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Trochanteric Bursitis

Trochanteric bursitis is a condition involving pain at the side of the hip, primarily caused by a tendinopathy of the gluteus medius or gluteus minimus. The condition may or may not leave the hip bursae unaffected.


Presentation

Trochanteric bursitis causes rather typical symptoms. The main symptom is pain, that is profoundly felt at the hip joint and spreads to the lateral side of the hip, although it does not affect the whole length of the leg. The pain worsens when one engages in physical activity of any type, including walking, running etc., or when one simply lies down on that side while sleeping.

Other typical findings include a considerable point tenderness at sites proximal to the trochanteric region [14]. Edema of the bursal region may also be present, but it is usually difficult to palpate. Movements carried out by the physician, such as an external hip rotation or flexion, induce further pain in patients suffering from trochanteric bursitis [15]. The types of movements that cause pain can be used diagnostically to differentiate between trochanteric bursitis and other pathologies leading to a similar clinical picture [16].

Disability
  • The remaining 60 patients (83.4%) had pathologic conditions of the adjacent areas, such as symptomatic lumbar spine arthrosis or ipsilateral hip damage, conditions that often mask the actual source of pain and disability.[ncbi.nlm.nih.gov]
  • Abstract A 66-yr-old white woman presented with progressive complaints of right lateral hip and thigh pain associated with a disabling limp without an antecedent history of trauma.[ncbi.nlm.nih.gov]
  • Nonarthritic Hip Joint Pain: Clinical Practice Guidelines Linked to the International Classifiation of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association .[physio-pedia.com]
Asymptomatic
  • The patient was asymptomatic with no signs of recurrence 5 years postoperatively.[ncbi.nlm.nih.gov]
  • This final patient underwent a second, more extensive partial excision of the iliotibial band, and was asymptomatic 1 year later.[ncbi.nlm.nih.gov]
  • Greater trochanter of the hip: attachment of the abductor mechanism and a complex of three bursae – MR imaging and MR bursography in cadavers and MR imaging in asymptomatic volunteers.[radsource.us]
Plethora
  • Another reason for this classification change is that, apart from trochanteric bursae, there is a plethora of other regional bursae that may undergo an inflammatory process as well.[symptoma.com]
  • To the authors’ knowledge, this is the first systematic review of the treatment of TB despite a plethora of case series in the literature.[ncbi.nlm.nih.gov]
Hip Pain
  • Specific examination for in presence should be a routine in all patients with RA, especially those with hip pain.[ncbi.nlm.nih.gov]
  • Trochanteric bursitis should always be considered in hip pain syndromes, as it is so easily relieved.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Trochanteric bursitis is a common cause of hip pain. A trial of conservative measures is warranted for this condition, even when calcinosis is present, before more invasive therapies are considered.[ncbi.nlm.nih.gov]
  • When this part gets inflamed, a person may feel a lateral hip pain but not actually affected by the hip joint.[allhealthsite.com]
  • All patients complained of recurrent lateral hip pain despite at least 2 localized injections with corticosteroids. Minimum follow-up was 1 year, and the cases of 22 patients were reviewed after 5 years.[ncbi.nlm.nih.gov]
Thigh Pain
  • CLINICAL FEATURES: A 53-yr-old obese female presented with acute severe lateral hip and posterolateral thigh pain.[ncbi.nlm.nih.gov]
  • Abstract A 66-yr-old white woman presented with progressive complaints of right lateral hip and thigh pain associated with a disabling limp without an antecedent history of trauma.[ncbi.nlm.nih.gov]
  • If you have persistent hip or thigh pain, which has not responded to “standard” therapies, PRP may be for you. Ask your doctor if PRP is right for you. Contact Sarasota Neurology for consultation to determine if platelet rich plasma will help.[prpstopspain.com]
  • The tenderness may extend into the lower buttock and lateral thigh. Pain can also be reproduced by resisted abduction and external rotation.[gponline.com]
  • Symptoms Common symptoms include: Pain at the side of the hip, which may also be felt on the outside of the thigh Pain that is sharp or intense at first, but may become more of an ache Difficulty walking Joint stiffness Swelling and warmth of the hip[mountsinai.org]
Low Back Pain
  • Six patients with low back pain had both hip and knee arthritis (including two patients with rheumatoid arthritis). Three patients had degenerative hip disease without low back complaints.[ncbi.nlm.nih.gov]
  • Recently this syndrome was found in hospital-referred, chronic low back pain (LBP) patients.[ncbi.nlm.nih.gov]
  • Predisposing factors include: abnormal hip biomechanics due to abnormal force vectors acting across the hip, age, gender, ipsilateral iliotibial band (ITB) pain, knee osteoarthritis, obesity, low back pain and specific sporting activities (3) Reference[gpnotebook.co.uk]
  • Other conditions associated with trochanteric bursitis include: chronic mechanical low back pain, degenerative arthritis or disc disease of the lower lumbar spine, degenerative joint disease of the knees, fibromyalgia, iliotibial band syndrome, inflammatory[cyberpt.com]
  • Low Back Pain and dysfunction can have a big impact and even cause lateral hip pain so make sure you address this also. For more reading on lateral hip pain – This is a good resource . Check out this quick hip stability and balance test![physioprescription.com]
Leg Pain
  • As the pain worsens, it can radiate done the side of the thigh or into the buttocks region, causing leg pain (sciatica). Your doctor will perform a detailed history and physical exam.[prpstopspain.com]
  • Symptoms: Pain on the outside of your hip that can refer down the outside of your leg to your knee Pain when you cross your legs Pain with walking, stairs or getting up from a chair Pain when you lie on your side Treatment Activity modification – avoiding[hoysphysio.com.au]
  • Knee ACL (Anterior Cruciate Ligament) Patellofemoral pain syndrome Meniscus Tear Osteoarthritis of the knee Hip Trochanteric Bursitis Hip Osteoarthritis Hip Strain Avascular Necrosis Low Back / Sciatica Nerve Sciatica (Disc herniation with resulting leg[nashrehab.com]
  • Running or jumping causes intense leg pain; strong pain causes sleep disturbance; you can have malaise or general weakness.[yourhealthyjoints.com]
Suggestibility
  • It is suggested that clinical trochanteric bursitis, especially when refractory to local corticosteroid treatment, may be the initial sign of hip disease.[ncbi.nlm.nih.gov]
  • This study suggests that there is no inflammatory component to so-called trochanteric bursitis, which accordingly casts doubt on both the terminology and the existence of this condition as a separate clinical entity.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The results of this small prospective observational histologic study, along with recent MRI and ultrasound studies on the topic, strongly suggest that there is no etiologic role of bursal inflammation in the trochanteric pain syndrome.[ncbi.nlm.nih.gov]
  • Other treatments include: Removing fluid from the bursa Steroid injection If none of the treatments work, your doctor may suggest surgery to remove the bursa. This is rarely needed.[mountsinai.org]
Tingling
  • Trochanteric bursitis typically causes pain on one or both hips that reaches all the way down to the knee, while usually sparing the foot, swelling and a tingling sensation when one moves.[symptoma.com]
  • Some patients occasionally report numbness or tingling in the groin or inner thigh. This usually resolves with time. It is quite normal to experience some swelling and discomfort in the leg, thigh and buttock region.[arthrohealth.com.au]
Radiculitis
  • Trochanteric bursitis (TB), often mimicking radiculitis, was diagnosed in 31 patients. Trochanteric bursitis was associated with lumbosacral strain and lumbar osteoarthrosis in 21 of 31 patients and with an S1 disk in 1 of those 31 patients.[ncbi.nlm.nih.gov]
Radiculopathy
  • Trochanteric bursitis is a common complication of lumbosacral strain, frequently mimicking radiculopathy. Gait alteration associated with back pain or static traction on gluteal musculature during rest therapy may be predisposing factors.[ncbi.nlm.nih.gov]

