What Is Trochanteric Bursitis?

Introduction

Trochanteric bursitis can be referred to by different names, so before we delve into what this condition is, let’s cover all of its alternate names. Trochanteric bursitis is also known as greater trochanteric pain syndrome (GTPS) or lateral hip pain.¹ It is a common, but painful condition that affects the outer area of the hips and thighs and can occur when the surrounding tissue of the hip bone (the greater trochanter) becomes irritated or inflamed via various causes.¹ Demographically, trochanteric bursitis is predominantly seen in women aged 40-60 years old.² The comprehension of trochanteric bursitis is crucial for several reasons. Firstly, the cause of trochanteric bursitis (commonly inflammation), can have a significant impact on an individual’s quality of life. Chronic pain and discomfort associated with this condition can hinder activities of daily life and cause mobility compromise. Additionally, early recognition and understanding of the condition are essential for prompt diagnosis and interventions in order to mitigate the impact on quality of life and long-term disability. 

This article aims to describe what trochanteric bursitis is, its anatomical location and function, review its aetiology and treatment options for individuals with this condition.

Function of the hip joint 

The hip joint plays a pivotal role in daily activities. It is a ball and socket joint that articulates (joints) the head of the femur (the greater trochanter/ball) and the acetabulum of the pelvis (socket).³ Functionally, it provides dynamic support to the weight of the body whilst also facilitating load distribution from the axial skeleton to the lower regions of the body, thus allowing complex mobility.³

A bursa is a small fluid-filled sac that lubricates the gluteal tendons and mitigates frictional forces between bone and tendons, facilitating graceful and smooth physiological motions.⁴ Specifically, the trochanteric bursa is located on the lateral aspect of the hip,⁴ deep to the gluteus maximus muscle where it inserts into the iliotibial tract.⁵ It covers the posterior area of the greater trochanter and the insertion of the gluteus medius tendon on the lateral area, as well as the proximal origin of the vastus lateralis muscle.⁵

Causes, risk factors and epidemiology 

The epidemiology and aetiology of trochanteric bursitis is complex and encompasses a distinct population of individuals with discrete symptom presentations. 

Causes and risk factors^1,6,4 

• direct trauma or repeat microtraumas (eg an older individual directly falling onto the joint can cause an inflammatory cascade within the bursa)
• mechanical overload 
• overuse leading to tendinopathies involving the gluteus medius or minimus
• compression of the tendon (and bursa) for instance in sedentary or bed-bound individuals  
• reduced strength and flexibility of the muscles around the hips and buttocks
• female gender
• poor pelvic control or weak hip abductors
• external coxa saltans (an auditory or palpable snapping with hip movement)  
• Gluteus medius and minimus tears (degenerative or traumatic eg via repetitive hip abduction in stair climbing or cycling) 
• Obesity
• Hormonal influences 

It is important to note an associated condition which is caused by bacterial infiltration of the bursa. In direct trauma causing skin puncture, microtraumas, cellulitis of the skin adjacent to the bursa, or less commonly tuberculosis, the bursa can become infected and result in septic bursitis which is a serious condition that requires emergency medical attention.⁶

Epidemiology 

The epidemiology of trochanteric bursitis, as mentioned in the introduction, is predominant in women compared to men. Middle-aged females (40-60 years old) are more susceptible to this condition, however, younger athletic females are also prone to the development of trochanteric bursitis. The pathophysiology of the higher incidence in women is due to higher Q angles, thus causing tighter iliotibial tracts and strain over the bursa during repetitive motions.⁶

Signs and symptoms 

Signs and symptoms essentially differ in the person who is observing the traits of the condition. Symptoms are what the individual experiences and notices, whereas signs are what a healthcare professional is able to observe during a physical examination.

