Trochanteric Bursitis

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Original Editors - Emy Van Rode

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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. An MRI can reveal a tear in the muscle. Iliotibial band disorders, Gluteal muscle atrophy and hip tendonitis are hard to differentiate from 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. An MRI must give more specific information. [6]
• Femoral neck stress fracture:
The hop test on one leg will cause pain in the ipsilateral groin region in case of a femoral neck stress fracture. [1]
• Lumbar spine disease and ipsilateral hip pain :
Differentiated with theFABER_Test [1]
(level of evidence A1)

Outcome Measures

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Physical Examination

Physical examination is performed based upon the history of previous injuries and it is used to confirm the source of the pain23 and establish any limitations or deficits that the patient might have. It also assesses the underlying disorder or anatomical impairment that may cause a bursitis.
The physical examination must have a stepwise approach which includes inspection, gait, palpation, Range of motion, muscle strength and the execution of special tests.23
The first part is the inspection. The most important aspect of inspection is the patient’s posture in a seated and upright position. 24 The patient with an irritated hip will tend to stand with the joint slightly flexed. In a seated position: slouching and leaning to the uninvolved slide allows the hip to seek a slightly less flexed position. The observation is also focused on the asymmetry, the gross atrophy, the spinal alignment or the pelvic skewness.
While observing the gait, one should look at leg length discrepancy, weakness and heel strike which contributes to the function of the gluteus maximus. 25
Bursae pain may be detected by palpation. We perform palpation to assess sources of the hip pain. The palpation starts with joint tenderness on the proximal and distal area of the hip. Also each part of the body that is associated with this injury must be assessed, e.g.: the bone, muscle, ligaments, etc. It is important to check the lumbar spine, sacroiliac joints, ischium, iliac crest, lateral aspect of the greater trochanteric bursa, muscle bellis and the pubic symphysis. They can determine a potential source of hip symptoms or pain. 23
The muscle strength can be assessed by resisted contraction which provokes symptoms.
The range of motion should be checked on the actual injured hip as well as on the contralateral hip. An active hip flexion, an internal and external rotation, an abduction and adduction will reproduce pain in the injured 4 area. The range of motion can be identified with several tests: the faber test, Trendelenburg test, Ober’s test, Thomas test and a test whereby the forced flexion combined with internal rotation could be helpful in diagnosing the cause of lateral hip pain.
23 level of evidence: 1A
24 level of evidence: 1A
25 level of evidence: 4

Medical Management

There are several ways to treat trochanteric bursitis, depending on whether or not the bursitis has an infection, and whether it is necessary to treat the lesion with or without surgery.
Nonsurgical treatment21

Aseptic trochanteric bursitis19,20
In most cases trochanteric bursitis is treated without surgery. If the pain results from overuse, it is recommended to reduce the activities and change the way of doing them.
Furthermore, an exercise program of stretching and strengthening with a physiotherapist will help to bring back full range of motion in the hip, sometimes in combination with anti-inflammatory medications or heat and ice applications to calm inflammation.
Improving strength and coordination in the buttock and hip muscles also enable the femur to move in the socket smoothly and can help reduce friction on the bursa.
If the above treatment fails to reduce the symptoms, an injection of cortisone into the swollen bursa may be required. This anti-inflammatory injection will reduce the symptoms for months, but it will not cure the problem itself.
Septic trochanteric bursitis19,20
Infectious trochanteric bursitis does occur, but only in exceptional cases.
Further examination of the bursa fluid in the laboratory is necessary to assess which bacteria has caused the infection. Once this is known, an (intravenous) antibiotic therapy can be prescribed.
Surgical treatment21
Only when the nonsurgical therapy fails, and when the pain is still unbearable, it is recommended to consider surgery. The aim of surgery is to remove the thickened bursa and bone spurs that have arisen on the greater trochanter. Also the large tendon of the gluteus maximus is treated. Some doctors prefer to remove a part of the tendon that rubs against the greater trochanter while others prefer to lengthen the tendon somewhat.

[19],[20] (Level of Evidence 5)
[21] (Level of Evidence 3A)

Physical Therapy Management ^{30, 31}

There are several treatments that can be used to reduce pain and swelling on a patient with trochanteric bursitis. When pain is the main complaint, we can relieve the pain for other underlying disorders so as to treat them more effectively.
Physical therapy is given to improve flexibility, muscle strengthening and joint mechanics. When these aspects are improved, pain will decrease. 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. Other physical therapy interventions are the use of ultrasound, moist heat and educating the patient on activity modification and correcting possible training errors.
The pain of this injury can be reduced in different phases: The first phase is to manage the pain and the inflammation. Pain being the main reason for treatment of the trochanteric bursitis, we can use two common treatments to decrease the pain: the use of ice and non-steroidal anti-inflammatory drugs (NSAIDs). The bursa inflammation can be treated with ice therapy and techniques or exercises that reduce the inflammation structures. There are also other treatments that a physiotherapist can use, e.g.: electrotherapy, acupuncture, taping techniques, soft tissue massage and the temporary use of a mobility aid to off-load the affected side.
The second phase is to reinforce the patient’s strength and to restore the normal ROM. The physiotherapist will also to improve the muscle length and resting tension, the proprioception, balance and gait.
The next phase of rehabilitation is the restoration of all functions. Many patients catch TB due to their common daily activities like running, walking, … . The goal of the physiotherapist is to provide a specialized program for the patient to improve the movement and to reduce the pain, so that the patient can perform his daily activities.
The final phase is to prevent a relapse. It may be as simple as training your abdomines or performing some foot orthotics to address any biomechanical faults in the legs or feet. The therapist will examine your hip stability and function by addressing any deficits in the core strength and balance. Furthermore, he will also teach the patient some self-management techniques. The ultimate goal is to see the patient safely returning to his former sporting or leisure activities!
30 level of evidence: 5A
31 level of evidence: 1A

