What is Trochanteric Bursitis?
Pain on the outside (lateral aspect) of the hip is commonly referred to as trochanteric bursitis. Trochanter refers to the greater trochanter which is located on the femur bone, this is where the bursa is located. The ‘-itis’ denotes inflammation of the bursa however, this is somewhat of a misnamed condition. The increased prevalence of radiological imaging has shown that bursal swelling is an inconsistent feature of lateral hip pain (Connell et al 2013; Bird et al 2001) and commonly the bursa doesn’t even show signs of inflammation (Silva et al 2008).
Trochanteric Bursitis Symptoms
Typical symptoms include lateral (outer) hip pain that can spread down the lateral thigh. Occasionally the pain can spread below the level of the knee. Typical symptom triggers include:
- Night time pain especially with lying on the affected side
- Climbing stairs
- Prolonged walking
- Pain for several steps after sitting for a period of time
What is a Bursa?
A bursa is like a ‘slippery sponge’ found in the body where soft tissues move over harder surfaces (usually bone). The slippery bursa reduces friction between the soft tissues, tendons and bone which helps protect tissues from damage. Bursae are found throughout the body and are normal. Bursitis is associated with other joints too such as the shoulder (subacromial bursitis / impingement). Bursitis is also found in the knee (prepatellar bursitis).
What is Bursitis?
When someone suspects or sees a bursa showing signs of swelling on a scan, commonly this is seen as a definitive diagnosis of ‘bursitis’. The next recommendation is invariably a cortisone (steroid) injection aimed at settling the inflammation (which as explained earlier, we now know is often not even present). In this model it is assumed that the bursa is solely responsible for the pain and problem. In reality, bursae are very tough structures that take a decent amount of pressure to become irritated and only become pathological/pain producing after a lot of unnecessary friction has come it’s way. There is now a lot of research out there supporting the idea that bursal distention is almost always a secondary finding associated with gluteal tendinopathy (Grimaldi et al 2015; Kong et al 2007; Woodley et al 2008 and many others).
What Is Gluteal Tendinopathy?
Compression is a big player in the development of tendinopathies (Cook and Purdam 2009, 2012) along with other factors such as volume overload (read more in our upcoming piece on tendons). While tendons are designed to resist large tensile forces, they are not great at tolerating compression.
The gluteal muscles, in particular the gluteus medius and gluteus minimus, while they may sound like Roman generals, they are the muscles on the side of the buttock and thigh that control the body’s position when standing, walking or running and are usually the forgotten muscle to strengthen in a sportsperson who is frequently running, jumping or changing direction.
Gluteal tendinopathy is a description of degeneration of these tendons (tendons connect muscles to bones) which results after persistent overload and compression. Tendinopathy is common but is often not painful until the tendon reaches a critical point where the tendon can no longer tolerate the force it is being subjected to.
What is the Role of Gluteus Medius and Minimus When Walking?
If the gluteus medius and minimus muscles are not conditioned, when we weight-bear on one leg, the hips and pelvis will shift and sway to the side – in much the same way as a catwalk model does when sashaying down the runway. (?pic or video of model walk from behind)
This results in an “adducted” position for your leg. If the muscles cannot hold the body stable over the top of the leg, on doing a single leg squat we see a significant lateral movement of the pelvis which is termed a Trendelenburg Sign. Each time the hips move excessively to the side during the gait cycle (walking), there is increased compression on the outside of the thigh. This can eventually lead to bursitis and tendon compression beneath the ITB (iliotibial band) and against the trochanter. Any increase in ITB tension further increases compression. Tightness and overactivity of other muscles on the outside of your thigh can influence tension of the ITB. These muscles include the TFL (tensor fascia lata), gluteus maximus and outer quadriceps and can increase subsequent compression.
This is particularly the case for those working in seated occupations over many years as there is a rapid increase in compressive loading when moving from a seated position (hip is slightly abducted) to a standing position (hip is adducted for functional loading) (Birnbaum et al 2004).
