Overview

Trochanteric bursitis occurs when there is irritation of the bursa near your hip joint. A bursa is a small sac filled with fluids that cushion the bones and tissues around your joints. They help to reduce friction between moving tissues of the body, such as between the bone and tendon, tendons and ligaments, bone and ligament, and between muscles. Trochanteric bursitis typically presents with lateral hip pain that worsens by walking, standing up from a chair, or lying on the affected area.¹ Patients experience tenderness around the greater trochanter of the thigh bone when examined.

Some of the leading causes of trochanteric bursitis are reoccurring microtrauma or any kind of trauma to the hip and tendinopathies of the hip muscles, especially the gluteus medius and minimus, due to their overuse. Activities such as cycling and stair climbing causes repeated hip abduction, resulting in irritation of the trochanteric bursa. Patients who are immobile and constantly lie on one side can put pressure on the trochanteric bursa, leading to the irritation and development of trochanteric bursitis. Underlying lower leg abnormal gait is also a cause of trochanteric bursitis.

To link trochanteric bursitis to abnormal gait, we need to understand what an abnormal gait entails. An abnormal gait means a change in your pattern of walking. Any deviation from the natural way you walk points to an abnormal gait. Some medical conditions that affect your brain and spinal cord can cause abnormal gait. Also, certain injuries to your lower limbs can lead to an abnormal gait.

Common gait abnormalities

• Antalgic gait: this is an abnormal pattern of walking due to pain. Obtaining an injury on your lower leg can make you walk with a limp secondary to the pain from the injury²
• Vaulting gait: this type of gait results from leg length discrepancies, and it is mostly seen in children. When a person’s leg is longer or shorter than the other leg, his posturing and walking pattern can become abnormal due to the differences in the leg length
• Trendelenburg gait: this type of gait occurs due to weakness in some muscles of the hip, like the abductor muscles. The hip tends to drop on the affected side when the person is walking
• Parkinsonian or propulsive gait: this is often noticed in individuals with parkinson's disease. There is rigid posture of their body, and their head and neck bend forward. Their steps are usually fast and short as they are trying to maintain the centre of gravity
• Scissors gait: from its name, your hip and thigh hit or cross in a scissors-like form when you are walking. Your steps may be slow and small. This type of gait affects people with the condition called spastic cerebral palsy
• Hemiplegic or spastic gait: this type of gait is found in people with multiple sclerosis and cerebral palsy. A spastic gait causes you to walk with one stiff leg. As you lift the affected leg, it may either drag or swing in a semicircular motion²
• Steppage gait: it happens when you can’t lift the front part of your foot, so instead of your heel touching the ground first when you walk, your toes hit the ground first. This is also called foot drop. This is common among people with muscle atrophy or peroneal nerve injury
• Waddling gait: this type of gait entails swaying from side to side when you walk. The walking pattern is like that of a duck. This can be linked to weak muscle conditions like muscular dystrophies or a hip dislocation present from birth
• Crouching gait: a crouching gait makes you walk with bent ankles, knees, and hips, almost like you’re about to squat. Your toes might drag as you move. This type of walking is common in people with cerebral palsy
• Shuffling gait: you walk without fully lifting your feet off the ground. You drag your feet while trying to walk. This can happen if you feel unsteady or have an injury that makes it hard to lift your feet while walking

How gait abnormalities lead to trochanteric bursitis

Gait abnormalities cause repetitive friction of the greater trochanter and the tissues surrounding it. This leads to microtrauma of the tendons attached to the greater trochanter, therefore leading to inflammation of the trochanteric bursa. Muscle imbalance as seen in trendelenburg gait alters hip biomechanics, leading to bursal inflammation. Furthermore, abnormal gait increases mechanical stress on the greater trochanter and the surrounding tendons, stirring up trochanteric bursa inflammation.³

Diagnosis and clinical assessment

• Patients with trochanteric bursitis experience persistent pain at the lateral side of the hip and/or buttock when lying on that side, standing for a long time, getting up from sitting, crossing the affected leg while sitting, or doing activities like climbing stairs, running, or jumping⁴
• About half of the people with this condition also feel pain spreading down the side of the thigh, sometimes reaching the knee or even below the knee⁴
• When doctors examine patients with trochanteric bursitis, they often find a very tender spot on the lateral side of the hip. Pressing on this area may cause a patient to wince or produce a pain-related vocalisation involuntarily. The pain is often at the spot where the gluteus medius or gluteus minimus tendon attaches to the greater trochanter
• Imaging modalities like X-ray, ultrasound, and magnetic resonance imaging (MRI) can be used to further confirm the diagnosis of trochanteric bursitis. With the help of imaging, we can rule out other causes of hip pain like osteoarthritis, avascular osteonecrosis, and septic arthritis. Ruling out these other conditions allows us to be sure to commence treatment for trochanteric bursitis³

Management strategies of abnormal gait-induced trochanteric bursitis

Before embarking on any method of managing trochanteric bursitis, the causative factor or underlying condition needs to be addressed first. Some of the managements include the following:³

• Pharmacologic therapy: pain reliefs like non-steroidal anti-inflammatory drugs (NSAID) are crucial for inhibiting the inflammatory response of trochanteric bursitis. Patients with a risk of developing gastrointestinal bleeding are not recommended such drugs. Other pain-relief medications may be substituted in such cases
• ·Physical therapy: strengthening and stretching the hip muscles like the gluteus medius and gluteus minimus is an important management of trochanteric bursitis⁵
• Corticosteroid injections: steroid injections can be used to manage trochanteric bursitis effectively. A localized dose of cortisone is administered, and these injections offer relief and directly target local inflammation
• Surgical management: this is the last call to action. Surgery for trochanteric bursitis is only considered for patients with symptoms lasting more than 6 to 12 months who have not improved with non-surgical treatments³

Summary

It is important to know that prevention is always better than cure. Diseases that affect the brain and spinal cord mostly lead to abnormal gait; hence, such diseases should be adequately managed so as to prevent the development of trochanteric bursitis. Leg length discrepancies should be taken seriously, and a doctor should be consulted so that treatment may be resumed. It is important to know that trochanteric bursitis often gets better once treated effectively. You are advised to consult a doctor when you feel persistent hip pain.