Key Research

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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1. J. Rosenberg, R. Patel. Hip tendonitis and bursitis review. http://emedicine.medscape.com/article/87169-overview. Level of evidence: (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. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment.Anesth Analg. May 2009, 108(5), 1662-70. Level of evidence: 1 A
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.
Retrieved from "http://www.physio-pedia.com/Trochanteric_Bursitis"
Category: Vrije Universiteit Brussel Project

12. Seong-Tae K. , Myung-Sang M. , Min-Geun Y. , Woo-Sung P. Jee-Hyun H. , Tuberculosis of the trochanteric bursa: a case report , 2009.
Level of Evidence 3 B
13. Christian W. A. Pfirrmann, MD Christine B. Chung, MD Nicolas H. , Theumann, MD Debra J. Trudell, RA Donald Resnick, MD, Greater Trochanter of the Hip: Attachment of the Abductor Mechanism and a Complex of Three Brusae - MR Imaging and MR Bursogrphy in Cadavers and MR Imaging in Asymptomatic Volunteers, 2001. Level of Evidence 5

14. Ramand D., Haslock I., Trochanteric bursitis - a frequent cause of 'hip' pain in rheumatoid arthritis, 1982. Level of Evidence 2 C

15. David P Lustenberger et al. , Efficacy of Treatment of Trochanteric Bursitis: A systematic Review, 2011. Level of Evidence 3 A

16. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92.

17. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. Jan 2003;84-8.

18. Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. Mar 2005;55(512):199-204.

19. Firestein, G.S., et al. Kelley's Textbook of Rheumatology, 9th ed. Philadelphia, Pa: Saunders Elsevier, 2012. Level of Evidence 5

20. Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. New York: Springer and Arthritis Foundation, 2008. Level of Evidence 5

21. Farmer KW, Jones LC, Brownson KE, et al. Trochanteric bursitis after total hip arthroplasty incidence and evaluation of response to treatment. J Arthroplasty. Mar 3 2009;[Medline]. Level of Evidence 3 A
22. Trochanteric bursitis. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:299-303.
Level of Evidence 5
23. Robert C. Grumet, MD, Rachel M. Frank, BS, Mark A. Slabaugh, MD, Walter W. Virkus, MD,Charles A. Bush-Joseph, MD, and Shane J. Nho, MD, MS*, lateral Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options. Level of Evidence 1A
24. Evaluation of the hip: history and physical examination; J.W. Thomas Byrd, MDa Level of evidence 1A
25. Stephanie J.Woodley, BPhty, MSc, PhD¹; Helen D. Nicholson BSc (Hons), MBChB, MD²; Vicki Livingstone, BSc, MSc, PhD³ ; Terence C. Doyle MBChB, MD4; Grant R. Meikle MBChB, FRANZCR5; Janet E. Macintosh BSc (Hons), BMed, PhD6; Susan R. Mercer BPhty (Hons), MSc, PhD7; Lateral Hip Pain: Findings FromMagnetic Resonance Imaging and Clinical Examination. Level of Evidence 4
26. Neil A. Segal, MD, David T. Felson, MD, James C. Torner, PhD, Yanyan Zhu, MSc, Jeffrey R. Curtis, MD, MPH, Jingbo Niu, DSc, and Michael C. Nevitt, PhD for the Multicenter Osteoarthritis (MOST) Study Group From the Department of Orthopaedics & Rehabilitation, University of Iowa and VA Medical Center, Iowa City, IA (Segal); Clinical Epidemiology, Boston University, Boston, MA (Felson, Zhu, Niu); Department of Epidemiology, University of Iowa, Iowa City, IA (Torner); Dept of Rheumatology, University of Alabama, Birmingham, AL (Curtis); and Dept of Clinical Epidemiology, University of California, San Francisco, CA (Nevitt). Greater Trochanteric Pain Syndrome: Epidemiology and Associated Factors. Level of evidence 1A
27. Firestein, G.S., et al. Kelley's Textbook of Rheumatology, 9th ed. Philadelphia, Pa: Saunders Elsevier, 2012.
Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. New York: Springer and Arthritis Foundation, 2008.
Ruddy, Shaun, et al., eds. Kelley's Textbook of Rheumatology, 6th ed. Philadelphia: Saunders, 2001. ; MedicineNet.com ; Hip bursitis

28. Michael T. Cibulka, DPT; Douglas M. White, DPT; Judith Woehrle, PT, PhD, Marcie Harris-Hayes, DPT; Keelan Enseki, PT, MS, Timothy L. Fagerson, DPT, MS; James Slover, MD, MS; Joseph J. Godges, DPT; Hip Pain and Mobility Deficits – Hip Osteoarthritis:Clinical Practice Guidelines Linked to the International Classification of Functioning,Disability, and Health from the Orthopaedic Section of the American Physical TherapyAssociation Level of evidence: 5A
29. David P Lustenberger, BS*, Vincent Y Ng, MD*, Thomas M Best, MD, PhD†, and Thomas JEllis, MD**Department of Orthopaedic Surgery, The Ohio State University Sports Medicine Center, TheOhio State University, Columbus, Ohio†Department of Family Medicine, The Ohio State University Sports Medicine Center, The OhioState University, Columbus, Ohio; Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review Level of Evidence: 1A
30. E. C. Falvey, R. A. Clark, A. Franklyn-Miller, A. L. Bryant, C. Briggs.Iliotibial band syndrome: an examination of the evidence behind a
number of treatment options.Scandinavian journal of medicine & science in sport,2009:8

31. Lavine R. Iliotibial band friction syndrome. Current Reviews in Musculoskeletal Medicine,2010;volume 3:18–22