Carol Kane: A 23-Year-Old Female With Buttock and Posterior Hip Pain

Learning Objectives

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Learn the common causes of posterior hip and buttock pain.
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Develop an understanding of the bursae of the hip and pelvis.
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Develop an understanding of the causes of ischial bursitis.
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Develop an understanding of the differential diagnosis of ischial bursitis.
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Learn the clinical presentation of ischial bursitis.
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Learn how to examine the hip and associated bursae.
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Learn how to use physical examination to identify ischial bursitis.
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Develop an understanding of the treatment options for ischial bursitis.

Carol “Candy” Kane

“Hello, Doctor, my name is Carol Kane, but my friends all call me Candy.” Carol “Candy” Kane is a 23-year-old receptionist with the chief complaint of, “I’ve got a pain in my butt.” Carol stated that she works as a receptionist for a local interior design firm and was in her usual good state of health until the firm decided to remodel the reception area and replaced her usual chair and desk with a glass-topped table that was “just too high. I was fine with my old chair and desk, but as you can see, I am really short, so the only way I can reach to use my laptop is to sit on the edge of my new chair—and that’s been a problem because the edge of the chair is hard, which is what I think is killing my butt. I’ve tried sitting on a pillow, but the boss doesn’t like me doing that because it sends the wrong message to our customers. I asked her if they would buy me a standing desk and they said that didn’t match the aesthetic narrative of the firm.”

“Carol—or, I’m sorry, Candy, have you ever had anything like this before?” She just shook her head no. She said she had tried taking Motrin and Tylenol, which only provided a little relief. The heating pad made the pain worse, and she volunteered that ice packs only made her cold, but provided no help. She stated that she had a pretty long commute and that driving was getting to be a problem because she had to sit on the right side of her butt to take the weight off the sore spot, making it difficult to use the clutch. By the time she got home, her back and her left buttock was killing her. Candy said that the left part of her butt felt kind of warm and swollen. I asked Candy what made her pain worse and she said, “Anything that involves sitting.” As a tear ran down her cheek, Candy said, “Doctor, I really need this job, but my butt really hurts and the pain is messing with my sleep. Every time I roll over, the pain wakes me up. My boyfriend doesn’t want to stay over because he says I keep waking him up and he needs his sleep.”

I asked Candy to point with one finger to show me where it hurt the most. She stood up, turned around, bent forward, and pointed to a spot just over her left ischial tuberosity and said, “Doctor, this is where it hurts!”

On physical examination, Candy was afebrile. Her respirations were 18 and her pulse was 64 and regular. Her blood pressure was 118/68. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the area over the left ischial tuberosity revealed mild swelling and felt “boggy” on gentle palpation. The area was warm, but did not appear to be infected. There was marked point tenderness over the left ischial tuberosity. Deep palpation of the area of Candy’s pain as well as passive extension of the hip exacerbated the pain. I performed a resisted hip extension test, which was markedly positive on the left and negative on the right ( Fig. 6.1 ). The right hip examination was normal, as was examination of her other major joints. Rectal and pelvic examinations were normal, other than pain with palpation of the left ischial bursa. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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Acute onset of left buttock and posterior hip pain attributed to sitting on the edge of a new task chair at work
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Pain localized to the area of the left ischial tuberosity
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Pain exacerbated by sitting
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No other specific traumatic event to the area identified
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No fever or chills
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Sleep disturbance
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Difficulty sitting for any length of time

The Physical Examination

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The patient is afebrile
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Point tenderness to palpation of the area over the ischial tuberosity
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Palpation of the area reveals warmth to touch
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There is swelling and “bogginess” over the left ischial tuberosity
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No evidence of infection
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Pain on extension of the left hip
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The resisted hip extension test was positive on the left (see Fig. 6.1 )

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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Normal rectal and pelvic examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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Examinations of joints other than the left hip were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the left hip and pelvis
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Ultrasound of the left hip and area over the ischial tuberosity

Test Results

The plain radiographs of the left hip were reported as normal. Specifically, there was no calcification in the area of the ischial bursa suggestive of chronic bursitis. Ultrasound examination of the left hip was normal, but there was an effusion around the left ischial bursa ( Fig. 6.2 ).