Rossi et al. Although these reported ages were slightly different, both of these reports indicated that the fragile characteristics of adolescent osteophytes are prone to avulsion fractures [ 11 ]. The ischial tuberosity is the starting point of the hamstring muscle, which includes the long head of the biceps femoris, semitendinosus, and semimembranosus of the biceps femoris. The semitendinosus and biceps femoris have a common tendon on the ischial bone, and the semimembranosus originates from the outside of the ischial tuberosity [ 12 , 13 ].
Furthermore, the long head of the biceps femoris ends in the capitulum fibulae, inserts on the fibular head, and has a small branch that inserts on the posterior-lateral aspect of the tubial condyle, and the semitendinosus and semimembranosus terminate in the medial aspect of the tibia with multiple insertion points. The main function of their contraction is to bend the knee and extend the hip joint. This position places the hamstring in a mechanically advantageous position, leading to increased forces at the ischium, which might contribute to AFIT [ 4 , 14 ].
AFIT is closely associated with competitive sports, such as football and track and field [ 15 , 16 ]. However, ischial tuberosity damage can also be caused by long-term chronic strain, such as ischial tuberculosis [ 16 ], and this disorder can be further developed to avulsion fracture. Even though AFIT occurs mostly in adolescents, adult injuries have also been reported [ 17 , 18 ]. In these cases, most of their fractures are caused by strong external forces.
In addition, in special cases, the presence of AFIT could lead to the pathological damage without trauma [ 19 ]. Patients often present with sudden pain in the back of the thigh or hip, followed by abnormal gait or the inability to walk. Physical examination often reveals the following: swelling of the buttocks, accompanied by ecchymosis, tenderness at the ischial tuberosity when touching the bones, inability to sit, and disorders of hip and knee flexion or extension.
If accompanied by nerve damage, it can be expressed as pain in the hips and large hind legs, and the most obvious symptom is extreme pain of the hip extension, adduction and external rotation [ 1 ]. X-ray examination is usually required when AFIT is suspected, and fractures with a significant displacement can be easily diagnosed Figure 2A. Computed tomography CT scans may be required for further confirmation of fractures with minor displacements. It can be used to distinguish fractures with small displacement or partial avulsion Figure 2B , and CT 3-dimensional reconstruction can more intuitively show the avulsion fractures Figure 2C.
It can detect occult fractures of the AFIT through the edema-like signal intensity of the ischial tuberosity and surrounding soft tissue, and the amount of subperiosteal fluid [ 22 ] Figure 2D.
Some investigators [ 15 ] have considered that ultrasound is also a useful diagnostic tool that can be used to identify whether nerve damage is present.
A X-ray of the right hip showing the avulsed ischial tuberosity. Note that the x-ray can detect larger displaced fracture blocks. B Typical computed tomography CT image of the avulsion fracture of the ischial tuberosity.
Note that CT can easily detect small displaced fracture blocks. C The 3D-CT clearly depicts the shell-like fragment of the displaced fracture block. Note that the 3D-CT scan can more intuitively show the avulsion fractures. Note that MRI can detect occult fractures through the edema-like signal intensity and subperiosteal fluid volume of the sciatic nerve nodules and surrounding soft tissues.
Figure from J Pediatr Orthop ; e72—e76 [ 27 ]. AFIT can be easily misdiagnosed [ 2 , 21 ], and is often misdiagnosed as a muscle strain in the proximal thigh [ 5 , 24 ]. Early diagnosis requires doctors to have highly skeptical awareness, especially for the pain of adolescent athletes at the ischial tuberosity. In addition, detailed medical history and physical examination are required, and imaging examination is also essential.
As mentioned earlier, AFIT should be first differentiated from hamstring injury [ 25 ]. In addition, the diagnosis of piriformis syndrome, intervertebral disc disease, and ischial tuberosity bursitis should also be excluded [ 4 ]. Some patients may have missed the acute phase at the time of treatment. At this time, AFIT can form a pseudoarticular joint, in which the bone mass is overgrown, similar to a bone tumor [ 26 ]. The histopathological examination of the pseudojoint shows the original bone-like tissue, which usually contains normal trabecular bones and cartilage tissues, and these needs to be differentiated from osteosarcoma and osteochondroma [ 20 ].
There is no consensus on the treatment of avulsion fractures of the ischial tuberosity. The general view is to choose the treatment method based on the degree of fracture displacement DFD.
Conservative treatment is considered for patients with small DFD, while surgical treatment options would be considered for patients with large DFD.
However, some scholars have considered that this is unscientific. For surgical treatment options, early and late, open reduction and internal fixation ORIF are the main options [ 28 ]. Ferlic et al.
Sikka et al. However, the conservative treatment did not achieve satisfactory results. In the end, the patient was restored to daily activities through surgical treatment. Sundar et al. It was found that 8 of these patients had a significant decline in exercise capacity.
Consistently, Kaneyama et al. In this case report, the authors used the subgluteal approach, which is relatively simple and safe.
This suggested that it is unscientific to judge the treatment according to the DFD. With this, it cannot be denied that the DFD is an important reference factor for determining whether surgery should be performed.
A number of scholars [ 2 , 18 ] have pointed out that many patients who received the conservative treatment ended up in chronic disability, such as long-term pain, muscle weakness, decreased exercise capacity and sciatica.