Workup

Trochanteric bursitis is diagnosed clinically and following the exclusion of other conditions that lead to a similar set of symptoms. The patient is expected to report symptoms such as pain radiating laterally down to the thigh, which worsens with physical strain. Laboratory testing serves as a method to exclude other potential pathologies, such as infection or autoimmune diseases, and imaging modalities, such as magnetic resonance imaging and computerized tomography scans, radiographs and ultrasonographic scans also serve as ways to exclude other conditions. A neurological assessment of the region is mandatory when the patient presents with such symptomatology and, should traumatization precede the onset of symptoms, the patient needs to be thoroughly evaluated for fractures before the diagnosis of trochanteric bursitis can be decided [17].

Treatment

Greater trochanteric pain syndrome is mainly treated symptomatically. The application of cold compresses on the hip joint, avoiding physical exercise or excessive mobility, injected corticosteroids and the administration of painkillers, such as NSAIDs (non-steroidal anti-inflammatory drugs) are the most popular treatment options [18] [19]. Patients whose condition fails to ameliorate, despite appropriate therapeutic measures, may need to consult an orthopedic surgeon [20]. Special consideration should be taken with reference to age groups that may have some limitation regarding drug ingestion: the use of NSAIDs should not be liberal by the senior population and women who are expecting should avoid corticosteroid injections as the pregnancy progresses.

