Introduction
Trochanteric bursitis is a type of hip bursitis which is caused by inflammation of the membrane containing the fluid-filled sac, which is found in the greater trochanter region (upper thigh).1 The term has been recently replaced by Greater Trochanteric pain syndrome (GTPS). The disease has been misdiagnosed with lumbar radiculopathy (injury to the spinal nerve in the lower back) as the symptoms for both conditions are similar and the pain can spread from the lateral hip to the knee (and even below the knee). Hence, GTPS is also known as the 'Great Mimicker'.2
What is trochanteric bursa?
The trochanteric bursa is the sac filled with fluid (contained in the membrane surrounding the bone) which aids in reducing friction between the movement of the greater trochanter (upper thigh bone/femur) and the surrounding tissues. It is located on the lateral side of the hip, deep within the iliotibial band. The membrane surrounding the bone (synovial membrane) becomes irritated or inflamed, leading to excess production of the synovial fluid and consequently the swelling of the bursa. Since the hip bone is located deep within multiple layers of fat, skin, and other tissues, the swelling may not be as evident as other types of bone swellings.1
Causes/Risk factors
This condition is seen more among females, the middle-aged and the elderly populations. The consulting orthopaedic surgeon identifies the causes and diagnoses properly to administer the correct treatment for the condition. Several risk factors have been identified for trochanteric bursitis, such as:1.3
- Hip fracture/injury: Those who had falls/accidents with injury to the hip or even lie on one side for a long period (for eg. bedridden patients)
- Repetitive stress on the hip: This happens due to activities such as cycling, running, climbing the stairs, or even standing for long can induce the inflammation of the bursa
- Tendonitis: Inflammation of the tendon of the gluteus medius (one of three gluteal/buttocks muscles, located on the outer surface of the hip)
- Spine problems: Painn in the lower spine, and scoliosis (sideways curvature of the spine) can also trigger trochanteric bursitis
- Rheumatoid arthritis: Auto-immunee disorder where the synovium of the hip bone becomes inflamed (swelling) and releases chemical substances which eventually lead to the destruction of the joint/bone
- Irregular gait: Due to the leg length differences in some individuals, there can be additional pressure on the hip whilst walking or performing other activities
- Bone deformities: Any type of hip bone abnormalities including bone spurs (projections) or calcium deposits can irritate the bursa
Symptoms
During the initial stages of hip bursitis, the patient will complain of sharp, intense pain; which will gradually subside to dull ache:1,3,4
- Tenderness of the hip: Gentle pressure on the hip causes pain for the patient. This can also be the situation when the person is lying on the affected side
- Pain that begins from the lower hip region and diffuses to the lower back, groin, thigh or even to the knee (in some cases)
- Pain during daily activities like walking, running, cycling or climbing stairs
- Prolonged inactivity (the person is constantly lying or sitting) can cause pain unilaterally (if they are accustomed to lying on the same side) or specifically in the lower back/groin (if they are sitting for long periods)
- Altered gait due to pain which is reflected while the person is walking at a brisk pace
- Some patients experience pain only on clinical examination (rotation of the hip or while the doctor moves the patient's leg)
Diagnosis
Trochanteric bursitis is commonly misdiagnosed for other types of lower back pain. You must consult with an orthopaedist who will take record your history of pain, perform a detailed physical examination and suggest tests that can confirm a proper diagnosis.
Physical exam
A physical exam is a classic method used to diagnose GTPS. The physician checks for skin changes, and tenderness and examines the hip joint. The commonly used methods involve asking the patient to move the leg away from their body (abduction) and towards the body's midline (adduction). An example of another test is known as 'External snapping hip' where the patient will lie on their side (the painful side will be up), and the physician will flex and extend the leg (whilst checking for the iliotibial tendon near the greater trochanter bone), and check for a snap (associated with the pain).
X-ray
This imaging technique will show if there are any changes in the hard tissues such as fractures, osteoarthritis, etc.
Ultrasound
This is not a usual diagnostic test, however, it will be done to check for excess fluid in the swollen trochanteric bursa.
MRI
A test that gives a detailed view of the affected soft tissue in the hip for bursa swelling or damage of the tendon.1
Treatments
Ice application
Applying ice/cold packs to the sore hip after vigorous exercise can reduce the chances of swelling.
Anti-inflammatory medications
You can take any painkillers such as Ibuprofen, naproxen, or celecoxib to soothe the pain. It is best advised to consult with your doctor before taking it, especially if you are taking medications for pre-existing diseases/conditions (to prevent any side effects).
Rest
Avoid any strenuous exercises or activities which may worsen the pain in the affected areas.
