eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Trochanteric Bursitis

Patrick M Foye, MD, FAAPMR, FAAEM, 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
Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine

Updated: Oct 1, 2009

Introduction

Background

Trochanteric bursitis is characterized by painful inflammation of the bursa located just superficial to the greater trochanter of the femur.^1,2,3 Patients typically complain of lateral hip pain, although the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh.⁴

The term greater trochanteric pain syndrome (GTPS) is now being commonly substituted for trochanteric bursitis, because the inflammatory etiology of the pain is being refuted by current research, using ultrasonographic, magnetic resonance imaging (MRI) – based, and histologic evidence.⁵

Pathophysiology

Inflammation of the affected bursa between the femoral trochanteric process and the gluteus medius/iliotibial tract may be caused by acute or repetitive (cumulative) trauma. Acute trauma includes contusions from falls, contact sports, and other sources of impact. Repetitive trauma includes bursal irritation resulting from friction by the iliotibial band (ITB), which is an extension of the tensor fascia lata muscle. (See image below and Image 1.) Such repetitive, cumulative irritation often occurs in runners but can also be seen in less active individuals. Other predisposing factors include a leg-length discrepancy and lateral hip surgery.⁶

Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.

Frequency

United States

Trochanteric bursitis is relatively common in physically active patients, as well as in sedentary individuals.

Unilateral and bilateral greater trochanteric pain syndrome (GTPS) have a prevalence of 15.0% and 8.5% in women, and of 6.6% and 1.9% men, respectively.⁷

International

In a study by Lievense and colleagues, the annual incidence of trochanteric pain in primary care was reported as being 1.8 patients per 1000.⁸

Mortality/Morbidity

• 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.

Race

No racial predilection has been reported.

Sex

Lievense and colleagues found that trochanteric bursitis seems to be much more common in females (80%) than in males.⁸

Age

Trochanteric bursitis can occur in adults of any age. The condition can also develop as a complication (in an estimated 1.4% of cases) of arthroscopic surgery of the hip.^9,10

Clinical

History

• With acute trauma, patients may recall specific details of the impact.
• The classic symptom is pain at the greater trochanteric region of the lateral hip.
• Pain may radiate down the lateral aspect of the ipsilateral thigh; however, it should not radiate all the way into the foot.
• The symptoms are made worse when the patient lies on the affected bursa (that is, when lying in the lateral decubitus position). The pain may awaken the patient at night.
• Hip movements (internal and external rotation), walking, running, weight bearing, and other strenuous activities can exacerbate the symptoms. Patients may report that the pain limits their strength and makes their legs feel weak.
• Onset may be insidious or acute.
• Symptoms are often related to increased activity or exercise.

Physical

• The most classic finding is point tenderness over the greater trochanter, which reproduces the presenting symptoms.
• Palpation may also reproduce pain that radiates down the lateral thigh.
• Bursal swelling may be present, but this may be difficult to appreciate in many patients.
• In obese patients, it may be difficult to locate the trochanter directly. Consider using the iliac crest as a landmark and assessing for the trochanter approximately 8 inches (20 cm) below the pelvic brim. Also consider palpating the region while passively circumducting the hip.
• Overlying skin changes of ecchymosis with abrasions may occur with recent trauma.
• Lateral hip pain can often be elicited by passive external rotation of the hip without provoking such symptoms by internal rotation. Also, the external rotation can be combined with passive hip abduction.
• Lateral hip pain can be reproduced with flexion of the hip and followed by resisted hip abduction.
• Groin pain or referred knee pain provoked by passive internal rotation of the hip may indicate hip joint pathology (such as osteoarthritis).
• To assess for sciatica or lumbosacral radiculopathy, perform a detailed neurologic examination of both lower extremities, including assessments of strength, reflexes, sensation, and dural stretch maneuvers (such as the straight leg raise).

Causes

• Acute trauma, such as 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 and/or the ITB during running or walking.
• Conditions that predispose patients to trochanteric bursitis include underlying lower leg gait and back or sacroiliac disturbances.
• At times, the bursitis develops spontaneously without apparent precipitating factors.

