Trochanteric Bursitis

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Original Editors - Emy Van Rode

Top Contributors - Mudra Shah, Emy Van Rode, Gertjan Van Gijsegem, Lionel Geernaert, Lena Vanderaa, Wendy Snyders, Admin, Kim Jackson, Andrea Nees, Rachael Lowe, Uchechukwu Chukwuemeka, Vidya Acharya, Wanda van Niekerk, WikiSysop and Claire Knott  

Search Strategy

Databases

• Pubmed
• Web of Knowledge
• Google scholar
• Medscape
• VUBis

Search words

• Hip bursitis
• Trochanteric Bursitis
• Greater trochanteric pain syndrome

Definition/Description

 For the definition of bursitis: Bursitis.
In the hip region there are 4 different types of hip bursitis: Trochanteric bursitis, iliopsoas bursitis, gluteal bursitis and ischial bursitis. Trochanteric bursitis is the more common. It is pain over the lateral part of the hip, paraesthesiae in the legs, and tenderness over the iliotibial tract. The term greater trochanteric pain syndrome is now often substituted for trochanteric bursitis.[2] The condition is more prevalent among women than among men. [3] (level of evidence A1) but also among patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity.
In this article, the condition trochanteric bursitis will be treated

Clinically Relevant Anatomy

The trochanteric bursae can be named as a cause of lateral hip pain, they lie above the lateral aspects of the greater femoral trochanter. There are four bursae that surround the greater trochanter. Three of them are present among most individuals. Bursae provides cushioning between bony prominences and the surrounding soft tissues. In this case they provide cushioning for the gluteus tendons, iliotibial band and tensor fascia latae.

Anatomically, there are two major bursitis and one minor that surround the greater trochanter.
The minor bursitis is called the gluteus minimus bursae, it is located cranial and ventral to the greater trochanter.The less important bursitis is the gluteus medius, this in contrast with the gluteus maximus. This last one is lateral to the greater trochanter and is situated between the gluteus medius tendon and the gluteus maximus muscle. It lies deep to the converging fibres of the tensor fascia latae. The iliotibial tract is formed by the gluteus maximus muscle and fascia. These powerful converging fibres are thus separated from the greater trochanter and from the attachment of the vastus lateralis muscle, situated by the bursa. In the illness greater trochanteric pain syndrome we mostly talk about the subgluteus maximus that is incriminated.

[4] (Level of Evidence 1A)
[12] (Level of Evidence 3B)
[13] (Level of Evidence 5)
[14] (Level of Evidence 2C)
[15] (Level of Evidence 3A)

Epidemiology /Etiology

The prevalence of unilateral GTPS is 15.0% among women and 8.5% among men, and that of bilateral GTPS is 6.6% among women and 1.9% among men(16). In a study by Lievense et al. 1.8 in 1000 patients in primary care had the annual incidence of trochanteric pain (18) .The study also found out that trochanteric bursitis is more prevalent among females (80%) than among males. (level of evidence 1A)

The etiology thought that trochanteric bursitis is caused by inflammation of the subgluteus maximus bursa.
Trochanteric bursitis can develop as a complication of arthroscopic surgery of the hip (in an estimated 1.4% of all cases) (17) or sometimes it can develop spontaneously without apparent negative factors (precipitating factors).

There are many factors that may cause greater trochanter pain syndrome:
- trauma:When the patient lands on the lateral hip region or bumps the hip into an object. Such trauma is caused by:
*ITBS: iliotibial band syndrome. It is the most common cause of lateral knee pain(30).The frictions between the lateral epicondyle and the iliotibial tract is through the repetitive motion. It is an overuse injury in combination with the weakness of hip abductor muscles(31).
* Dysfunction of the insertion of gluteus medius
* or both, during frequent training on hard or banked running surface