What is Greater Trochanteric Pain Syndrome?
Unfortunately, the longer these abnormal / compensatory movements are going on for due to the underlying gluteal tendinopathy, the more other structures can become overloaded and painful. Gluteal tendinopathy and trochanteric bursitis often co-exist with pain from other structures around the pelvis that are also being overloaded. These areas include the sacroiliac joint, hamstring tendons and the hip joint itself. Given the typical complexity of this type of presentation, these conditions are referred to under the umbrella term “Greater Trochanteric Pain Syndrome” (GTPS).
What Scans are Needed for GTPS Diagnosis?
In short, most cases do not require any scans as the diagnosis is clinical. That is, the doctor or physiotherapist should be able to make the diagnosis based on the story of your pain and their examination. In cases that are not classic, imaging may be required. The commonest imaging modalities used include;
- X-rays – to look for other causes of hip pain such as osteoarthritis
- Ultrasound – to directly look at the bursa and the tendons. Unfortunately the bursa and the tendons can be located quite deep under the skin and the quality of the image may be relatively poor. This is a particular problem if the patient is overweight
- Magnetic resonance imaging (MRI) – also directly looks at the bursa and the tendons and is less affected by patient size
Although a picture of an unhappy tendon and bursa may seem useful for diagnosis, many studies have shown that patients will have similar ‘abnormal’ findings in the other hip that has no pain! This makes interpretation of these ‘abnormal’ findings tricky. Hence, diagnosis is usually clinical and imaging is reserved for those with atypical cases.
How to Treat Trochanteric Bursitis / Greater Trochanteric Pain Syndrome
GTPS is a stubborn problem with no quick fix, especially as most of us put up with symptoms longer than we probably should! GTPS can be effectively managed though but this often requires a longer timeframe than many musculoskeletal injuries. The most important part of management is a good assessment to determine which structures are involved and how they became injured. Then its necessary to establish a specific treatment plan to address these issues. Each individual is unique in their presentation so they will need a program designed for their particular set of symptoms and circumstances.
Understanding the ‘why’ is very important. Usually there is a need to reduce load on the affected tissues by adjusting exercise or postural loads. For example, any activity that can be completed without causing pain (immediate or delayed) is fine to continue. These activities range from working out at the gym to doing the grocery shopping. However, if symptoms are increased the next morning then this indicates that the load/activity needs to be adjusted to a more manageable level. Likewise, certain postures such a prolonged sitting, particularly in a low chair or couch, or propping on one hip while standing or holding a young child, place additional stress on the outer hip and can cause symptoms to persist. Even sitting or lying in bed with legs crossed over the midline will contribute to compressive loads and exacerbate symptoms.
Trochanteric bursitis / GTPS Exercises and Physiotherapy
Physiotherapy treatment should be focussed upon reducing compression of the gluteal tendons and improving the capacity of the degenerated tendons.
To reduce compression and offload tight lateral hip structures, soft tissue techniques can be used. Techniques such as self trigger releases or dry needling may be effective in the short term but should never be the sole treatment. The best outcomes are achieved through addressing poor postural and movement habits and correction of muscle activation patterns. Treatments that have limited supportive science in the treatment of trochanteric bursitis include ultrasound, ice therapy, TENS and stretching of the ITB. Although stretching of the ITB sounds helpful in theory, anatomy lab studies have shown that the ITB cannot be stretched. To increase the length of the ITB it must be cut surgically. Furthermore, manoeuvres aimed at ‘stretching’ the ITB can result in more compression and worse symptoms.
