Gluteal Bursa Injection

Indications and Clinical Considerations

Bursae are formed from synovial sacs that allow easy sliding of muscles and tendons across one another at areas of repeated movement. These synovial sacs are lined with a synovial membrane, which is invested with a network of blood vessels that secrete synovial fluid. Inflammation of the bursa results in an increase in the production of synovial fluid with swelling of the bursal sac. With overuse or misuse, these bursae may become inflamed, enlarged, and, on rare occasions, infected. Although there is significant intrapatient variability as to the number, size, and location of bursae, anatomists have identified a number of clinically relevant bursae, including the gluteal bursa. The gluteal bursae lie among the gluteal maximus, medius, and minimus muscles, as well as between these muscles and the underlying bone ( Fig. 126.1 ). These bursae may exist as a single bursal sac or in some patients as a multisegmented series of sacs that may be loculated.

The gluteal bursae are vulnerable to injury from both acute trauma and repeated microtrauma. Acute injuries frequently take the form of direct trauma to the bursa from falls directly onto the buttocks or repeated intramuscular injections, as well as 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 these bursae may occur.

The 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. Physical examination may reveal point tenderness in the upper outer quadrant of the buttocks. Passive flexion and adduction as well as active resisted extension and abduction of the affected lower extremity reproduce the pain. Sudden release of resistance during such maneuvers markedly increases the pain ( Fig. 126.2 ).

Plain radiographs of the hip may reveal calcification of the bursa and associated structures consistent with chronic inflammation. Magnetic resonance imaging and/or ultrasound imaging is indicated if occult mass or tumor of the hip is suspected. The injection technique described later serves as both a diagnostic and therapeutic maneuver.

Clinically Relevant Anatomy

There is significant intrapatient variability in the size, number, and location of the gluteal bursae (see Fig. 126.1 ). The gluteal bursae lie among the gluteal maximus, medius, and minimus muscles, as well as between these muscles and the underlying bone. The action of the gluteus maximus muscle includes the rider’s flexion of trunk on thigh when maintaining a sitting position while riding a horse. This action can irritate the gluteal bursae, as can repeated trauma from repetitive activity, including running.