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Trochanteric Bursitis

  • Author: Douglas D Dean, DO; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 16, 2016
 

Background

Trochanteric bursitis is characterized by painful inflammation of the bursa located just superficial to the greater trochanter of the femur.[1, 2, 3] Activities involving running and those involving the possibility of falls or physical contact, as well as lateral hip surgery and certain preexisting conditions, are potentially associated with trochanteric bursitis.

Patients typically complain of lateral hip pain, though the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh.[4] The most classic physical finding is point tenderness over the greater trochanter, which reproduces the presenting symptoms. Bursal swelling may be present but may be difficult to appreciate.

Generally, no laboratory studies are necessary, though on rare occasions, blood work may be needed to rule out other conditions. Plain radiographs of the hip and femur may be performed to assess for possible fracture, underlying degenerative arthritis, calcium deposition in soft tissue in the region of the greater trochanteric bursa, or bony lesions. Bone and computed tomography (CT) scanning can also be used to exclude underlying diseases. Ultrasound and magnetic resonance imaging (MRI) are able to visualize the trochanteric bursa when present.

Treatment may include physical therapy, adjunctive measures such as rest and application of ice, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), injection of corticosteroids and anesthetics, and symptomatic treatment with topical, sustained-release local anesthetic patches.

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Pathophysiology

Acute or repetitive (cumulative) trauma may give rise to inflammation of the affected bursa. Acute trauma includes contusions from falls, contact sports, and other sources of impact.

Other factors that may predispose to trochanteric bursitis include a leg-length discrepancy and lateral hip surgery.[5] Even if no true anatomic leg-length discrepancy is present, running on banked surfaces essentially produces a functional leg-length discrepancy because the contact surface of the downhill foot is lower. In addition, individuals with a broader greater trochanteric width in relation to their iliac crest width appear to be more likely to develop trochanteric bursitis.[6]

The term greater trochanteric pain syndrome (GTPS) is now frequently substituted for the term trochanteric bursitis. Ongoing research using ultrasonography, MRI, and histologic analysis suggests that GTPS may be a better label for this condition, in that the regional pain and reproducible tenderness may be associated with myriad causes besides bursitis, such as tendinitis, tendinosis, tendinopathy, muscle tears, trigger points, ITB disorders, and general or localized pathology in surrounding tissues.[2, 7, 8, 9]

It is also worth noting that there are several other bursae in the vicinity of the trochanteric bursa (as noted in the image below) that may also present with pain. The subgluteus medius bursa lies between the gluteus medius tendon and the anterior-superior aspect of the lateral greater trochanter. The subgluteus minimus bursa lies between the gluteus medius tendon and the anterior facet of the greater trochanter. In addition, the subgluteus maximus bursa is more distally located between the distal attachment of the gluteus maximus and the femur.[10] Despite this, the older term, trochanteric bursitis, is still commonly used to describe most lateral hip pain.

Tr B = trochanteric bursa; G Med B = subgluteus me Tr B = trochanteric bursa; G Med B = subgluteus medius bursa; G Min B = subgluteus minimus bursa.
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Etiology

Acute trauma (eg, from a fall or tackle) that causes the patient to land on the lateral hip region can result in trochanteric bursitis. More commonly, repetitive (cumulative) trauma is involved. Such trauma is caused by the repetitive contracture of the gluteus medius, the ITB, or both during running or walking.

Conditions that predispose patients to trochanteric bursitis include underlying lower leg gait disturbances, spinal disorders, and sacroiliac disturbances. Osteoarthritis of the hip may also be responsible, though this diagnosis generally manifests as groin or knee pain rather than lateral hip pain. Another predisposing factor is piriformis syndrome, because the piriformis muscle inserts on the greater trochanteric bursa.

Trochanteric bursitis can also develop as a complication of arthroscopic surgery of the hip (in an estimated 1.4% of cases).[11, 12, 13] At times, the bursitis develops spontaneously without apparent precipitating factors.

