Continuing Education Activity

Trochanteric bursitis is a common cause of lateral hip pain that occurs when the hip bursa becomes inflamed. This can be due to repetitive microtraumas, such as may occur with running or exercise, tendinopathy of surrounding musculature, gross trauma, including falls from a height with direct compression to the bursa, or it can occur idiopathically. Diagnosis is clinical and based primarily on history and physical examination, although imaging, including plain film radiographs, is important to rule out other causes of hip pain. Treatment modalities are nearly exclusively nonoperative and include non-steroidal anti-inflammatories (NSAIDs), physical therapy, and stretching, and in some cases, cortical steroid injections are provided for pain relief. Surgical excision of the trochanteric bursa is reserved for refractory patients that do not respond to nonoperative treatment. This activity reviews the evaluation and management of trochanteric bursitis and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

• Describe the etiology of trochanteric bursitis.
• Review the history and physical of a patient with trochanteric bursitis.
• Summarize the treatment options for trochanteric bursitis.
• Outline the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by trochanteric bursitis.

Introduction

Trochanteric bursitis (TB), also known as greater trochanteric bursitis (GTB) or greater trochanteric pain syndrome (GTPS), is a common disorder and frequent cause of lateral hip pain. The bursa, a small fluid-filled sac, acts as a lubricating medium for nearby gluteus tendons to gracefully slide over during the physiologic range of motion. The trochanteric bursa is located on the lateral aspect of the hip, lying superficial to the hip abductor musculature and deep to the iliotibial band (ITB). Due to its superficial position and proximity to large tendons, the trochanteric bursa can become inflamed and is a common pain generator and a common reason for presentation to the orthopedic surgeon or family physician.[1]

Inflammation to the bursa can be due to repetitive microtraumas such as running or exercise, tendinopathy of surrounding musculature, gross trauma including a fall from a height with direct compression to the bursa, or inflammation can be idiopathic without a discernable cause. Diagnosis is clinical and based primarily on history and physical examination, although imaging, including plain film radiographs, is important to rule out other causes of hip pain. Treatment modalities are nearly exclusively nonoperative in nature and include non-steroidal anti-inflammatories (NSAIDs), physical therapy, stretching, and cortical steroid injections are often provided for pain relief. Surgical excision of the trochanteric bursa is reserved for refractory cases that do not respond to nonoperative treatment.[2][3]

Etiology

The underlying cause of trochanteric bursitis can be repetitive microtrauma, blunt trauma, or idiopathic. Overuse of the surrounding musculature leading to tendinopathies of the gluteus medius and/or minimus is common. Repetitive hip abduction seen in stair climbing or cycling can contribute to an inflammatory cascade of the bursa. Older patients who sustain falls directly over the bursa can initiate an inflammatory cascade within the tissue. Sedentary or bed-bound patients are also prone to trochanteric bursitis, as constant pressure over the greater trochanter of the proximal femur can also initiate the inflammatory response of the bursa.[4][2]

Epidemiology

Trochanteric bursitis is transmodal in distribution affecting those of all ages. GTB is common and thought to affect roughly 15% of women and 8% of men.[5] Middle-aged women are most commonly affected, although young female athletes are also prone to developing GTB. Females have increased Q angles which leads to tighter ITBs which cause strain over the bursa when exposed to repetitive motion, including running and jumping.[6]

History and Physical

Patients will often present complaining of unilateral lateral hip pain. Suspicion for trochanteric bursitis should be high in the differential if the pain onset is gradual, the patient maintains the ability to ambulate, and pain improves with over-the-counter anti-inflammatory medication. The patient will often be able to localize the pain focally to the area directly over the greater trochanter of the proximal femur. Younger patients may include a history of repetitive athletics, including running, cycling, or jumping sports. Middle-age and older patients may have a history of direct compression from sustained immobilization or low-energy trauma such as ground-level falls.[7]

Physical examination is the gold standard for the diagnosis of trochanteric bursitis. It is important to rule out a hip fracture on clinical physical examination. Patients should maintain their ability to straight leg raise without pain, and a log roll (internal and external rotation of the leg at the hip joint with the hip flexed to 90 degrees) will also not elicit pain in the hip joint. Patients will have localized pain with deep palpation over the greater trochanter on the lateral aspect of the proximal femur. Pain often worsens with prolonged activity or maneuvers involving stabilization of the pelvis, such as standing on one leg.[8] Examination of the skin is often normal, without erythema or increased warmth, as the etiology is non-infectious. Pain is often elicited with adduction of the femur and relieved with abduction as this tensions and relieves tension on the overlying iliotibial band (ITB), respectively.