Differential Diagnoses

Osteoarthritis

Other Problems to Be Considered

Fracture of the femur: This must be considered if significant trauma has occurred, particularly in elderly or osteoporotic individuals.
Avascular necrosis of the femoral head
Hip fracture (eg, stress fracture of the femoral neck)
Lumbosacral radiculopathy and trochanteric bursitis: Both can cause pain that radiates down the lower limb.
Gluteus medius bursitis
Gluteus medius partial tear
Iliopsoas bursitis
ITB tendinitis
Osteoarthritis of the hip: Note, however, that this disorder generally manifests with groin or knee pain.
Soft-tissue metastases¹¹
Tuberculous trochanteric bursitis¹²
Iliopsoas tendonitis¹³
"Internal" snapping hip¹³
"External" snapping hip¹³
Iliotibial band inflammation¹³
Gluteal tendon injury¹³

Workup

Laboratory Studies

• Generally, no laboratory studies are necessary for the diagnosis of trochanteric bursitis.
• On rare occasions, blood work may be needed to rule out infection or connective-tissue disease.

Imaging Studies

• Plain radiographs of the hip and femur may be performed to assess for possible fracture, underlying degenerative arthritis, or bony lesions. Pelvic tilting caused by a leg length discrepancy may be appreciated better with standing anteroposterior pelvis and hip films.
• Bone scanning, computed tomography (CT) scanning, and MRI also can be used to exclude underlying diseases. In patients who are suffering from greater trochanteric pain, MRI and ultrasonographic scans potentially can be employed to differentiate gluteus medius tendinitis from trochanteric bursitis.¹⁴
• A 2008 study concluded that on MRI examination, patients with trochanteric bursitis have peritrochanteric T2-signal abnormalities and a higher incidence of abductor tendinopathy. However, the report cautioned that MRI is a poor predictor of trochanteric bursitis, because these findings are not specific to this pathology.¹⁵

Procedures

• Occasionally, diagnostic injection of local anesthetic into the trochanteric bursa may be helpful, particularly in an obese individual in whom the diagnosis is not yet certain.

Histologic Findings

Bursal inflammation

Treatment

Rehabilitation Program

Physical Therapy

While only limited controlled studies have proven the usefulness of physical therapy (PT) for this condition, a specific and goal-directed PT program often seems quite reasonable. PT can be incorporated to teach the patient a home exercise program, emphasizing stretching of the ITB, tensor fascia lata (TFL), external hip rotators, quadriceps, and hip flexors. The use of phonophoresis and soft-tissue massage also may be helpful. (See images below and Images 2-3.)

This photo demonstrates one method of stretching the iliotibial band (ITB) in the standing position. One foot is crossed over the other, and the patient leans away from the side being stretched. The exercise is performed by letting the side to be stretched lean in toward the wall. The patient should feel the stretch at the lateral aspect of the hip that is closest to the wall. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.

This photo demonstrates one method of stretching the iliotibial band (ITB) in the supine position. The foot that is ipsilateral to the stretch is crossed over the contralateral knee. Next, the thigh that is ipsilateral to the stretch is pulled across the midline (adduction). The patient should feel the stretch at the lateral aspect of the hip, in the area shown by the dark line. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.

Transcutaneous electrical nerve stimulation (TENS) can be considered in resistant cases.

Medical Issues/Complications

• Chronic pain
• Limited activity level
• Limping (antalgic gait)
• Sleep disturbance, which is especially problematic for a patient who usually sleeps in the side-lying position

Surgical Intervention

Generally, no surgical intervention is required for cases of trochanteric bursitis, because most patients respond well to nonsurgical treatment. However, longitudinal release of the ITB combined with subgluteal bursectomy appears to be a safe and effective treatment for patients with symptoms that are refractory to conservative management.¹⁶ Only rarely does a patient with trochanteric bursitis need a bursectomy and partial resection of the greater trochanteric process.^17,18,19

Consultations

The patient may be referred to a physiatrist or other musculoskeletal specialist.²⁰

Other Treatment

Treatment may include relative rest, ice, injection, and nonsteroidal anti-inflammatory drugs (NSAIDs).^21,22