A study by Fearon et al suggested that the pain of GTPS may be associated with an increased expression of substance P in the trochanteric bursa. The investigators found the presence of substance P in the trochanteric bursa to be significantly greater in patients with GTPS than in the controls, although the neuropeptide’s presence in tendons attaching to the greater trochanter did not differ significantly between the two groups.[14]

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Epidemiology

Trochanteric bursitis (ie, GTPS) is relatively common among physically active and sedentary patients. The prevalence of unilateral GTPS is 15.0% in women and 8.5% in men, and that of bilateral GTPS is 6.6% in women and 1.9% in men.[15] In a study by Lievense et al, the annual incidence of trochanteric pain in primary care was reported as being 1.8 per 1000 patients.[16]

Trochanteric bursitis can occur in adults of any age. Lievense et al found that trochanteric bursitis appeared to be much more common in females (80%) than in males.[16] No racial predilection has been reported.

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Prognosis

No mortality is associated with trochanteric bursitis. Morbidity includes chronic pain, limping, and pain-related sleep disturbances that occur when the patient is lying on the affected side.[17]

Most patients with trochanteric bursitis respond very well to a combination of corticosteroid injection, physical therapy, and activity restriction. Some patients may require repetition of the corticosteroid injection.

A retrospective study of 164 patients who presented with trochanteric pain found that at least 36% were still symptomatic after 1 year and 29% were still symptomatic after 5 years; thus, many patients developed chronic pain at this site.[16] Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold greater risk of persistent symptoms after 1 year than patients without OA. Patients treated with corticosteroid injection were 2.7 times less likely to have chronic pain at this site at 5 years than patients who were not treated in this manner.

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Patient Education

As with any medical condition, patients should be educated with regard to the nature of the condition, causative factors, and treatment plan. As with any therapy involving injection, patients should be educated to watch for any signs or symptoms of local infection at the injection site.

As with any corticosteroid injection, diabetic patients should be instructed that they may experience a transient increase in their blood glucose levels. All patients should be informed that symptoms usually do not begin to improve until a few days after the corticosteroid injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time during which the local anesthetic has worn off but the corticosteroids have not yet begun to have a therapeutic effect.

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Contributor Information and Disclosures
Author

Douglas D Dean, DO Resident Physician, Department of Physical Medicine and Rehabilitation, Eastern Virginia Medical School

Disclosure: Nothing to disclose.

Coauthor(s)

Peter Gonzalez, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, Eastern Virginia Medical School

Peter Gonzalez, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding

Scott F Nadler, DO Assistant Director of Occupational/Musculoskeletal Medicine, Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Director of Sports Medicine, University Hospital

Scott F Nadler, DO is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Sports Medicine, American Medical Association, Association of Academic Physiatrists, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD Professor of Medicine, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas Medical School at Houston

Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference would like to thank medical student Dena Abdelshahed and Drs. Greg Gazzillo, Debra Ibrahim, Evish Kamrava, Jason Lee, and Dev Sinha for their help in previous revisions of the source articles.

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Tr B = trochanteric bursa; G Med B = subgluteus medius bursa; G Min B = subgluteus minimus bursa.
Photo demonstrates method of stretching iliotibial band (ITB) in standing position. One foot is crossed over other, and patient leans away from side being stretched. Exercise is performed by allowing side that will be stretched to lean in toward wall. Patient should feel stretch at lateral aspect of hip that is closest to wall. Stretching should be done in controlled, sustained manner, never a ballistic manner with sudden jerking movements.
Photo demonstrates method of stretching iliotibial band (ITB) in supine position. Foot ipsilateral to stretch is crossed over contralateral knee. Next, thigh ipsilateral to stretch is pulled across midline (adduction). Patient should feel stretch at lateral aspect of hip, in area shown by dark line. Stretching should be done in controlled, sustained manner, never in ballistic manner with sudden jerking movements.
Table.
For trochanteric bursitis (greater trochanteric pain syndrome [GTPS]), medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and focal corticosteroid injections; these are employed in conjunction with the rest of the rehabilitation plan.
 
Although an off-label use, another option is symptomatic treatment with a topical, sustained-release local anesthetic patch, such as the Lidoderm (lidocaine transdermal) patch, especially when there is an associated sleep disturbance due to the patient lying on the side affected by GTPS.
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