Posture and gait defects should also be addressed, as they contribute to the pathogenesis of greater trochanteric pain syndrome. Orthotics, braces, canes and various other devices can be prescribed, in order to correct the way a patient walks. In case the aforementioned measures do not achieve a satisfactory degree of improvement, other options, including transcutaneous electrical nerve stimulation or extracorporeal shock wave therapy, can be chosen.

Corticosteroid injections are also widely prescribed for the treatment of trochanteric bursitis. It has been observed that they exhibit considerable success in terms of pain management and in the duration of the results. The only contraindication for injected corticosteroids is advanced pregnancy and a hip that seems infected. Physical therapy, on the other hand, is an option to rehabilitate such patients: targeted exercises may help some patients recover faster. At the same time, maintaining low levels of strenuous activity is vital to avoid excessive pressure to the joint. As a last resort, surgery can correct the syndrome if conservative symptomatic treatment fails to do so [21].

Prognosis

The condition does not lead to death, but may cause considerable morbidity to affected individuals. Painful symptoms are usually experienced periodically and a certain degree of limping may be anticipated in some cases as well [13]. Treatment options, such as corticosteroid injections and physical therapy usually suffice to treat the symptoms.

Etiology

There are many factors that contribute to the onset of trochanteric bursitis. An individual that has sustained trauma to the hip joint and particularly those whose daily physical activity leads to multiple falls (eg. athletes) or other types of trauma to this region, are susceptible to developing bursitis. Underlying conditions that affect the skeletal system, such as spinal deformities, or other conditions leading to an abnormally balanced gait can also contribute to the pathogenesis of the disease. Lastly, trochanteric bursitis can arise as a result of the piriformis syndrome, characterized by the insertion of the piriformis muscle into the trochanteric bursa or following arthroscopic surgery, although the latter occurs rarely [5] [6] [7]. Some patients may experience symptoms related to trochanteric bursitis without any of the aforementioned factors.

Epidemiology

Trochanteric bursitis usually affects individuals older than 50 years old and exhibits a predilection for female patients. The discrepancy between women and men is greater when the bursitis affects both hips [8], and, in general, it has been estimated that women are affected by the condition as much as 4 times more frequently than men.

Sex distribution
Age distribution

Pathophysiology

The basic pathophysiological alteration featured in cases of trochanteric bursitis include inflamed bursae. This inflammatory process is mostly induced by excessive physical exercise that leads to repeated falls with the side of the hip; other causes include a difference in the length of the patient's legs and surgical procedures performed on the hip [9]. During the past years, given the fact that other regional structures such as tendons or muscles are affected in cases of trochanteric bursitis, the condition is widely referred to as greater trochanteric pain syndrome [10] [11] [12]. Another reason for this classification change is that, apart from trochanteric bursae, there is a plethora of other regional bursae that may undergo an inflammatory process as well.

Prevention

The key to preventing the occurrence of greater trochanteric pain syndrome is maintaining a healthy lifestyle, protecting oneself from repeated falls that damage the hip and engaging in physical exercise in such a way, so as to minimize damage dealt to the joint. Proper shoes that do not exert abnormal pressure to the legs are of paramount importance, as are special shoes designed for flat feet.

Summary

Trochanteric bursitis is otherwise known as greater trochanteric pain syndrome. It is a condition causing inflammation of the bursae which are adjacent to the greater femoral trochanter [1] [2] [3]. Pain at the hip joint that extends to the sides of the thigh is the predominant symptom [4].

Trochanteric bursitis is diagnosed clinically and with the aid of imaging modalities capable of evaluating the condition of the bursae, such as an ultrasonographic scan or a magnetic resonance imaging scan (MRI). Laboratory testing, X-ray scans and computerized tomography scans are mainly carried out in order to eliminate the possibility of other diseases, which can lead to similar symptomatology. The condition is treated symptomatically, with the administration of painkillers, physical therapy, corticosteroids and local anesthetics. Patients are advised to engage in physical exercise that does not burden the hip in an excessive manner, and a plethora of therapeutic options are available for those who do not respond to conservative treatment.

Patient Information

The hip joint is protected by the bursa, a sac filled with fluid that serves the purpose of a "shock-absorber", in order to minimize damage and friction between structures like the muscle, bone or tendon. The hip joint is one of the biggest joints of the body and withstands a great deal of pressure and weight on a daily basis. Under various circumstances, the protective bursa is damaged, becomes swollen or infected and leads to a condition referred to as the greater trochanteric pain syndrome, or trochanteric bursitis.