Evaluation

Imaging Evaluation

Following the physical examination in patients with a high clinical suspicion for trochanteric bursitis, plain film radiographs, including a two-view hip and pelvis, should be obtained to rule out an associated fracture or other osseous abnormalities. Plain films will be unremarkable in the setting of trochanteric bursitis. Advanced imaging is rarely necessary to diagnose trochanteric bursitis but is often ordered if there is a concern for an occult fracture of the femoral neck. Trochanteric bursitis will show up as an area of increased signal on T2 sequence magnetic resonance imaging (MRI) is obtained; however, this is not necessary for diagnosis.[9] Ultrasound is also not routinely employed for diagnosis but would show increased fluid signal with the trochanteric bursa. 

Laboratory Evaluation

Laboratory workup is not routinely performed if clinical suspicion is high for trochanteric bursitis in the absence of constitutional symptoms. If the patient has associated fevers, chills, or other signs of systemic infections, CBC with differential can be obtained to look for the presence of leukocytosis. If suspicion exists clinically for an underlying septic hip joint, acute inflammatory markers, including ESR and CRP, can be obtained.[7]

Treatment / Management

Initial management for trochanteric bursitis is always nonoperative. Antibiotics are not indicated in the management of trochanteric bursitis. 

Pharmaceutical

Oral non-steroidal anti-inflammatories (NSAIDs) assist in blocking the inflammatory cascade and aid in symptomatic pain relief and propagation of bursitis. Before initiating NSAIDs, it is important to ensure patients have no contra-indications to the medications. NSAID therapy should be bypassed in those currently on blood thinners or at high risk of gastrointestinal bleeding.

Physical Therapy

Physical therapy directed toward quadriceps strengthening and ischial tibial band stretching is important in addressing the underlying pathology. Hip abduction exercises should also be initiated to stretch and strengthen the gluteus medius and minimus.[10][11] Teaching proper running, jumping, and technique to adolescent athletes is also very important. It is necessary to maintain hip mobility and flexibility while treating trochanteric bursitis.

Corticosteroid Injections

Trochanteric bursitis is also amenable to steroid injection. Injections deliver a localized dose of cortisone, often coupled with local anesthetic lidocaine or marcaine, to provide relief and directly target local inflammation. Injections can be delivered by both orthopedic surgeons and primary care providers. These are minor outpatient procedures performed under the usual procedural sterile technique. Long-term outcomes are similar in those who receive corticosteroid injections versus those who undergo physical therapy.[12]

Platelet-Rich Plasma Injections (PRP)

The use of PRP throughout the field of orthopedics and sports medicine remains a continued hot topic of debate.[13] A recent Level I systematic review of available randomized clinical trials (RCTs) and case series in the literature (3 RCTs and 2 case series), noted improvement in patients at 3rd and 12-month follow-up, although the authors noted the lack of high-quality evidence supporting PRP injections over the other aforementioned nonoperative modalities.[14] Thus, PRP is not considered the standard of care for GTB at this time.

Extracorporeal Shock Wave Therapy

extracorporeal shock wave therapy (ESWT) is an effective treatment for greater trochanteric pain syndrome, especially for those who have high signals on MRI. One study showed that ESWT yielded better results than corticosteroid injections or home exercises. With a success rate of 86.8% after two months following therapy, ESWT, in combination with a certain exercise regimen, is secure and successful for GTPS.[15]

Surgical Management

Surgical management for trochanteric bursitis is rarely employed. Surgery is reserved for refractory cases or those not responding to usual conservative therapy. Surgical management includes sharp excision and debridement of the bursa.[16]

Differential Diagnosis

The differential diagnosis for trochanteric bursitis includes Femoroacetabular impingement, fracture of the greater trochanter, femoral neck, or intertrochanteric hip fracture, a hamstring avulsion injury, or simple muscle strain or sprain.[17] Femoral acetabular impingement should also be considered in athletic patients presenting with hip pain and must be ruled out.[18] Trochanteric bursitis can be easily differentiated from the pathology mentioned above by history, careful physical examination, localizable pain over the trochanter, and negative plain film radiographs.

