HIP/trochanteric bursitis

What is trochanteric bursitis?

Anatomy of Trochanteric Bursitis

Trochanteric bursitis is a condition characterized by tissue damage and inflammation of the trochanteric bursa (a small fluid filled sac located at the outer aspect of the hip) causing pain in the hip.

The femur (thigh bone) has a bony process at the top of the bone known as the greater trochanter (figure 1). This bony prominence is a point of attachment of several gluteal muscles and forms the outer most point of the hip. The gluteal muscles originate from the pelvis and insert into the top of the femur (thigh bone) overlying the greater trochanter (figure 2). Between the gluteal muscles and the greater trochanter lies a bursa known as the trochanteric bursa (figure 1). A bursa is a small sac filled with lubricating fluid and is designed to reduce friction between adjacent soft tissue layers.

The gluteal muscles are primarily responsible for moving the hip and stabilizing the pelvis during activity and are particularly active during walking, running, jumping, climbing stairs, lunging and squatting. During contraction of the gluteals, friction is placed on the trochanteric bursa. Pressure may also be placed on the trochanteric bursa following a direct impact. When these forces are excessive due to too much repetition or high force, irritation and inflammation of the bursa may occur. This condition is known as trochanteric bursitis.

Causes of trochanteric bursitis

Trochanteric bursitis most commonly occurs due to repetitive or prolonged activities placing strain on the trochanteric bursa. This typically occurs due to repetitive running or walking (especially up hills or on uneven surfaces) jumping, squatting, lunging activities (placing strain on the bursa via the gluteals) or due to prolonged pressure on the bursa (such as excessive side-lying particularly on hard surfaces). Occasionally, the condition may occur suddenly due a direct blow to the point of the hip (such as a fall onto a hard surface).

Signs and symptoms of trochanteric bursitis

Patients with this condition typically experience pain in the outer aspect of the hip. Pain may also radiate down the outer aspect of the thigh as far as the knee. In less severe cases, patients may only experience an ache or stiffness in the hip that increases with rest following activities placing strain on the bursa. These activities typically include side lying excessively (especially on hard surfaces), running, jumping, climbing stairs, sitting cross legged, getting in and out of the car or walking excessively (especially up hills or on uneven surfaces). The pain associated with this condition may also warm up with activity in the initial stages of injury.

As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. Patients with trochanteric bursitis typically experience pain on firmly touching the trochanteric bursa (figure 1). Occasionally, a feeling of lower limb weakness may also be present particularly when attempting to climb stairs, perform a squat or accelerate whilst running.

Diagnosis of trochanteric bursitis

A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose trochanteric bursitis. Further investigations such as an Ultrasound, X-ray, CT or MRI scan are often required to assist with diagnosis and assess the severity of the condition.

Prognosis of trochanteric bursitis

Most patients with this condition heal well with appropriate physiotherapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with trochanteric bursitis.

Contributing factors to the development of trochanteric bursitis

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• joint stiffness (particularly the hip)
• muscle tightness (particularly the gluteals)
• muscle weakness (especially the hamstrings and gluteals)
• poor biomechanics
• inappropriate or excessive training
• inadequate warm up
• inadequate rehabilitation following a previous buttock or hip injury
• poor pelvic or core stability
• neural tightness
• leg length discrepancy

Physiotherapy for trochanteric bursitis

Physiotherapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound, TENS etc)
• stretches
• dry needling
• joint mobilization
• the use of crutches
• ice or heat treatment
• exercises to improve strength, flexibility and core stability
• correction of abnormal biomechanics (e.g. the use of orthotics)
• education
• anti-inflammatory advice
• activity modification advice
• a gradual return to activity program

Other intervention for trochanteric bursitis

Despite appropriate physiotherapy management, some patients with this condition do not improve adequately. When this occurs the treating physiotherapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition.

Exercises for trochanteric bursitis

The following exercises are commonly prescribed to patients with trochanteric bursitis. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Gluteal Stretch

Begin lying on your back (figure 3). Using your hands, take your knee towards your opposite shoulder until you feel a stretch in the buttocks or front of your hip. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercise is pain free.

Figure 3 – Gluteal Stretch (right leg)

Transversus Abdominis Activation

Begin this core exercise lying on your back as demonstrated (figure 4). Slowly pull your belly button in, "away from your belt line", and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony prominence at the front of your pelvis (figure 4). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activities (e.g. when walking etc.) provided it is pain free.

Figure 4 – Transversus Abdominis Activation