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. 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. Between the gluteal muscles and the greater trochanter lies a bursa known as the trochanteric bursa. 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 running, jumping, climbing stairs 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.
Trochanteric bursitis most commonly occurs due to repetitive or prolonged activities placing strain on the trochanteric bursa. This typically occurs due to repetitive running, jumping, walking 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).
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. Occasionally, a feeling of lower limb weakness may also be present particularly when attempting to climb stairs, perform a squat or accelerate whilst running.
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.
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.
The success rate of treatment for this condition is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from ANY activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate, appropriate treatment in patients with trochanteric bursitis is essential to ensure a speedy recovery. Once the bursitis is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
Patients with this condition should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury onset or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities, regular icing, the use of a compression bandage (where possible) and keeping the affected leg elevated (i.e. lying on the opposite side). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
Patients should also undergo a graduated flexibility and strengthening program of the surrounding muscles to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
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)
- poor biomechanics
- inappropriate or excessive training
- inadequate warm up
- muscle weakness (especially the hamstrings and gluteals)
- inadequate rehabilitation following a previous buttock injury
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)
- joint mobilization
- ice or heat treatment
- exercises to improve strength, flexibility and core stability
- correction of abnormal biomechanics
- the use of crutches
- anti-inflammatory advice
- activity modification advice
- a gradual return to activity program