Trochanteric bursitis

This common cause of hip pain is often misdiagnosed, writes Dr Louise Newson.

The bursa occurs between the trochanter and overlying iliotibial band (Photograph: SPL)
The bursa occurs between the trochanter and overlying iliotibial band (Photograph: SPL)

Trochanteric bursitis is also called greater trochanteric pain syndrome. It is a common cause of pain in the hip and is often misdiagnosed as hip disease or lower back pain.

1. Aetiology

Trochanteric bursitis is more common in women than in men. The incidence of greater trochanteric pain is about 1.8 patients per 1,000 per year.1 It most often occurs in people aged 30-50 years. It can also be a cause of hip pain in younger people, especially runners.

It is usually caused by stresses at muscle insertions on the greater trochanter, leading to inflammation. This microtrauma results in degenerative changes of tendons, muscles or fibrous tissues. The painful bursa occurs due to friction between the trochanter and the overlying iliotibial band.

Conditions associated with trochanteric bursitis include osteoarthritis of the hips, lower back or knees, degenerative disc disease of the lumbar spine, obesity and fibromyalgia.

2. Symptoms

Trochanteric bursitis typically presents with pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh.2 Many people find it is a deep pain, which may be aching or burning. The pain may increase over time and it may last for months, even years.

The pain is often more intense lying on the affected side. It may worsen when getting up from a low seat, or with exercise and climbing the stairs. Occasionally, patients experience numbness in the upper thigh.

A 'snapping' sound may be heard by patients. This usually occurs due to the iliotibial band popping over the greater trochanter. Some patients may present with a limp. It can also be associated with sciatica.

Key points
  • Trochanteric bursitis is a common cause of hip pain.
  • It is more common in women than in men, and in those aged 30-50 years.
  • It typically presents with pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh.
  • Most patients are usually very tender to palpation over the greater trochanter area.
  • Treatment involves rest and reduced activity; the condition is usually self-limiting.
  • Other helpful interventions include ice packs, NSAIDs and physiotherapy.
  • It is important to differentiate any associated conditions, such as osteoarthritis.

3. Diagnosis

The diagnosis is usually made on clinical findings. Most patients are usually tender to palpation over the greater trochanter area.

The tenderness may extend into the lower buttock and lateral thigh.

Pain can also be reproduced by resisted abduction and external rotation.

However, pain on flexion and extension of the hip is indicative of intra-articular hip disease and not usually present in patients with greater trochanteric bursitis.

Although X-rays of the hip, pelvis and lower spine may show evidence of associated musculoskeletal conditions, there are no definitive X-ray findings of greater trochanteric bursitis.

4. Treatment

Patients should be recommended to rest and also to decrease their activity. Most people with greater trochanteric pain syndrome improve with time, as it is usually a self-limiting condition.

Patients need to be informed that it can often take at least two to three months for this condition to resolve.

Applying an ice pack for 10-20 minutes several times a day may improve symptoms. NSAIDs may help to reduce the pain and swelling. Patients who are overweight or obese will benefit from losing weight.

Physiotherapy, especially focusing on iliotibial band and hip rotator stretching, is often recommended. A localised steroid injection into the point of maximum pain is beneficial for some patients.

Surgical intervention may be necessary in refractory cases. Multiple surgical options for persistent trochanteric bursitis include bursectomy, longitudinal release of the iliotibial band, proximal or distal Z-plasty, osteotomy and repair of gluteus medius tears.3

Any associated conditions, such as degenerative disc disease, must be differentiated and treated accordingly.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Newson is a GP in the West Midlands

References

1. Williams BS, Cohen SP. Anesth Analg 2009; 108(5): 1662-70.

2. Strauss EJ, Nho SJ, Kelly BT. Sports Med Arthrosc 2010; 18(2): 113-19.

3. Lustenberger DP, Ng VY, Best TM et al. Clin J Sport Med 2011; 21(5): 447-53.

 

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