Gluteal medius tear presents as lateral hip pain that exacerbates with prolonged sitting, climbing stairs, and walking. The pain is usually associated with Trendelenburg gait. Trochanter bursitis pain increases while sitting with the cross legs. Both conditions are painful while lying on the affected site.[19] 

Snapping hip syndrome is associated with pain on the lateral side of the trochanter and the feeling of catching and "giving way" while climbing stairs and running. Palpation of the snapping over the greater trochanter while flexing the hip joint confirms the diagnosis.[17] Pyriformis syndrome leads to retrotrochanteric pain that exacerbates with prolonged sitting and getting to bed at night. The piriformis stretch test differentiates it from other peritrochateric painful entities. The piriformis stretch test includes hip flexion, adduction, and internal rotation. A positive test presents as a re-creation of deep gluteal pain.[20]

Prognosis

The prognosis is promising with trochanteric bursitis, as patients can expect complete resolution of symptoms with conservative management without any long-term sequelae. Resolution with NSAIDs and/or corticosteroid injection can be expected within just several days of initiation of treatment. Refractory bursitis is rare, although some patients do report a return of symptoms with re-irritation or repetitive trauma.

Complications

Complications of trochanteric bursitis are rare. Complications are more closely associated with NSAID use and, infrequently, corticosteroid injection. NSAIDs can cause gastric ulceration and subsequent bleeding in those that are high-risk or are taking anticoagulants. Gastrointestinal (GI) bleeding can be occult, and patients should be counseled regarding signs or symptoms of anemia. Complications associated with corticosteroid injections include elevated blood glucose levels (especially in those with poorly controlled diabetes), injection site irritation, or injected site bleeding.[21]

Postoperative and Rehabilitation Care

Rehabilitation therapy plays a key role in treating and preventing hip bursitis by strengthening the muscles around the hip joints. These muscles support and stabilize the pelvic girdle to lessen tendon irritability and joint reaction forces. Therapeutic, manual, stretching, and strengthening exercises are performed in 3 phases.

Phase 1 management of pain and inflammation includes Ice therapy, non-steroidal anti-inflammatory drugs, acupuncture, topical massage, and brief usage of mobility assistance devices to off-load the afflicted side. Side-lying leg raises, standing hamstring stretching exercises, Clamshells, proprioception, balancing, and piriformis stretching exercises are included in phase 2 rehabilitation. The 3rd phase includes training of core muscles, gait, and biomechanics analysis. Patient education, postural awareness, and return to sports activity are the last rehabilitation phase's main goals.[22][23]

Deterrence and Patient Education

While proper stretching, form, and training technique can help prevent trochanteric bursitis in the young athlete, many cases are secondary to trauma or are idiopathic and, therefore, not preventable. However, it is important to educate patients on the positive prognosis and success of non-operative management. Reassurance, along with initiation of anti-inflammatories and/or corticosteroid injections, typically leads to the resolution of symptoms and patient satisfaction. It is essential that clinicians counsel patients on the potential side effects of NSAIDs and corticosteroid injections before initiating treatment. Patients should understand the risk: benefit ratio before proceeding with treatment.

Enhancing Healthcare Team Outcomes

Interprofessional teamwork is essential for both the diagnosis and treatment of trochanteric bursitis. This interprofessional team can include clinicians (MDs, DOs, NOs, or PAs), orthopedic specialists, chiropractors, physical therapists, and nurses. All team members should maintain open communication lines with the other caregivers involved in the case and maintain updated and accurate records of all patient interactions, interventions, and status changes. This communication is crucial to the successful diagnosis and management of these patients. The interprofessional case model will drive optimal patient results. [Level 5]

Primary care clinicians should be educated in the diagnosis and treatment as they are often the first to encounter patients with trochanteric bursitis and can prevent the increased healthcare costs associated with specialist consultation. For most patients, the outcomes are excellent, but recovery may take a few weeks.[24] [Level  1]