Trochanteric Bursitis and other Hip Bursa’s.

 Before reading this remember hip bursitis is massively wrongly OVERDIAGNOSED! Be sure to listen to the physioedge ‘lateral hip pain’ podcast to ensure you have made a correct diagnosis.

 Clinically Relevant Anatomy

A bursa is a small sack of fluid which is usually positioned in between a bone and a muscle or tendon. The function of a bursa is to prevent friction between the bone and overlying soft tissue.

There are several bursas around the hip joint, including

  • Trochanteric bursa – on the outside of the hip between the greater trochanter and the attachments of the gluteal muscles.
  • Gluteus medius bursa – a smaller bursa, between the gluteus medius muscle and the greater trochanter, just medial to the trochanteric bursa.
  • Iliopsoas bursa – between the iliopsoas muscle at the front of the hip joint and the underlying bone.
  • Ischial bursa – Between the hamstring tendons and the base of the pelvis.
See more HIP ANATOMY
Epidemiology/aetiology

The most commonly injured bursa is the trochanteric bursa. This can be injured in one of two ways, through a direct impact to the bursa, such as a fall onto the outer hip, known as traumatic bursitis. Or through repetitive friction from the overlying muscles and tendons, usually during running. This repeated friction results in the bursa becoming inflamed and swollen. Every time the tendons then rub over the bursa, this causes pain.

Commonly seen between the fourth and sixth decade of life (Mulford,2007) and there appears to be a higher prevalence in women than men (Shapira et al, 1986) which could be attributed to the altered biomechanics.

Potential Causes
  • Trauma (22-44%) .  (Gordon,1961)
  • Overuse/micro trauma to muscles/tendons and fibrous tissue often as a result of poor to biomechanical abnormalities (Raman and Haslock, 1982).
  • If you over pronate then you are more susceptible to this injury as the knee falls inwards which increases the angle at the hip.
  • Weakness in the hip abductors, especially gluteus medius has the same effect.
  • Tight structures surrounding the hip such as the ITB, hip flexors and hamstrings.
  • A bone spur – a small excess growth of bone which can aggravate the bursa.
Characteristics and Clinical presentation:
  • Intermittent pain on the lateral of the hip which is worse during activities such as running, climbing stairs or getting out of a car.
  • Usually an ache in nature but intensity can vary.
  • Can complain of numbness in the thigh which lies in no dermatomal pattern.
  • Pain which gradually gets worse.
  • Pain when you press in on the outside of the hip.
  • Pain which radiates down the outer thigh.
Differential diagnosis
Examination
  • Important to isolate the structure causing pain through palpation and special tests. Check out a hip assessment to familiarise yourself with the process.
  • Specific tenderness over the greater trochanter.
  • Pain may be reproduced by resisted abduction or external rotation.
Diagnosis.
Usually assessed on clinical findings. X-Rays may rule out differential diagnosis possibilities (ie Hip OA) and MRI may show soft tissue changes/ calcifications of the greater trochanter. However often these images will not change the treatment therefore rather than expose a patient to radiation often a course of physiotherapy will be provided. If this fails then a corticosteriod injection may be advised or eventually surgical management.
Management

General advice for patient

  • Rest until there is no pain.
  • Apply ice to the area.
  • Run only on flat, even surfaces.
  • See a sports injury professional.

Healthcare professional or Physiotherapy management

  • Prescribe anti-inflammatory medication e.g. ibuprofen.
  • Advise activity modification
  • Send you for an X-ray or MRI to confirm the injury is not as a result of a bone spur.
  • Refer you for physical therapy to correct muscle imbalances.
  • Use Ultrasound to help reduce pain and inflammation.
  • Prescribe orthotics to correct foot biomechanics.
  • Aspirate the bursa.
  • Give a steroid injection followed by rest.
  • Operate if it is a long term injury.

References

Gordon EJ. Trochanteric bursitis and tendonitis. Clin Orthop. 1961; 20:193-202.
 Mulford K. Greater Trochanteric Bursitis. The Jounral of Nurse Practitioners. 2007:328-332.

Raman D, Haslock I. Trochanteric bursitis—a frequent cause of “hip” pain in rheumatoid arthritis. Ann Rheum Dis. 1982;41(6):602-603.

Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Arch Phys Med Rehabil. 1986;67(11):815-817.

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