What is the treatment for ischial tuberosity pain in an ice hockey goalie?

Treatment of Ischial Tuberosity Pain in an Ice Hockey Goalie

For an ice hockey goalie with significant pain over the ischial tuberosity from repetitive pressure, initial management should focus on relative rest with activity modification, cryotherapy (ice and water applications for 10-minute periods), NSAIDs for short-term pain relief, and eccentric strengthening exercises once acute pain subsides. 1

Initial Assessment and Activity Modification

The goalie should immediately reduce activities that cause pain, particularly prolonged sitting on the ischial tuberosity during games and practices 1. This represents an overuse tendinopathy affecting the hamstring insertion at the ischial tuberosity, commonly seen in athletes with repetitive loading 1, 2, 3.

Key diagnostic considerations:

• Rule out acute avulsion fracture if there was a specific traumatic event (sudden sprint, forceful hamstring contraction) 2, 4, 5
• Distinguish between apophysitis (gradual onset, younger athletes age ~14 years) versus tendinopathy (older athletes, repetitive microtrauma) 5
• Examine for point tenderness directly over the ischial tuberosity and pain with resisted knee flexion 3

First-Line Treatment Protocol

Cryotherapy

Apply ice mixed with water through a wet towel for 10-minute periods, up to 3-4 times daily 1. This provides superior tissue cooling compared to ice alone and effectively reduces acute pain and swelling 1. Avoid direct ice-to-skin contact to prevent cold injury 1.

NSAIDs

Prescribe NSAIDs for short-term pain relief (typically 7-14 days) 1. Topical NSAIDs are equally effective and have fewer systemic side effects than oral formulations 1. However, NSAIDs do not alter long-term outcomes and should not be used chronically 1.

Relative Rest

The athlete should avoid sitting directly on the ischial tuberosity during goalie activities 1. Consider using padded cushioning or modifying goalie stance temporarily. Complete immobilization should be avoided as it causes muscle atrophy 1. Allow continuation of activities that do not worsen pain 1.

Second-Line Treatment (If No Improvement After 2-4 Weeks)

Eccentric Strengthening

Implement eccentric hamstring exercises as the cornerstone of rehabilitation 1. Eccentric strengthening has proven effective for tendinopathies and may reverse degenerative changes 1. This should begin once acute pain subsides.

Corticosteroid Injection (Use With Caution)

Local corticosteroid injection may provide acute-phase pain relief superior to oral NSAIDs, but does not alter long-term outcomes 1. Inject peritendinous rather than intratendinous to avoid weakening the tendon and risk of rupture 1. Reserve this for cases with severe pain limiting rehabilitation participation.

Critical caveat: Corticosteroids may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1. Use judiciously in athletes requiring high hamstring loads.

Imaging Considerations

Plain radiographs are indicated if:

• Acute traumatic onset suggesting possible avulsion fracture 2, 4, 5
• Symptoms persist beyond 4-6 weeks despite conservative treatment 5
• Patient is adolescent (age 14-18) where apophyseal injury is more common 5

MRI or ultrasound can identify tendon thickening, partial tears, or bursitis if diagnosis remains unclear 1, 6.

Surgical Referral Indications

Consider surgical consultation if:

• Failed 3-6 months of conservative therapy 1
• Acute avulsion fracture with >2 cm displacement 2, 4
• Chronic nonunion of avulsion fracture causing persistent pain and weakness 4
• "Hamstring syndrome" with tight tendinous structures causing chronic sciatic-type pain radiating down posterior thigh 3

Surgery (division of tight hamstring insertions or osteosynthesis of avulsion fragments) provides complete relief in approximately 88% of carefully selected cases 3, 4.

Return to Play Strategy

The goalie should progress through:

1. Pain-free daily activities
2. Pain-free eccentric strengthening
3. Sport-specific movements without goalie stance
4. Modified goalie activities with padding
5. Full return when pain-free with all movements 1

Avoid premature return as this represents an overuse injury requiring adequate healing time, typically 6-12 weeks for conservative management 1, 5.