They also indicated that once a neurological injury occurs, either early or late, surgery must be performed. On the other hand, some investigators [ 34 , 35 ] have considered that since the results of early surgery and late surgery are similar, they suggested that regardless of the size and extent of the fracture, the patient should initially receive conservative treatment, and subsequently choose surgery if the first treatment fails. Nevertheless, some investigators [ 14 , 36 ] have suggested that early surgery should be performed as long as the indications for surgery are met.
From all the cases reported in literatures, it is not difficult to observe that it appears that all patients who have undergone surgery, whether early or late, have recovered to pre-injury levels. If the fracture is not healed or persistent pain is observed, surgery should be chosen. AFIT diagnosis and treatment flowchart. In the early stage of conservative treatment, the main tasks include rest and pain control.
Although, again, different groups used slightly different programs. However, there is some general trend in treatment approaches: from easy to hard, from using orthosis to without using orthosis, strengthened muscle or even jogging, subsequently. For example, Ceretti et al.
During the first phase 0—3 weeks , when inability score index ISI was approximately , the patient received RICE rest, ice, compression and elevation , nonsteroid anti-inflammatory therapy, and 1 week of careful passive mobilization with soft stretching. Metzmaker et al. Furthermore, the studies all judged the recovery of patients according to similar, but slightly different, evaluation systems, allowing the exercise intensity to be gradually intensified until the maximum value of recovery was reached [ 38 ].
For the choice of surgical location, most investigators [ 15 , 39 ] selected the special position of prone, hip and knee flexion, which was considered conducive for the exposure of ischial tuberosity. However, other investigators [ 14 ] preferred the lateral position. Regarding the choice of surgical approach, most investigators preferred the transverse incision under the gluteal approach.
They argued that the transverse incision was good for aesthetics, and the exposed field of view was thus broad, which was conducive to fracture reduction and internal fixation. In , Saka et al. The advantages of this surgical approach were presented as follows: 1 it has a wide surgical field of view; 2 if necessary, the surgical incision can be expanded; 3 the risk of iatrogenic injury of the sciatic nerve can be reduced; 4 the nerve damage can be easily revealed; and 5 it can also be applicable to the ORIF of chronic avulsion fracture.
Regarding the choice of internal fixation, the options included metal screws, absorbable screws, bone anchors, Kirschner wires and steel wires.
In cases with larger fractures, some investigators also chose steel plate and screw fixation. However, there was no consensus for the internal fixation material due to the small number of surgical cases. Nevertheless, from the available data, there were many cases in which metal screws and bone anchors were used.
The Kocher-Langenbeck approach is the preferred surgical approach for the treatment of AFIT in advanced nonunion [ 2 , 21 ]. This surgical approach facilitates the fixation of the plate to the outer edge of the ischial tuberosity, avoiding direct contact between the internal fixation and stool during sitting. However, when this surgical approach is taken, the ischial tuberosity is located at the deepest part of the incision, which is not conducive to the reduction and fixation of the fracture.
Therefore, as mentioned earlier, the subgluteal surgical approach advocated by Saka et al. The gluteus maximus muscle covers the ischial tuberosity when your leg is straight and your thigh is extended. When your knee is bent and your thigh is flexed, the gluteus maximus moves and leaves the ischial tuberosity uncovered.
A bursa is a fluid-filled sac that acts as a cushion between tendons and bones in joints. For example, you have bursas in your hips, knees, elbows, and shoulders. Anything that puts pressure on a bursa can cause inflammation, leading to a painful condition called bursitis. In some cases, repetitive motions can cause bursitis. A baseball pitcher, for example, may get bursitis in the elbow or shoulder of their pitching arm.
Similarly, leaning on or pressing against a joint can irritate the bursa inside. Sitting, especially, on a hard surface, can irritate your ischial bursa, causing ischial bursitis. Diagnosing ischial bursitis starts with a physical exam and a review of your symptoms. Your doctor may have you sit, stand, and move your legs and hips, while noting your symptoms. In some cases, your doctor might take a small fluid sample from the affected bursa. Bursitis often resolves on its own with rest.
As you heal, there are several things you can do to manage ischial tuberosity pain. Over-the-counter pain relievers, such as acetaminophen Tylenol or a nonsteroidal anti-inflammatory drug , such as naproxen Aleve or ibuprofen Advil , may be enough to ease your symptoms.
Physical therapy to help strengthen muscles and improve flexibility may be helpful. Simply climbing stairs can also be helpful — just be sure to hold on to a railing in case you feel pain that affects your balance.
You can read more about local corticosteroid injections here. In the majority of cases, ischial pain can be managed very effectively by adhering to the following routines. The most effective aspects are avoiding aggravating activities and prolonged sitting. Modifying seating positions This could be using a seat with better cushioning to alleviate pressure on the painful area. Specialist seat cushions are available if needed. Ceasing aggravating sporting activities This does not mean that you will have to stop cycling, running etc forever.
These are suggested exercises only. If you are at all concerned about whether these exercises are suitable for you or if you experience any pain while doing them, please seek appropriate clinical advice from your GP or Physiotherapist.
Ischial sitting bone bursitis pain.
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