For best results, a good quality exercise program is required. This should be graduated focussing on controlled loading of the gluteal muscles as well as activation of other stabilising muscles around the pelvis depending on the patient’s unique presentation. Ideally these exercises should be performed in functional or upright positions. Often these are only performed in a side-lying position which is not a natural or functional position. Clams or side leg lifts can be useful in the early stages but do not provide the necessary load required to develop strength for standing tasks. For best outcomes, rehab should be supervised by adequately trained physiotherapists. All of the physiotherapists at Newcastle Sports Medicine are experts in treatment of GTPS.
Trochanteric Bursitis Injections
There are 2 main types of injection performed for trochanteric bursitis; cortisone and platelet-rich plasma (PRP). Both have a role and depends on the individual circumstance. In general, injections are reserved for those who are not responding to physiotherapy.
Trochanteric Bursitis Steroid / Cortisone Injections
Cortisone (Steroid) injections reliably reduce pain associated with tendons and bursae in the short-term. Their long-term effect has been a source of debate for many years. An important study on tennis elbow demonstrated that patients had more pain 1 year after a cortisone injection than if they had had no treatment (Bisset et al 2006). Given primum non nocere (the doctors’ motto of ‘first cause no harm’), well-founded concerns were raised regarding the use of cortisone injections. The findings in the tennis elbow study were then assumed to apply to multiple tendons. The theory is that cortisone is catabolic and slows inflammation but also slows healing processes down. Therefore cortisone may help pain in the short-term but is unhelpful for long-term recovery. Although this makes logical sense, subsequent studies have not backed up this theory.
Several studies have shown benefit for peritendinous (around the tendon but not into the tendon) cortisone injections for other tendons. Furthermore, a recent GTPS study confirmed that a single cortisone injection helps pain more than no treatment in both the short- and long-term (Mellor et al 2018). In the same study though, exercise and education helped patients more than a cortisone injection. What wasn’t assessed was the combination of cortisone as well as education and exercise. In clinical practice, this combination would be the recommended course of action if pain is not settling quickly with physiotherapy. However, multiple cortisone injections are likely harmful to the long-term health of the tendons and may predispose to significant tears. In general, cortisone should be used judiciously and patients usually should not have more than a couple of cortisone injections for the same condition.
Trochanteric Bursitis PRP Injections
Platelet-rich plasma (PRP) injections have been popular for nearly 20 years now and also split medical opinion. The premise behind PRP injections (a concentrate of platelets from your own blood) is that tendons degenerate in regions of poor blood flow. By delivering a super-charged shot of your own blood to the degenerate tendon, healing may be stimulated (anabolic not catabolic). At the same time, the platelets release transmitters that can improve pain in the region as well.
Once more the logic is reasonable but robust science does not exist to support or refute the efficacy of PRP injections. Certainly 2 studies have demonstrated benefit (Fitzpatrick et al 2018, Lee et al 2016) with the use of PRP. The clinical improvements also seem larger than with the use of cortisone. The experimental nature and cost of PRP injections means they tend to only be offered when a patient is not improving despite good quality physiotherapy and a cortisone injection.
Trochanteric Bursitis Surgery
Surgery is rarely required but options are available for patients that have persistent symptoms despite high quality non-operative care. The options include;
- Bursectomy (removal of the bursa) +/- ITB release
- Repair of tendon tears
- Artificial tendon surgery (LARS ligament)
Unfortunately, most research on surgical outcomes is of low quality. Studies do claim benefit but there are significant limitations in the research. In our experience, most surgeons are wary of performing surgery for trochanteric bursitis as the success rates can be variable.
Trochanteric Bursitis / GTPS Summary
GTPS is a common condition that responds in most cases to an exercise program that is specific to the individual. The program should address the gluteal tendons as well as any associated pelvic issues such as sacroiliac joint dysfunction. Injections are not needed in all cases but frequently patients will need injection therapy as an adjunct to their rehabilitation program if their pain is not improving quickly. The commonest injection options are cortisone and PRP. In a handful of cases, pain may not improve and surgery may be attempted although success rates can be variable.
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Written by Tim Schneider and Dr Ross Cairns
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