Ischial Tuberosity Pain (aka ‘Weavers Bottom’ or Pain in the Butt)
What are the symptoms of ischial tuberosity pain?
The symptoms of ischial tuberosity pain are, plain and simple: a pain in the butt, or colloquially ‘PITA’. Clients will typically describe pain on the bottom of the buttock and in the hamstrings, often quite severe and prolonged when sitting, especially on firm surfaces and when running or lifting objects. The area may also be quite tender and sensitive to touch.
The ischial tuberosity is a swollen part or broadening of the bone in 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. Ischial tuberosity pain may be experienced by a wide range of athletes, including soccer players, cyclists, and any type of jumpers or runners, especially hurdlers. It is apparently often misdiagnosed as ischial bursitis, an even more painful condition than tendonitis.
How does an ischial tuberosity injury develop?
The ischial tuberosity is the point of origin of the adductor and hamstring muscles of the thigh, as well as the sacrotuberous ligaments. The forceful pull of these muscles, can happen during a variety of sports, as a result of a trauma, such as a fall or other type of injury, or through the overuse of the hamstrings, as is common among runners and soccer players. In rare cases an avulsion fracture or separation of the ischial tuberosity or apophysis can occur.
This article has been motivated by my having recently suffered from hamstring tendonitis as a result of carrying an awkward 40kg portable air conditioner down two flights of stairs in a townhouse in Perth, severely overloading my hamstrings and other associated muscles and ligament attached to the pelvic area.
The condition is generated by similar overloads in athletes of many kinds as indicated above and is a well recognised and widely occurring sports injury. It is also triggered by sitting for extended periods on hard surfaces and got the name “Weavers Bottom” as the leaning position that they adopted when weaving led to its regular occurrence. In this case, and that of many athletes, it is effectively a repetitive stress injury – while in my case it was a single acute overload incident followed by a later compounding trauma.
In addition to its frequency in athletes, its common occurrence in bicycle riders results from the weight on the saddle being born by the ischial tuberosity. It also occurs with invalids confined largely to wheelchairs, and no doubt those spending hours on computers sitting on inappropriate seats and / or with inappropriate ergonomics.
The condition is normally that of hamstring tendonitis, less commonly it can be ischiogluteal bursitis of the bursar separating the gluteus maximus from the underlying bone or both. The pain is felt directly on the ischial tuberosity and in the hamstrings. These were the locations of my pain. In addition there appeared to be some entrapment of one or both of the sciatic/tibial nerve and possibly that of the descending cutaneous superior gluteal nerve. The numb sensation was felt in and down the mid to posterior lateral aspects of the thigh and lateral to frontal in the calf. It was triggered by certain seating positions on a hard or firm seat but was not painful unless rolled across.
Typically treatments include RICE (rest, ice, compression, elevation), NSAIDS (nonsteroidal anti-inflammatory drugs), cortisone injections and physiotherapy.
Many muscles and ligaments can be involved in and associated with ischial tuberosity pain and include the following where many related trigger points are found:
- Sacrospinous, sacrotuberous and posterior sacral ligaments
- Semitendinosus and semimembranosus muscles
- Gluteus Maximus and Minimus muscles
- Quadratis and iliocostalis lumborum muscles
- Adductor magnus and longissimus thoracis
- Biceps femoris-long head
My initial approach for the first day was rest and ice plus a paracetamol codeine combination, followed by an NSAIDS COX-2 inhibitor for six days to little effect.
Like many other clients we see after such treatments have failed, I desperately needed an alternative treatment. As I had to go to Perth, I visited one of our therapists in Subiaco, LG, as we cross-refer and cross-treat when in Perth.
Having previously encountered similar, but not identical conditions, she made an assessment of the probable treatment areas and priorities (she was familiar with me being a pain in the butt but not having one).
Lee at this time provided a fairly standard treatment as I had little time available, being on my way to return to Denmark, WA. This included treating the Longisimus and Illiocostalis Thoracics, Gluteals, Piriformis, Hamstrings and Adductors that gave some relief but not resolution.
A week after getting home to my Denmark property I managed to severely aggravate the condition after a tumble down some stairs, adding trauma to overload without the protection of imbibed red wine.
So I had two weeks of PITA, sitting on multiple cushions, feeling like an ancient weaver and taking ibuprofen when it got too bad before I could return to Perth on the way to the Adelaide meeting.
I went straight to see Lee, as I was not looking forward to 3-4 hours on the plane after an unpleasant 5 hours drive to Perth. This time she decided release was needed through the sacroilliac area, and planned additional moves to address the illiolumbar, posterior sacral, sacrospinous and sacrotuberous ligaments.
Treatment followed a typical lower back Bowen Therapy approach covering most of the muscle groups identified above. Also she included a series of moves around the Greater Trochanter crossing the insertions of the Quadratus Femoris, Obturator Externus, Gemullus Inferior, Obturator Internus, Gemullus Superior, Piriformis, Gluteus Medius and Gluteus Minimus. The moves that appeared to make the difference were, in my case, those addressing the illiolumbar, sacroilliac and sacrotubureous ligaments. Lee commented that the left sacrotuberous ligament in particular appeared tightened and therefore shortened placing further load onto the ischial tuberosity in addition to the left adductor magnus.
Almost immediately following this treatment my level of discomfort when seated was reduced significantly and with the reinforcement of some ibuprofen (along with my requisite water) a short time later I was able to sit through a movie, 3.10 to Yuma, for some 2 plus hours. This simply would not have been possible prior to the treatment, as I could barely sit at all without considerable pain and discomfort – let alone for 2 plus hours.
I maintained my water and ibuprofen regimen and was able to sit for extended periods without the previous pain levels. The trip the following day to Adelaide, in the standard uncomfortable seat, was achieved with only nominal discomfort.
I managed to get a follow-up treatment just prior to returning to Denmark, a 400km plus drive, and both during the drive and subsequently I have been virtually pain free, without any ibuprofen but occasional red wine ingestion. I still have to exercise care when lifting and otherwise stressing the hamstrings as I think it will be some time before they fully recover.
I thought that this would provide a useful case study as it includes a therapist and client view, treatment regimen and related experiences. It may be of value when encountering clients or friends who fall into the at risk categories of athletes, bicycle riders, wheelchair-confined persons, and fools who think they are still like Arnie!!
DP – Denmark, WA
- There have been some European studies that have found a gradual and progressive onset of ischial tuberosity pain particularly in males not falling into typical risk categories may be due to silent prostatitis and suggest referral to their medical practitioner in such cases may be wise.