Trochanteric Bursitis
1. Introduction
Trochanteric bursitis is a condition used to describe pain and inflammation of tissues that are situated around the outer part of the hip or upper thigh (1). The greater trochanter is a large, bony point that you can feel on the outside of the upper thigh. It serves as a useful attachment point for muscles that help stabilise your pelvis. The bursa is a type of thick tissue that helps to reduce friction between the bone (greater trochanter) and the tendons (gluteal tendon). In some cases, irritation of these bursae tissues can lead to pain and inflammation. This is how the term “trochanteric bursitis” originated (2).
In recent years it has been more widely appreciated that trochanteric bursitis may also be linked to pain originating from the tendons that insert into the greater trochanter (3). Sometimes the pain can refer down the thigh or into the buttock. It is possible that the pain is radiating from the lower back and for this reason, a thorough assessment is necessary to accurately diagnose the condition (4).
Treatment of trochanteric bursitis will aim to reduce compression, modify the load on the irritated bursa and gradually strengthen around the hip. If the pain is in fact referring from the lower back, the treatment may be quite different. Further description of low back pain and referred pain can be found in the relevant section of the website.
Frequently Asked Questions
- Trochanteric bursitis is a term used to describe pain and inflammation of tissues that are located on the outside of the upper thigh/hip.
- In the general population, trochanteric bursitis affects just 1% of people (1).
- It is more common in females than males from ages 40-60 years (1).
- No.
- Trochanteric bursitis can be treated well with good rehabilitation.
- Trochanteric bursitis is not linked to any other serious medical conditions (2).
- It is much more likely to affect females than males, aged 40-60 years old.
- It can affect people who are both active and sedentary.
- You are more likely to suffer from it if you already have low back pain, hip osteoarthritis or you are overweight (2).
- Pain located on the outside of your hip or upper thigh.
- It is often tender to touch or to lie on the affected hip.
- The pain is often worse with walking, standing on one leg, e.g. when dressing or climbing stairs.
- The area may appear slightly warm or swollen to the touch (3).
There are many things you can do to help you recover from trochanteric bursitis (4, 8):
- Modify your activity by avoiding painful movements and compressing the outer hip.
- Rest is necessary for the early stages, but in time it is important to progressively strengthen the muscles that support this area.
- Advice from a qualified physiotherapist will be helpful in most cases.
- This will depend upon several factors including, but not limited to, your general health, the activities you wish to return to and the stage of the condition.
- Recovery is normally within 3 months.
- Some patients require a longer period of rehabilitation.
- Further treatment such as surgery is very rarely considered (10, 12).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Pain that is located around the outside of the upper thigh/hip and may radiate further down the outer thigh.
- Commonly there is tenderness over the outer hip. For this reason, people suffering from trochanteric pain syndrome struggle to sleep on the affected side.
- The pain is worse with tasks that involve standing on one leg such as walking, running, dressing and climbing the stairs.
- The pain can be worse for the first few steps after sitting when sitting crossed legged, sitting in a low chair or lying on the non-painful side and the affected leg drops down. This is because all these positions increase the compression of the tendon and bursa (2,4,5).
3. Causes
Trochanteric bursitis often starts after a sudden increase in activity, especially involving stairs, hills or running on a camber. If there is insufficient strength in the gluteal (bottom) muscles to be able to control the hip position on one leg, then the bursa and tendons are placed under increased stress and can start to become painful. Additionally, people who have this condition often have poor postural habits such as standing shifted onto one leg and sitting crossed legged (7).
This condition is most common in peri- and post-menopausal women. It is thought that the hormonal change at this time causes the collagen in the tendon to change and weight gain around the hips and tummy increases the load on the area (7, 8).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing trochanteric pain syndrome or gluteal tendinopathy. It does not mean everyone with these risk factors will develop symptoms.
- People aged 40-60 years are most likely to develop trochanteric bursitis.
- Gender – Women are 80% more likely to develop trochanteric pain syndrome than men.
- Being overweight – as this increases the load on the area.
- A sudden increase in activity especially if it involves stairs, hills or running/plyometric exercise.
- Poor strength in the abductor (outer) muscles of the hip.
- Poor postural habits such as standing ‘hanging off the hip’ or sitting with legs crossed (4, 5, 8).
