Gluteal bursitis is an uncommon cause of buttock pain that is frequently misdiagnosed as primary hip pathological conditions. A patient with gluteal bursitis frequently reports pain at the upper outer quadrant of the buttock and with resisted abduction and extension of the lower extremity. The pain is localized to the area over the upper outer quadrant of the buttock, with referred pain noted into the sciatic notch. Often, the patient is unable to sleep on the affected hip and may report a sharp, catching sensation when extending and abducting the hip, especially on first awakening.
The gluteal bursae lie between the gluteal maximus, medius, and minimus muscles and between these muscles and the underlying bone. These bursae may exist as a single bursal sac or in some patients may exist as a multisegmented series of sacs that may be loculated. The gluteal bursae are vulnerable to injury from acute trauma and repeated microtrauma. The action of the gluteus maximus muscle includes the flexion of trunk on thigh when maintaining a sitting position when riding a horse. This action can irritate the gluteal bursae and result in pain and inflammation. Acute injuries frequently take the form of direct trauma to the bursa from falls directly onto the buttocks or repeated intramuscular injections and from overuse such as running for long distances, especially on soft or uneven surfaces. If the inflammation of the gluteal bursae becomes chronic, calcification of the bursae may occur.
What are the Symptoms of Gluteal Bursitis
Physical examination of patients with gluteal bursitis may reveal point tenderness in the upper outer quadrant of the buttocks. Passive flexion and adduction and active resisted extension and abduction of the affected lower extremity reproduce the pain. Sudden release of resistance during this maneuver markedly increases the pain.
Examination of the hip and sacroiliac joint is normal. Careful neurological examination of the affected lower extremity should reveal no neurological deficits. If neurological deficits are present, evaluation for plexopathy, radiculopathy, or entrapment neuropathy should be undertaken. These neurological symptoms can coexist with gluteal bursitis, confusing the clinical diagnosis.
How is Gluteal Bursitis diagnosed?
Plain radiographs of the hip may reveal calcification of the bursa and associated structures consistent with chronic inflammation. Magnetic resonance imaging (MRI) is indicated if occult mass, tumor of the hip, or tear of the gluteal muscles is suspected. Electromyography should be performed if neurological findings are present to rule out plexopathy, radiculopathy, or nerve entrapment syndromes of the lower extremity. Based on the patient’s clinical presentation, additional tests, including complete blood cell count; human leukocyte antigen (HLA) B-27 testing; automated serum chemistries, including uric acid; erythrocyte sedimentation rate; and antinuclear antibody testing, may be indicated. The injection technique described here serves as a diagnostic and therapeutic maneuver for patients with gluteal bursitis.
Gluteal bursitis is often misdiagnosed as sciatica or attributed to primary hip pathological processes. Radiographs of the hip and electromyography help distinguish gluteal bursitis from radiculopathy of pain emanating from the hip. Most patients with a lumbar radiculopathy have back pain associated with reflex, motor, and sensory changes, whereas patients with gluteal bursitis have only secondary back pain and no neurological changes. Piriformis syndrome sometimes may be confused with gluteal bursitis but can be distinguished by the presence of motor and sensory changes involving the sciatic nerve. These motor and sensory changes are limited to the distribution of the sciatic nerve below the sciatic notch. Lumbar radiculopathy and sciatic nerve entrapment may coexist as the “double crush” syndrome. The pain of gluteal bursitis may cause alteration of gait, which may result in secondary back and radicular symptoms that may coexist with this entrapment neuropathy.
Initial treatment of the pain and functional disability associated with gluteal bursitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. The repetitive movements that incite the syndrome should be avoided. For patients who do not respond to these treatment modalities, injection of gluteal bursa with a local anesthetic and steroid may be a reasonable next step.
To inject the gluteal bursa, the patient is placed in the lateral position with the affected side up and the affected leg flexed at the knee. Preparation with antiseptic solution of the skin overlying the upper outer quadrant of the buttocks is carried out. A syringe containing 4 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 25-gauge, 1½-inch needle. The point of maximal tenderness within the upper outer quadrant of the buttocks is identified with a sterile gloved finger. Before needle placement, the patient should be advised to say “There!” immediately if he or she feels a paresthesia into the lower extremity, indicating that the needle has impinged on the sciatic nerve. Should a paresthesia occur, the needle should be withdrawn immediately and repositioned more medially. The needle is carefully advanced perpendicular to the skin at the previously identified point until it impinges on the wing of the ilium. Care must be taken to keep the needle medial and not to advance it laterally, or it could impinge on the sciatic nerve. After careful aspiration and if no paresthesia is present, the contents of the syringe are gently injected into the bursa. Minimal resistance to injection should be felt. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
The proximity to the sciatic nerve makes it imperative that this procedure be performed only by clinicians well versed in the regional anatomy and experienced in performing injection techniques. Many patients also report a transient increase in pain after injection of the bursae.
This injection technique is extremely effective in the treatment of gluteal bursitis. It is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. Most side effects of this injection technique are related to needle-induced trauma to the injection site and underlying tissues. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection. The avoidance of overly long needles helps decrease the incidence of trauma to underlying structures. Special care must be taken to avoid trauma to the sciatic nerve.
The use of physical modalities, including local heat and gentle stretching exercises, should be introduced several days after the patient undergoes this injection technique. Vigorous exercises should be avoided because they would exacerbate the symptoms. Simple analgesics, NSAIDs, and antimyotonic agents such as tizanidine may be used concurrently with this injection technique.