• Corticosteroid injection into the trochanteric bursa^23,24,25
  • Many authors and clinicians consider injections to be an important option within the comprehensive treatment plan. A randomized, controlled clinical trial has shown that corticosteroid and lidocaine injection for trochanteric bursitis is an effective therapy with a prolonged benefit.²⁶
  • Trochanteric bursa injections are commonly performed without radiographic guidance. However, some preliminary data suggest that radiological confirmation (for example, with fluoroscopy) is necessary for accurate trochanteric bursa injections, especially in patients who are obese, have a history of trauma, suffer from chronic inflammation, or have had previous surgery, as well as when repeated injections are necessary. Such confirmation may also be needed in patients with chronic pain who therefore have developed peripheral sensitization, which may lead to the injection of medicine into tender areas rather than into areas involved in pain generation.²⁷
  • The procedure for diagnostic injection is to use local anesthetic without epinephrine (for example, 5 mL of 1-2% lidocaine), which is injected into the affected trochanteric bursa using a 22-gauge needle. A 1.5-in (3.8-cm) needle may be adequate for a slimmer patient, but a heavier patient may require a 3.5-in (8.9-cm) needle to reach the bursa. The needle is advanced to the greater trochanter (with contact with the bone being made in order to confirm depth and appropriate placement) and is then withdrawn slightly so that it is located within the bursa. The local anesthetic can then be injected directly into the bursa. If the patient receives appropriate relief, this would be considered confirmation of trochanteric bursitis as the etiology of the pain.
  • This injection of local anesthetic can then be followed by the administration of steroids (by using the needle that is already in place and switching to a syringe containing the corticosteroid). Injection of 40-80 mg of methylprednisolone acetate or triamcinolone acetonide should be adequate. This injection may be repeated at 4-6 weeks if pain relief has been less than 50%.
  • In most cases, in which the diagnosis of trochanteric bursitis seems straightforward from the clinical evaluation, a diagnostic injection (or local anesthetic injection) is not necessary prior to the corticosteroid injection. In these cases, the most straightforward approach is to perform the same needle approach outlined above, followed by the delivery of a mixture of a corticosteroid and a local anesthetic (such as 40-80 mg of long-acting methylprednisolone [eg, Depo-Medrol] and 5 mL of 1% lidocaine).
  • Further specifics of the injection procedure and potential complications are beyond the scope of this text. Interested clinicians are encouraged to read other appropriate sources.
  • In their study, Lievense and colleagues found that, depending on the treatment setting (primary care vs hospital vs specialist), injection rates were 34%, 34%, and 37%, respectively, resulting in improvement rates of 60-66% at follow-up visits 1 year and 5 years later. In patients who received a corticosteroid injection, the chance of recovery at 5 years was 2.7-fold higher than it was for patients who had not received an injection. Thus, the report indicated that corticosteroid injections are predictive for improvement at 5 years, with the injection being associated with a lower likelihood of chronic pain development at the site at which it was administered.⁸
• Relative rest includes restriction of activities, such as climbing stairs or getting in and out of chairs. Direct pressure on the affected site also should be avoided.
• Evaluation and correction of underlying gait abnormalities are important and may be addressed with assistive devices (eg, cane, walker, orthotics, shoe lift, knee brace).
• Use of deep-heating modalities (eg, ultrasound, TENS) should be considered in resistant cases (10-12 wk).

Medication

For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral NSAIDs and focal corticosteroid injections; these are employed in conjunction with the rest of the rehabilitation plan.

Nonsteroidal anti-inflammatory drugs

Oral NSAIDs can help to decrease pain and inflammation and may be used for several weeks. Various oral NSAIDs can be used. The choice of an NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Ibuprofen (Motrin, Advil, Nuprin, Rufen)

DOC for mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-800 mg PO tid/qid

Pediatric

<6 months: Not established
6 months to 12 years: 4-10 mg/kg PO tid/qid
>12 years: Administer as in adults

Interactions

May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity

Contraindications

Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; to minimize risks of side effects, patient should avoid taking multiple NSAIDs concurrently; caution in patients taking anticoagulants or systemic corticosteroids, as well as with bleeding disorders or significant alcohol use; caution in congestive heart failure, hypertension, and decreased renal and hepatic function

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with a small body size, in elderly patients, and in persons with renal or liver disease. Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.

Dosing

Adult

500 mg PO, followed by 250 mg PO q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg PO; not to exceed 10 mg/kg/d

Interactions

Probenecid may increase toxicity of NSAIDs; co-administration with ibuprofen may decrease effects of loop diuretics; co-administration with anticoagulants may prolong PT (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug

Flurbiprofen (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Dosing

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Interactions

May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug

Corticosteroids

In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. When corticosteroid injections are used, there are a variety of corticosteroid preparations from which to choose. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Again, there are various local anesthetic agents from which to choose.

Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, Adlone)

Used commonly for local injections of bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.

Dosing

Adult

40 mg (1 mL), intralesionally, is common for many sites, often mixed with few mL of local anesthetic, such as 1% lidocaine

Pediatric

Not established

Interactions

Local corticosteroid injections are not known to produce the same degree of medication interaction as that resulting from oral or other systemic administration of corticosteroids

Contraindications

Documented hypersensitivity; skin infection at the site of injection; use caution when performing injections in any patient on anticoagulants or with a history of bleeding disorders, because of the risk of hemorrhage or local bruising

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Never inject corticosteroids through an area of infected skin; diabetic patients may sometimes experience a transient elevation of blood glucose level after a local corticosteroid injection

Follow-up

Further Outpatient Care

• The patient should return for re-evaluation within approximately 1 month. Assess for a therapeutic response to the corticosteroid injection and to any other interventions (eg, PT) that have been initiated.
• The patient should be instructed to contact the physician sooner than 1 month after the injection if there is significant progression of the symptoms or if there are any local signs of infection at the injection site.

