Trochanteric bursitis is painful inflammation of the trochanteric bursa(e) present near the greater trochanter of the femur. The term trochanteric bursitis is substituted by greater trochanteric pain syndrome because apart from bursitis, muscle tears, tendinopathy, trigger points, disorders of iliotibial band may or any other problem in the area may cause pain on the lateral aspect of the hip which gets labeled as trochanteric bursitis. Trochanteric bursitis generally occurs in adults and is more common in females. Anatomically broader greater trochanters is associated more with trochanteric bursitis than narrower ones.
Trochanteric bursitis is also called greater trochanteric bursitis.
Greater trochanter is a projection on outer or lateral aspect of femur.
[Read more on hip joint anatomy.]
There are four bursae around greater trochanter. Out of these three burase are constant (two major and one minor).
The minor bursa is the gluteus minimus bursa. This bursa lies above and slightly anterior to the proximal superior surface of the greater trochanter.
Subgluteus medius and the subgluteus maximus bursae are the major bursae around trochanter. The gluteus medius bursa is situated posterior and superior to the proximal edge of the greater trochanter. The subgluteus maximus is lateral or superficial to the greater trochanter.
Subgluteus maximus bursa is commonly called trochanteric bursa. This bursa functions as a gliding mechanism for the anterior portion of the gluteus maximus as it passes over the greater trochanter to insert into the iliotibial band.
Causes of Trochanteric Bursitis
- Acute trauma – fall causing contusions over the site, impact injuries.
- Repetitive injury during running or walking due to contracture of gluteus medius, iliotibial band or both.
- Leg-length inequality
- Surgery on lateral side of hip [ where the bursa is], arthroscopy of hip
There are few conditions which are known the patients to predispose for trochanteric bursitis
- Gait disturbances
- Disorders of spine and sacoiliac region
- Osteoarthritis hip
- Piriformis syndrome
Presentation of Trochanteric Bursitis or Greater Trochanteric Pain Syndrome
There is pain on lateral aspect of the hip where greater trochanter is which is either acute onset or insidious onset. The pain may radiate to lower lateral aspect of thigh. The pain worsens when patient lies on affected side. The pain could severe enough to awaken the patient in the night.
Walking, running or sitting cross legged may exacerbate the symptoms. There might be history of increased activity recently.
There could be a history of impact during trauma.
On examination, there is a tenderness over greater trochanter and in vicinity. Swelling may or may not be noticed.
Signs of acute trauma may be visible in patients with history of acute injury.
On examination passive external rotation and extreme adduction. Resisted abduction would also reproduce the symptoms.
- Gluteal tendon injury
- Tendinitis – Gluteus medius or iliopsoas
- Hip Fracture
- Iliotibial Band Syndrome
- Lumbosacral Radiculopathy
- Piriformis Syndrome
Lab tests are generally not required for diagnosis. However, blood tests may be done for ruling out infection or connective-tissue disease.
In troachnteric bursitis, the xrays are normal. Xrays are beneficial to rule out bony pathology like fracture, arthritis, or timorous conditions lesion or calcium deposits.
CT would be able to tell better about underlying bony pathology.
MRI is able to differentiate degenerative changes, tendon tears, or bursal effusions and considered by many as investigation of choice.
Treatment of Trochanteric Bursitis
This includes curtailing activities like climbing stairs, getting in and out of chairs. Sports participation should be restricted.
Sleeping in the position which puts direct pressure on the affected site should be avoided.
This should be done about 3-4 times per day and each time about 15-20 minutes.
Intrabursal Corticosteroids injections
Corticosteroid injections are very important part of the treatment and studies have shown that patients who have received corticosteroid injections have less likelihood of chronic pain at 5 years than those who did not receive. Corticosteroid injections are avoided in diabetic people and pregnant females.
Local anesthetic can be used along with corticosteroid injections.
NSAIDs reduce inflammation and pain by their anti-inflammatory actions. They can be used to control pain and swelling. Pain can also be controlled by application of topical, sustained-release local anesthetic patches.
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy is a noninvasive surgical procedure that uses sound waves to stimulate healing.
Correction of Underlying Abnormalities
Any correctable abnormality that could be cause of bursitis should be evaluated and corrected.
If patient does not respond to treatment, patient must be evaluated for piriformis syndrome.
The athletes may be allowed to return to sports when symptoms have resolved and there is no return of symptoms on practice drills.
When symptoms have resolved, the patient should be put on following
- Stretching of iliotibial band
- Stretching of the tensor fascia lata
- Stretching of the external hip rotators
- Quadriceps stretch
- Stretching of hip flexor muscles
- Phonophoresis and soft-tissue massage
- TENS in resistant cases.
Most of the patients of trochanteric bursitis do no trequire surgery. In refractory cases, longitudinal release of iliotibial band with subgluteal bursectomy may help.
Rarely, partial removal of the greater trochanteric process may be done.
Prevention of Trochanteric Bursitis
As bursitis is mostly due to overuse, it is important to modify the activities causing because most cases of bursitis are caused by overuse, the best treatment is prevention. It is important to avoid or modify the activities that cause the problem.
Correction of underlying conditions such as leg length differences, posture abnormalities, or poor technique in sports or work must be corrected.
Activity level should be build up gradually. Repetitive activities that put stress on the hip should be avoided.
All patients should be advised to avoid lying on the affected side, if possible. Running on banked surface should be avoided. Protective padding is used in athletes in contact sports.
Patient of trochanteric bursitis respond well to treatment.Some patients may require repetition of the corticosteroid injection.
Persistent pain, reduced mobility and limping may occur as complication in some patients.
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