- Hip osteoarthritis
- Leg length differences (4)
-Stress on the soft tissues: it is a result of an abnormal or poorly positioned joint or bone, such as differences in the length of the legs or arthritis in a joint.
-Previous surgery: when it is localized around the hip or prosthetic implants in the hip.
- Incorrect posture: this condition is the result ofscoliosis, arthritis of the lumbar (lower) spine and other spine problems.
- Lumbar spondylosis
- Sacroiliac disorder
- Lower leg gait
- Excessive or rapidly increased mileage
- Poorly cushioned shoes
- Excessive pronation
- Increased BMI(4)

Characteristics/Clinical Presentation

Following characteristics may occur:
- Chronic pain and/or hip tenderness in the lateral aspect of the hip that may radiate down the thigh.22
 More specifically while palpaiting superior and posterior of the greater trochanter.
 Maximum tenderness at the insertion of the M. Gluteus maximus
 Can also be felt over the iliotibial tract [4]
- Pain limits the strength and makes the legs feel weak
- Pain in the area of the greater trochanter whilst walking or running. It can be felt over the lateral aspect of the leg until the knee
- Stair-climbing is most painful [11]
- Patient is not able to lie down on the affected side
 Development of pain-related sleep disturbance [2]
- Lower back pain can be related to Trochanteric Bursitis [6]
- Weakness of the hip-abductors
 Resistance test can cause tenderness - Pain and tenderness can arise while resisting external rotation
- A snap felt in the lateral aspect of the hip [1] (level of evidence A1)
[22] (Level of Evidence 5)

Differential Diagnosis

Trochanteric bursitis is one of the pathologies that can cause lateral hip pain. The other pathologies that are associated with this pain could be:
• Gluteal tendonitis (gluteus medius or minimus muscles)
• Gluteal muscle dysfunction (atrophy, tear,…)
• Iliotibial band disorders ( Snapping Hip syndrome)
• Femoral Fractures (Femoral neck stress fractur)
• Lumbar spine disease (including zygapophysical joints, sacroiliac joint, and intervertebral discs and ligaments)
• Ipsilateral and/or contralateral hip arthritis.
• Pain radiation patterns may complicate the diagnosis of GTPS because of anatomical overlap with the iliotibial tract and mid-lumbar dermatomes
• damage to the nerve supply of surrounding structures may elicit neuropathic symptoms that can stimulate GTPS
• chronic mechanical low back pain
• Rheumatoid arthritis
• leg length descrepancy
• Post surgical lumbar disk desease
• Radiculopthy or other neurologic sequelae
• Obesity
• Fibromyalgia
[6],[7](level of evidence 1A)
[4] (Level of Evidence 1A)

Diagnostic Procedures

• Gluteus medius tendonitis [3]
• Iliotibial band disorders (_Snapping_Hip):
Confirmed with positive Ober's_Test. [6]
• Gluteal medius muscle disfunction :
Confirmed with positive Trendelenburg_Test. Tenderness involving the whole muscle instead of point tenderness. A tear of the muscle can be revealed with an MRI.[7]

 Iliotibial band disorders, Gluteal muscle atrophy and hip tendonitis are hard to differentiate with a trochanteric bursitis because they could be in relation with, or even be the cause of this disorder. For instance, while testing for Iliotibial band disorders or gluteal muscle atrophy, symptoms will also occur when suffering from a bursitis. MRI must give more specific information. [6]

• Femoral neck stressfracture:
The hop test on one leg will cause pain in the ipsilateral groin region in case of a femoral neck stressfracture. [1]
• Lumbar spine disease and ipsilateral hip pain :
Differentiated with the FABER_Test  [1]
(level of evidence A1)

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Physical Examination

The first part of the physical examination is to observe the person’s gait for abnormalities like asymmetry of the waist and hips, a favored side while walking. Further, an examination of the hip is important to establish any limitations or deficits that the patient may have. It is possible that there is an underlying disorder or anatomical impairment present that may cause a bursitis or tendonitis. A weakness of the Mm. Gluteï, a unilateral tilt of the pelvis because of a leg length difference and lumbar spine disorders like scoliosis could be responsible for a bursitis or tendonitis. [1] (level of evidence A1)