Deterrence

• Advise the patient to avoid lying on the affected side, if possible.

Complications

• Progressive or persistent pain with associated limping and decreased mobility
• Potential complications resulting from focal corticosteroid injection include the following:
  • Bleeding, bruising, infection, and allergic reactions may occur after the injection.
  • Necrotizing fasciitis has been observed from a single steroid injection of the greater trochanteric bursa.²⁸
  • Transient elevation of blood glucose levels may occur after corticosteroid injection in a diabetic patient.
  • Local anesthetic injected intravascularly potentially could cause cardiac arrhythmia.
  • Subcutaneous skin atrophy can occur with more superficial administration of corticosteroids.
  • Peripheral nerve dysfunction is possible if the injection is administered very close to or within a major nerve.

Prognosis

• Most patients with trochanteric bursitis respond very well to a combination of corticosteroid injection, PT, and activity restriction. Some patients may require a repeat of the corticosteroid injection.
• A retrospective study of 164 patients who presented with trochanteric pain found that after 1 year, at least 36% were still symptomatic, and that after 5 years, 29% were still symptomatic; thus, many patients developed chronic pain at this site. Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold risk of persistent symptoms after 1 year, as compared with patients without OA. Patients treated with corticosteroid injection were 2.7 times less likely to have chronic pain at this site at 5 years, as compared with those treated without such injections.⁸

Patient Education

• As with any medical condition, the patient should be educated with regard to the nature of the condition, causative factors, and treatment plan.
• As with any injection, the patient 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.
• Additionally, as with any corticosteroid injection, patients should be informed that the symptomatic improvement from the corticosteroid usually does not begin to take effect until a few days after the injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time in which the local anesthetic has worn off but the steroids have not yet begun to have a therapeutic effect.

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Bursitis.

Miscellaneous

Medicolegal Pitfalls

• Never inject corticosteroid into a site that appears to be infected.
• In the presence of significant trauma, always check the radiograph for evidence of fracture before proceeding with treatment.
• If it is thought that the pain may be secondary to metastatic cancer, consider performing a bone scan, even if the plain radiograph findings are negative.¹¹

Special Concerns

• Pregnancy - A focal corticosteroid injection can be performed during pregnancy. Oral NSAIDs should be avoided, especially in the third trimester.
• Pediatric population - For a patient who is a minor, obtain informed consent from the parent or legal guardian before proceeding with any injection.
• Geriatric population - The physician should use caution when administering oral NSAIDs to elderly patients.

Multimedia

Media file 1: Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.

Media file 2: This photo demonstrates one method of stretching the iliotibial band (ITB) in the standing position. One foot is crossed over the other, and the patient leans away from the side being stretched. The exercise is performed by letting the side to be stretched lean in toward the wall. The patient should feel the stretch at the lateral aspect of the hip that is closest to the wall. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.

Media file 3: This photo demonstrates one method of stretching the iliotibial band (ITB) in the supine position. The foot that is ipsilateral to the stretch is crossed over the contralateral knee. Next, the thigh that is ipsilateral to the stretch is pulled across the midline (adduction). The patient should feel the stretch at the lateral aspect of the hip, in the area shown by the dark line. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.

References

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Keywords

trochanteric bursitis, bursitis, trochanter, bursitis hip, greater trochanteric bursitis, bursitis injection, trochanteric injection, greater trochanteric pain syndrome, extra-articular snapping hip syndrome, external snapping hip syndrome, painful inflammation of the bursa, lateral hip pain, repetitive contracture of gluteus medius, repetitive contracture of the iliotibial band

Contributor Information and Disclosures

Author

Patrick M Foye, MD, FAAPMR, FAAEM, 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, FAAPMR, FAAEM 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.

Coauthor(s)

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
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.

Medical Editor

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, 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

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the revision of this manuscript.

Evish Kamrava, 4th year medical student, St. George's University School of Medicine, Class of 2009, assisted with the 2008 revision of this manuscript.

Jason Lee, 4th year medical student, St. George's University School of Medicine, Class of 2010, assisted with the 2009 revision of this manuscript.

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