The symptomatic presentation of trochanteric bursitis can vary from person to person, however, there are general symptoms that most people with the condition will experience:⁶

• Unilateral Pain in the hip/thigh/buttock area.
• Worse pain when lying on your side or with direct pressure.
• Pain increases with exercise such as periods of walking, standing or running.
• Gradual onset of pain 
• Tenderness to touch.
• Pain sitting with your legs crossed.
• Pain when standing on the affected leg (sometimes called hanging on the hip)
• Pain when climbing stairs
• Pain when lifting legs in/out of a car or bed

A healthcare professional will likely perform a physical hip examination to discern the cause of the hip pain and presenting symptoms. A hip exam is the gold standard for the diagnosis of trochanteric bursitis. During this examination, your doctor will likely ask you to perform a few movements of the legs and hips and possibly ask you to walk around the room to assess your gait, they will be looking for other conditions that are important to exclude such as hip fractures.⁶

Investigations and diagnosis

As mentioned in the investigation of trochanteric bursitis signs, the gold standard for its diagnosis is a physical hip examination. If there is a high suspicion of trochanteric bursitis, a plain film radiograph can be conducted to exclude more sinister causes of the hip pain, such as fractures or other osseous/ bone abnormalities. Ultrasound and MRI imaging can also be utilised for diagnosis, but not necessary.⁴ Laboratory evaluations and investigations are not commonly performed with high clinical suspicion of trochanteric bursitis, however, if an individual has signs of infection, a blood test can help to ascertain for any infective causes.⁴

There are certain conditions that present similarly to trochanteric bursitis and when there is clinical suspicion of a condition, there are also others that need to be considered before confirming the diagnosis. In the case of trochanteric bursitis, the differential diagnoses are:⁶

• GTPS (including external coxa saltans, gluteal tendinopathy and gluteal tears)
• Lumbar spine referred pain 
• Osteoarthritis of the hip
• Femoroacetabular impingement
• Femoral head stress fracture
• Labral tears
• Bony metastasis
• Neck-of-femur fracture
• Rheumatoid arthritis
• Femoral head avascular necrosis

Treatment and management 

It is important to understand the symptoms that you may be experiencing, in order to help avoid certain activities that may be exacerbating symptoms. 

A key mechanism for easing muscle pain is to gradually strengthen the muscles surrounding the bursa, to ease pain and facilitate the continuation of daily life activities. 

Physical therapy directed towards quadriceps muscles and ischial tibial band strengthening are key mechanisms in addressing the underlying pathophysiology of trochanteric bursitis.⁴

Medical management involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). These aim to block the inflammatory pathway that causes pain symptoms in trochanteric bursitis. Corticosteroids can also be used subsequent to discussion with a healthcare professional. A local injection into the outer hip provides direct pain relief and targets local inflammation.⁴

Surgical management is usually the last recommended option for trochanteric bursitis and only considered once conservative, pharmacological and preventative measures have been attempted unsuccessfully. Surgical options involve the excision and debridement of the inflamed bursa.⁴

Prevention 

Rehabilitation and at home methods to reduce strain on the trochanteric bursa are critical in the prevention of this condition. Symptom improvement can include:¹

• Spread your weight evenly across both feet and not leaning on just one leg.
• Avoid low chairs.
• Avoid sitting with your legs crossed.
• Avoid sleeping on the painful side. Lying on your back with a pillow under your knees or lying on your good side with a pillow between your legs to keep them in line with your hip joints.
• Keep active and staying at work even if you have to modify your duties
• Lose weight if you are overweight

Summary 

Trochanteric bursitis is a significant condition in musculoskeletal health and its comprehension and attention is required for the mitigation of chronic symptoms that could prevail if left untreated. The intricate mechanisms of the hip joint and the vital role of the trochanteric bursa underpin the importance of trochanteric bursitis’ impact on daily life. As a growing societal and economic burden, the awareness and education of this condition becomes paramount. Through the collaboration of healthcare professionals and individuals, more effective treatment and management can be implemented to minimise the progression of symptoms and potentiate overall well-being.