Have you ever experienced a literal “pain in the butt”?
If so, the pain could be due to an injury or tissue damage around the ischial tuberosity, which is more commonly referred to as the sitting bones.
Since the ischial tuberosity helps to support your weight while sitting, any pain that occurs there can feel excruciating and prevent you from doing any extended amount of sitting, making driving and sitting at a desk to work virtually impossible.
Getting ischial tuberosity pain treated is important, so it is necessary that you know what causes it and what symptoms to look for.
What is the Ischial Tuberosity?
In order to understand what causes pain in the ischial tuberosity, we need to address the bony structure itself.
First, the word “ischial” means that it comes from the ischium, the lower and back part of the hip bone. The root word for “tuberosity” is “tuber”, a Latin word meaning “a bump” or “a swelling”.
Therefore, the best way to define the ischial tuberosity is that it is the bony protrusion that aids us in sitting. The ischial tuberosity is located on the superior ramus of the ischium.
When you stand up, the gluteus maximus (which is the main extensor muscle found in the human hip) covers and protects the ischial tuberosity, but when you are in a seated position, it leaves the ischial tuberosity uncovered.
Aside from the gluteus maximus, the ischial tuberosity is also associated with the hamstrings, the adductor magnus (the major thigh muscle), and the sacrotuberous ligament (which forms the bridge between the upper and lower body).(1)
Damage can occur to these muscles and ligaments from athletics or injuries and can make sitting on the ischial tuberosity quite painful.
Causes of Ischial Tuberosity Pain
Athletes and yoga practitioners tend to experience pain in the area of the sitting bones due to exercise overload or accidentally stretching the wrong way.(2)
A continued exaggeration of the leg muscles can cause strain in the hamstrings, adductor, and sacrotuberous ligament.
Pain coming from these sources is generally felt in the lower area of the buttock while running, briskly walking, or sitting.
Excessive pain in this area can develop into inflammatory swelling, which places pressure on the site of the pain, exaggerating the symptoms even more.
That is why it is important to pay attention to these common causes of ischial tuberosity pain:
- A stress fracture in the sits bones
- A tear in the hamstrings
- Bruising of the hamstring attachment
- Tendonitis located in the hamstring muscle
These types of injuries can result from various types of physical activity, including:
- A strain or injury while running
- Improperly or exaggeratedly doing forward bends/stretches that can cause inflammation in the hamstring attachment
- Overstretching a hamstring muscle (which results in a loud popping sound)
- Straining the adductor magnus
- A serious slip-and-fall accident
Additionally, doctors have found that the ischial tuberosity is involved in ischiofemoral impingement syndrome (IIS), which is a hip impingement issue that is characterized by chronic hip pain resulting from a narrowing of the space between the femur and the sit bones.(3)
This leads to the soft tissue in the area getting pinched in between these two bones. IIS can be caused by the following:
- Trauma or overuse of the hip
- Imbalance in the adductor or abductor
- Instability in the spine or pelvis
- Instability in the hip
- Iatrogenic conditions
- Pathologies including tumors
Also, ischial bursitis (or “runner’s butt”) is caused by inflammation of the bursa, a fluid-filled sac that is found between the ischial tuberosity and the hamstring muscle.(4)
The bursa produces lubrication that is meant to lessen the amount of friction and irritation that can be generated between the tissues.
However, when it continuously is subjected to physical trauma, pain, inflammation, and swelling result.
Pain in the area of the sit bones can be difficult to diagnose and sometimes gets misdiagnosed, which is why it is important to see a doctor to help determine the root cause and formulate the best treatment method.
Symptoms of injuries and ailments in the area of the ischial tuberosity can vary, but the biggest common denominator in any of these injuries or ailments is the pain.
Since the pain can come from different sources, it is best to contact a doctor to see about a proper diagnosis and receiving treatment.
Aside from the pain, other indicators of problems around the sitting bones include:
- A dull ache in the gluteal area
- Feeling as if you have pulled a muscle
- Tingling pain around the hamstring muscle
- Pain when sitting for extended periods of time (generally for more than an hour)
- Eventual intolerance for sitting more than 15 minutes
- Burning in the ischial tuberosity
Those with prior injuries to the spine or pelvic region might have exponentially worse experiences of these symptoms.
Those who end up seeing a doctor for ischial tuberosity pain often end up failing squats, toe-touching tests, and/or the straight leg test; they also tend to score as positive on the Faber test.(5)
For the most part, those who present with injuries to the sitting bones and surrounding areas perform at-home treatments before seeking help from their doctors.
Generally, people start off by taking over-the-counter non-steroidal anti-inflammatory medications (NSAIDs) as needed to ease the pain and will supplement this with the application of ice or cold packs.(6)
Those with injuries will often choose to limit or completely stop running or other forms of exercise and feel the need to limit their sitting to short bursts of time.
For some, NSAIDs and cessation from physical activities can help, but serious cases require more extensive treatment options.
The RICE (Rest, Ice, Compression, and Elevation) method of healing is often recommended, but it might not actually be that helpful.
