 1:50:00 AM
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JLS_PT_OCS
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I would second Alex's concern.
Tisha-
Any female athlete triad stuff going on with her? When was her LMP?
Plain films of pelvis and hip? Repeat films? Nuc Med bone scan?
I think everyone here has given great advice, but let's rule out the scary stuff (ie fem neck stress fracture) or non soft tissue stuff (pelvic stress fx) before we go too much further.
If she doesn't have a stress fracture, then it makes me think of Barrett's description of pain from an abnormal neurodynamic being kind of like a grease fire. Unless you put it out the right way, it will not get any better, regardless of how long you let it burn. Water won't help, either (sometimes it makes it worse).
Keep us posted.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Ischial Bursitis - September 22, 2005 3:30:00 AM
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Barrett
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Jason,
Exactly.
I'm wondering where this patient's ipsolateral hip rests when she lies supine.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Ischial Bursitis - September 23, 2005 2:14:00 AM
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JLS_PT_OCS
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Internal rotation perhaps?
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Ischial Bursitis - September 23, 2005 6:14:00 AM
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tishasutton
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From: Oklahoma City, OK USA
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Thanks for the great advice!
I saw her quickly this morning and from this visit- She has no pain with any repeated movements of lumbar spine, standing, prone, or supine. She has a neg SLR bilaterally.Sitting root neg bilaterally.
Her SI did have tenderness to the right side- but neg sulcus, her right leg was shorter with the supine to sit - but is was VERY SLIGHT.
I treated it as an anterior rotation of the illium on the sacrum- I adjusted her with a MET.
She describes her pain- like she is sitting on a quarter on that right side. She has NO pain with a hamstring stretch and has great flexibility, but has pain with any type of hamstring muscle activity. Her pain starts at the origin, but goes to the muscle belly of the hamstring as well. She also c/o of adductor pain with any increase in activity. She is not willing to have any more injections- because her pain is managable as long as she is activity restricted.
The bone scan is a good idea -she is PRIOR ARMY :-)In fact this is her first AF assignment- the x-ray done of her pelvis and hip have come back negative.
She did have some pain provication left transverse process at L5 with right rotation- with some stiffness noted. She says that the pain was very SLIGHT.
I applied some joint mobilizations in right rotation at L5 on S1.
I sent her home with bridges this weekend- and a lumbar rotation stretch.
She will come back on Monday morning.
I will keep you posted.
Again, thank you for all of your insight- it is appreciated.
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Re: Ischial Bursitis - September 23, 2005 6:25:00 AM
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JLS_PT_OCS
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Hmm.
If plain films are negative, then I do recommend you talk with the referring physician about a bone scan (or order it yourself- we have those privileges in the Army, not sure about AF?).
I would also recommend you look at her neurodynamic exam more closely and maybe consider some light eccentric exercise if she is painful at hamstring origin.
Good luck!
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Ischial Bursitis - September 25, 2005 2:33:00 PM
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ginger
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From: Melbourne Victoria
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to Falls PT, I'm interested in the surgeon you mentioned . Why would you describe him as very reputable if his SIJ dysfunction people take FOUR MONTHS to see improvements. Four days tops would be my criteria for sij success. maybe he is relying on exercise alone to produce results, in which case it may have nothing to do with his intervention at all.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Ischial Bursitis - September 26, 2005 4:45:00 AM
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Yogi
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Alex, Good Info. Tips like that are one of the best things about the Forum.
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