There are various causes that can lead to this condition. Amongst the popular ones are: repeated trauma to the hip due to a fall or blow to the area, excessive physical exercise that damages the hip, a difference in the length of one's legs and spinal deformities (eg. scoliosis). An infection can also cause this condition, as can many other systematic diseases, such as diabetes, gout or thyroid conditions. Trochanteric bursitis typically causes pain on one or both hips that reaches all the way down to the knee, while usually sparing the foot, swelling and a tingling sensation when one moves. Patients face a great deal of difficulty when walking or resuming motion after having remained in a sitting or lying position for a long time.

The condition is diagnosed with the aid of the medical history and symptoms, physical examination and tests that are mainly performed to rule out other causes, rather than to confirm trochanteric bursitis.

The first steps towards the reduction of pain and related symptomatology is applying some basic personal measures. Patients are advised to sleep with their weight on the hip that is unaffected, rest a lot and avoid intense physical activity that involves the legs and can burden the hip. Applying ice on the hip can help to reduce the swelling, and painkillers should also be encouraged if the pain is intolerable. Remaining in a standing or sitting position for a long time can adversely affect the hip joint; it should therefore be avoided. Footwear should be appropriate for the type of exercise undertaken, comfortable and orthotics should be prescribed for people with feet problems, since the feet influence the posture as well.

As far as further medications are concerned, corticosteroid injections have been proven efficient in reducing symptoms and achieving long-term results. There are other therapy options available for cases that do not respond to the types of treatment mentioned above, and surgery is chosen as the last option if nothing else proves beneficial.

References

Article

  1. Brinker MR, Miller MD. The adult hip. In Fundamentals of Orthopaedics (pp.269-85). Philadelphia, Pa: WB Saunders. 1999
  2. Silva F, Adams T, Feinstein J, et al.. Trochanteric bursitis: refuting the myth of inflammation. J Clin Rheumatol, 2008 14(2), 82-6.
  3. Steinberg JG, Seybold EA. Hip and pelvis. In G. G. Steinberg, C. M. Akins, & D. T. Baran (Eds.), Orthopaedics in Primary Care (3rd ed.)(pp.171-203). Baltimore, Md: Lippincott, Williams & Wilkins. 1998
  4. American Academy of Orthopaedic Surgeons. Trochanteric bursitis. In R. K. Snider (Ed.). Essentials of Musculoskeletal Care, (pp. 299-303), 1997 Rosemont, Ill: Author.
  5. Clarke MT, Lee PT, Arora A, et al. Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty. J Bone Joint Surg Br, 2003 85(6), 913-7.
  6. Farmer KW, Jones LC, Brownson KE, et al. Trochanteric bursitis after total hip arthroplasty incidence and evaluation of response to treatment. J Arthroplasty 2009
  7. Clarke MT, Arora A, Villar RN, Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res, 2003 84-8.
  8. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil, 2007 88, 988.
  9. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In Physical Medicine and Rehabilitation (pp. 783-812). Philadelphia, Pa: WB Saunders. 1996
  10. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg, 2009, 108(5), 1662-70.
  11. McGee DJ. Hip. In Orthopedic Physical Assessment (2nd ed.) (pp. 333-71). Philadelphia, Pa: WB Saunders. 1992
  12. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy, 2008 24(12), 1407-21.
  13. Bianchi S, Martinoli C. Hip. In Ultrasound of the Musculoskeletal System (pp. 561-62). Germany: Springer. 2007
  14. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum, 2001 44(9), 2138-45.
  15. Ho GW, Howard TM. Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction. Curr Sports Med Rep, 2012, 11(5), 232-8.
  16. Kaltenborn A, Bourg CM, Gutzeit A, et al. The hip lag sign - prospective blinded trial of a new clinical sign to predict hip abductor damage. PLoS One, 9(3), e91560. 2014
  17. Bertoli AM, Saurit V, Alvarellos A, et al. Soft tissue metastases presenting as greater trochanteric pain syndrome. J Clin Rheumatol, 2003, 9(6), 370-2.
  18. Green SM (Ed.). Nonsteroidal anti-inflammatory drugs (NSAIDs). 2000, Tarascon Pocket Pharmacopoeia (pp.11-2). Loma Linda, Calif: Tarascon Pub.
  19. Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome. Am J Sports Med, 2009 37(9), 1806-13.
  20. Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med, 2011, 21(5), 447-53.
  21. Lennard TA (Ed.). Fundamentals of procedural care. 1995. Physiatric Procedures in Clinical Practice (pp. 1-13). Philadelphia, Pa: Hanley & Belfus.

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Last updated: 2018-06-22 01:45