An examination of the lumbar spine and knee is also required when the patient complains about pain in this area’s. This pain can refer to the patient’s hip pain. In general, it is important to observe, to palpate, to check the range of motion and to test the strength of the muscles and other anatomic structures that are involved in this issue. The range of motion can be checked with several tests: The faber test, trendelenbrug test, Ober’s test, Thomas test [1] and the snapping hip maneuver could be helpful in diagnosing the cause of lateral hip pain.[6]

Medical Management

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Physical Therapy Management

Physical therapy is given to improve flexibility, muscle strengthening and joint mechanics. When these aspects are improved, pain will decrease. [4] The therapy consists of stretching the M. Tensor fasciae latae and the Iliotibial band because these aspects are often shortened and causes an increased friction with the bursa. [1] Iliotibal band syndrome can be confirmed with a positive Ober’s test.[6] When physical examination shows weakness of the hip abductors, the physical therapist must give exercises for strengthening the hip abductors. Weakness of these group of muscles can be noticed while testing the patient on trendelenbrug gait. Other physical therapy interventions are the use of ultrasound, moist heat, patient education regarding activity modification and correcting possible training errors. [3]

To heal trochanteric bursitis it is necessary to proceed to infiltration of the bursa with antiphlogistic medication (Corticosteroid-injections). In case of a persistent bursitis surgery has to be considered as well. [8]

(levels of evidence A1, C)

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

• Pubmed
• Medscape
• Web of Knowledge
• Google scolar
• Book: Meeusen R. Heup- en liesletsels, reeks sportrevalidatie. 90-5583-724-5, 2000.

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

see adding references tutorial.

1. J. Rosenberg, R. Patel. Hip tendonitis and bursitis review. http://emedicine.medscape.com/article/87169-overview. Level of evidence: 1 (A1)

2. Patrick M Foye, MD, Todd P Stitik, MD. Trochanteric bursitis review. http://emedicine.medscape.com/article/87788-overview Level of evidence: 1 (A1)

3. Kyndall L. Boyle, MS, Shane Jansa, MS, Chad Lauseng, MS, Cynthia Lewis. Management of a Woman Diagnosed with Trochanteric Bursitis with the Use of a Protonics® Neuromuscular System. Journal of the Section on Women’s Health, volume 27, No.1, March 2003

4. Bryan S. Williams, Steven P. Cohen: Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. ANESTHESIA & ANALGESIA, Vol. 108, No. 5, May 2009
Level of evidence: 1 (A1)

5. Dina L. Jones, Diagnosis of Trochanteric Bursitis Versus Femoral Neck Stress Fracture, case report. Physical Therapy. Volume 77. No 1. January 1997

6. Katherine Margo, MD, Jonathan Drezner, MD, and Daphne Motzkin, MD. Evaluation and management of hip pain: An algorithmic approach. The journal of family practice, vol 52, No 8, august 2003.

7. M. Lequesne, P. Mathieu, V. vuillemin-Bodaghi, H. Bard, P. Dijan. Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome: Diagnostic Value of Two Clinical Tests. Arthritis & Rheumatism, Vol. 59, No. 2, February 15, 2008, pp 241–246
Level of Evidence: 1 (A1)

8. Cohen S.P., Narvaez J.C., Lebovits A.H., Stojanovic M.P. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. British Journal of Anaesthesia volume 94 , No 1: 100–6, 2005
Level of Evidence: 3 (C)

9. Woodley S.J., Nicholson H.D., Livingstone V., Doyle T.C., Meikle G.R., Macintosh J.E., Mercer S.R. Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination. Journal of orthopaedic & sports physical therapy, Vol 38, No. 6, June 2008, pp 313 - 328

10. Paluska S.A., An overview of Hip Injuries in Running. Sports Med 2005; 35, pp 991 – 1014

11. Ombregt L., Bisschop P., ter Veer H.J., Van de Velde T., A System of Orthopaedic Medicine. 1999.