5. Prevalence
In the general population trochanteric bursitis affects 1% of people. However, it is much more common in women aged 40-60 years old (1).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects your day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scan are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your trochanteric pain. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Rehabilitation of trochanteric bursitis can be modified dependant on the severity of your symptoms and the tasks or hobbies you want to return to. The aim of treatment is to reduce compression, modify the load on the bursa/tendon and strengthen the muscles that help stabilise your hip.
You can reduce compression on the bursa and tendon by (8,10):
- Trying to stand equally on both legs; if you stand on one leg, do not let your hip push out to the side. This is probably a habit so ask family and friends to watch you.
- Avoid sitting with your legs crossed.
- Avoid sitting on low chairs.
- Avoid firm mattresses; you may find using a softer mattress overlay is helpful.
- Avoid lying on the affected hip at night. Use a large pillow between your legs when lying on your unaffected side to keep your hips in a neutral position.
- Avoid stretching the bottom muscles. The position of stretch increases compression over the outer hip.
Modify the load on the irritable tissues:
- Reduce your exercise, especially if it involves stairs or hills.
- When walking, try to avoid overstriding.
- If the pain is very severe you may need to rest completely from exercise. However, it is beneficial to keep doing something if possible. You can measure if you have done too much by checking whether your pain is much worse at night or the next day.
Strengthening the hip muscles:
It is important to strengthen the muscles that stabilise the hip to help to stop the hip from dropping from side to side when completing the one-legged activity (please refer to the exercise plans below). The exercise challenge will slowly increase as your symptoms improve.
9. Trochanteric Bursitis
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Early exercises focus on trying to improve the strength of the muscles of the outside of the hip without placing too much stress on the area. This should not exceed any more than 3/10 on your perceived pain scale.
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Intermediate exercises involve more challenging strength exercises, starting to move towards more functional tasks. This should not exceed any more than 3/10 on your perceived pain scale.
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As your hip pain reduces and you start to feel ready to return to higher-level activities, it is important to make these same exercises more dynamic and increase the demand for the exercises. This should not exceed any more than 3/10 on your perceived pain scale.
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10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting, and sprinting exercises (5, 9, 10).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Corticosteroid injections have traditionally been used to treat trochanteric bursitis. In most cases, this is not considered to be appropriate as there is often tendon involvement leading to this type of pain (3). Corticosteroid injections, particularly given repeatedly, can have long term consequences for our tendons. However, in cases where there is evidence of inflammatory changes in the bursa a corticosteroid injection may be of some benefit.
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References
- Reid. (2015). The management of greater trochanteric pain syndrome: a systematic review. Journal of Orthopaedics 13, 15-28.
- Williams & Cohen. (2009). Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. Anaesthesia & Analgesia. 108, 1662-1670.
- Long et al. (2013). Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American journel of roetgenology 201, 1083-1086.
- Chowdhury, R., Naaseri, S., Lee, J. and Rajeswaran, G. (2014). Imaging and management of greater trochanteric pain syndrome. Postgraduate medical journal. 90, 576-581.
- Kimpel, D.M., Garner, C.C., Magone, K.M., et al. (2014). Greater trochanteric hip pain. Orthopaedic Nursing. 33, 95-99.
- Makki, D. and Watson, A.J. (2010). Septic trochanteric bursitis in an adolescent. American Journal of Orthopaedics 39, 1-3.
- Mallen, C.D., Peat, G., Thomas, E., et al. (2007). Prognostic factors for musculoskeletal pain in primary care: a systematic review. British Journal of General Practice 57, 655-661.
- Mallow, M. and Nazarian, L.N. (2014). Greater trochanteric pain syndrome diagnosis and treatment. Physical medicine and rehabilitation clinics of North America. 25, 279-289.
- Novatnack, E.S., Protzman, N.M. and Weiss, C.B. (2015). Primary septic greater trochanteric bursitis. Journal of Global Infectious Diseases April-June 7, 93-94.
- Diane Reid. (2015). The management of greater trochanteric pain syndrome: a systematic review. Journal of Orthopaedics 13, 15-28.
- Watts, R.A., Conaghan, P.G., Denton, C., et al. (Eds.) (2013). Oxford Textbook of Rheumatology.
- Wilson, J. and Furukawa, M. (2014). Evaluation of the patient with hip pain. American Family Physician 89, 27-34.