Physiotherapy
Your doctor will refer you to a physiotherapist who will recommend suitable exercises to stretch the iliotibial band in the hip and increase the flexibility and strength of the hip. A sports medicine physician will perform the same for athletes who experienced hip pain during training, based on the patient's symptoms and nature of injury/pain.
Cortisone shots
In case of severe pain where painkillers/rest/physiotherapy does not provide any relief, the physician will administer a single cortisone injection along with local anaesthesia into the swollen bursa. This procedure can reduce pain temporarily (months) or even permanently in some patients.5
Low energy shock wave therapy
Some patients with severe pain from trochanteric bursitis are unable to walk properly or perform rehabilitation exercises. Shock wave therapy is advised by a physiotherapist only after a proper assessment of the hip and surrounding areas and confirming GTPS. A minimum of 3 sessions with at least one-week intervals are recommended for mid to long-term pain alleviation (4-15 months).
Surgery
Surgery should be the last treatment method for hip bursitis. The procedure involves surgical removal of the swollen bursae; it is to be noted that the removal of the bursa does not affect the patient's ability to move the hip (the hip can function as expected).1
Prevention
It is not always possible to prevent hip bursitis, however, there are a few measures that can be taken to reduce the inflammation or pain:1,3
- Avoid long hours of strenuous exercise regimens. In the case of athletes, it is strictly advised to take short breaks so that the risk of permanent damage is significantly reduced
- For physically disabled people, it is advised to change their sleeping/lying down/sitting position often, so that there is reduced stress on one side of the hip or lower back
- It is recommended to wear properly fitting shoes in cases of leg-length inequalities
- Maintain the strength and flexibility of the hip by undertaking simple exercise routines
How should I sleep with trochanteric bursitis?
If you have trouble sleeping with hip pain, it is strictly advised to change your regular sleeping positions. Do not sleep on very hard or soft mattresses, as it can trigger the pressure points on the hip and worsen the pain.6
What aggravates trochanteric bursitis?
Extreme exercises or activities which put additional stress on the hip must be performed only with sufficient breaks. These are generally not advised for those with trochanteric bursitis:
- Running
- Biking
- Exercise routines like squats, leg lifts, and gym cardio workouts (eg., treadmill, exercise bike).7
Summary
Greater trochanteric pain syndrome is a type of hip bursitis, which is characterized by hip pain that can radiate to the lower back, groin, thigh, or knee. It is seen among individuals with high levels of physical activity (eg. athletes, sportspersons) and also those with reduced physical activity. It is important to take breaks especially if there are situations with long periods of stress on the hip. The most common clinical diagnostic test is the physical examination to assess the strength and flexibility of the hip. Minor pain can be relieved through home treatment such as ice/cold packs, painkillers and rest. It is advised to consult with a physician if pain persists and interferes with the individual's daily activities.
References
- Funiciello M. Hip (Trochanteric) Bursitis. Arthritis-health [Internet]. [cited 2022 Sep 23]. Available from: https://www.arthritis-health.com/types/bursitis/hip-trochanteric-bursitis.
- Tan LA, Benkli B, Tuchman A, Li XJ, Desai NN, Bottiglieri TS, et al. High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for evaluation of degenerative lumbar pathologies. Journal of Clinical Neuroscience [Internet]. 2018 [cited 2022 Sep 23]; 53:89–91. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0967586818301012.
- Hip Bursitis - OrthoInfo - AAOS [Internet]. [cited 2022 Sep 23]. Available from: https://www.orthoinfo.org/en/diseases--conditions/hip-bursitis/.
- NHS Ayrshire & Arran - Greater Trochanteric Pain Syndrome (GTPS) [Internet]. [cited 2022 Sep 23]. Available from: https://www.nhsaaa.net/allied-health-professionals-ahps/musculoskeletal-service/greater-trochanteric-pain-syndrome-gtps/.
- Konstantakos E. Cortisone Injections (Steroid Injections). Arthritis-health [Internet]. [cited 2022 Sep 23]. Available from: https://www.arthritis-health.com/treatment/injections/cortisone-injections-steroid-injections.
- CSO [Internet]. 2021. Causes of Hip Pain at Night and Ways to Find Relief; [cited 2022 Sep 23]. Available from: https://centerforspineandortho.com/news/causes-of-hip-pain-at-night-and-ways-to-find-relief/.
- Seven Exercises to Avoid with Hip Bursitis | The Orthopedic Institute of NJ [Internet]. [cited 2022 Sep 23]. Available from: https://orthopedicnj.com/news/seven-exercises-to-avoid-with-hip-bursitis
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