A decrease in blood flow to any damaged tissue will slow down the healing process since the wounded area needs a sufficient amount of oxygen carried through the blood stream in order to heal.
Resting, applying ice, and doing compressions and elevation tend to only relieve pain in the short-term.
For those with chronic injuries to the ischial tuberosity, the RICE method is usually completely ineffective and can complicate injuries if proper treatment is not sought.
In many cases, mild physical exercise or free hand exercises can help to control some of the symptoms of ischial tuberosity pain.
Heavy workouts and many types of athletic sports should be avoided until a doctor can confirm that the injury is fully healed.
Additionally, many patients who present with severe ischial tuberosity pain are instructed to undergo physiotherapy in order to relieve the pain.
However, physiotherapy is not always an effective solution since it is not able to rectify the damage that has been done to the muscular tissues or ligaments found around the ischial tuberosity.
One of the more effective types of treatment used for sit bone pain is Prolotherapy.
Prolotherapy is an injection procedure geared toward treating connective tissue injuries that have not successfully healed with the RICE method or noninvasive surgical procedures.(7)
When the injection is given, a substance is released into the body and causes an inflammatory response on site, causing new blood vessels to form.
This leads to the healing of the damaged soft tissue and a reduction in the physical pain felt around the ischial tuberosity.
Prolotherapy is generally performed by a licensed medical doctor who has been trained in how to administer the injection.
This doctor often has specialized knowledge of the spine and/or pelvic area.
An alternative to Prolotherapy for severe cases of ischial tuberosity pain is platelet rich plasma injections.(8)
The body’s cytokinin tend to be rich in platelet plasma.
This particular procedure involves taking blood from a patient, separating out the platelets, then putting them back into the patient’s body.
For those with ischial tuberosity bursitis, this allows for a much quicker recovery time and gives the patient a significant amount of relief from the pain they experience.
Similarly, stem cell therapy is also being explored as a potentially effective treatment for ischial tuberosity injuries.
Regenerative stem cells are taken from the patient through blood work, processed, and placed back into the patient’s body.
The stem cell procedure targets an affected ligament and creates an inflammatory response on the site.
This helps the damaged tissues heal themselves, thereby reducing the sensation of pain.
When to See a Doctor
Ischial tuberosity pain can signal the presence of a serious injury that will require more than just rest and ice to heal.
If you are struggling to sit down for more than 15 or 20 minutes at a time and are experiencing severe pain while briskly walking, running, playing sports, or doing yoga, you should contact your doctor to see about making an appointment.
If you have been in pain for more than a few days, you should consider calling your Primary Care Physician’s office.
The longer an injury to the soft tissue around the ischial tuberosity is left untended, the more excruciating the pain can become and the damage might become somewhat more permanent.
Extensive and previously untreated damage can result in more invasive therapies.
Extensive research endeavors on the sit bones pain have been undertaken by numerous scientists and doctors for about two decades now.
While the verdict is still out on what type of treatment seems to be the most effective, current research seems to revolve most heavily around the benefits of Prolotherapy, platelet-rich plasma therapy, and stem cell therapy for treating serious cases.
Scientific research is currently being conducted on various treatment methods for the sit bones pain, especially on Prolotherapy.
There is some evidence to suggest that Prolotherapy is an effective treatment for ischial tuberosity pain involving damage to the sacrotuberous ligament.(9)
However, many of the existing reports on the successful administration of Prolotherapy are based on anecdotal evidence, so more research is needed to determine the true effectiveness.
Studies are also being done to determine just how well platelet-rich plasma treatments help treat ischial tuberosity bursitis.
According to a 2014 study done by Fader, Mitchell, Traub, Nichols, Roper, Dan, and McCarty, platelet-rich plasma therapy is a safe and effective treatment for athletes with chronic hamstring-related injuries.(10)
Additionally, multiple studies have recently been published which have investigated the presence of avulsion stress fractures of the ischial tuberosity in athletes.
According to a 2016 study conducted by Yang, Yi, Ahn, Im, and Park, overuse by athletes (including young athletes) can cause stress fractures in this area, which can even occur up to five weeks after the athlete runs a marathon.(11)
Furthermore, a 2015 study by Tederko, Besowski, Jakubiak, Łyp, Bobecka-Wesolowska, and Kiwerski reveals that wheelchair footrest elevation causes a steady rise in the average pressure placed on the ischial tuberosities.(12)
These researchers found that, due to this increased amount of pressure, footrest elevation might lead to a heightened risk of pressure ulcers.
Ischial tuberosity injuries might not seem that serious at first.
You might simply think that you have pulled a muscle when, in fact, you have endured serious tissue damage around the area where your sit bones are located.
The sooner you can get an ischial tuberosity injury diagnosed, you will have a better chance at a fuller and quicker recovery.
There are multiple treatment options available with plenty of research to back them up, so it is important that you contact your doctor to discuss your symptoms and treatment plans.
That pain in your butt should not have to be a long-term “pain in the butt.”