eMedicine Specialties > Sports Medicine > Hip

Hip Tendonitis and Bursitis: Treatment & Medication

Author: Jeffrey Rosenberg, MD, Director of Primary Care Sports Medicine Fellowship, Assistant Residency Director, Mountainside Hospital and Mountainside Family Practice Associates; Consulting Staff, New Jersey Sports Medicine Institute
Coauthor(s): Rutvik Patel, DO, Fellow in Sports Medicine, Mountainside Sports Medicine
Contributor Information and Disclosures

Updated: Mar 31, 2008

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The initial treatment for all chronic hip overuse injuries is similar, and this can be taught to patients in the office or via formal physical therapy. The initial alleviation of overuse pain is accomplished with relative rest of the painful area. The patient may continue to work out other body parts and attempt to maintain cardiovascular fitness. Pain relief can be improved with oral anti-inflammatory medications, as well as with modalities such as ice, ultrasound treatment, and high-intensity galvanic stimulation. Patients thought to have tendinopathy can use acetaminophen for pain relief because the affected tendon is not inflamed.
 
To prevent further symptoms, increasing the length of the muscle-tendon unit with stretching and increasing joint flexibility are paramount. Active stretching of the injured muscle must be accomplished to improve its length. At the same time, the injured muscle must be strengthened. Eccentric exercises, in which the muscle is lengthened and tightened at the same time (such as with lunges) should be added once full lengthening has returned. Once the proper length of the muscle has been attained and its strength restored, the addition of activity and sport-specific exercises completes the rehabilitation. Increasing the flexibility and strength of the opposing muscle groups is also required. 

Because most of these muscles attach to the pelvic ring, attention to stretching and strengthening of all peripelvic tissues is helpful. Increasing the strength of the abductor muscles, such as the gluteus medius, should improve pelvic stability. Manual therapies are also helpful for manipulating the symphysis pubis and SI joints.

Leg-length discrepancies greater than 1 cm should be corrected with shoe lifts to improve balance and pelvic symmetry. Likewise, correction of any pes planus and the use of anti-pronation devices with an over-the-counter or custom orthosis is imperative for active individuals who do weight-bearing exercises or who run and walk regularly.

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Medical Issues/Complications

If the patient's condition is not responding as expected to treatment for the initial diagnosis, a second look at the symptoms and perhaps an additional piece of imaging may be performed to confirm that the diagnosis was appropriate (see Differentials and Other Problems to Be Considered).

Intra-abdominal or pelvic pathology can occasionally cause hip pain. If any gastrointestinal symptoms such as a change in bowel habits; the presence of blood in stool; or the presence of gynecologic symptoms such as bloating, new menstrual irregularities, or dyspareunia are present, a gastrointestinal or genitourinary workup may be necessary.

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Surgical Intervention

• Surgical therapy for chronic hip overuse injuries is occasionally necessary. Partial tendon excision and debridement of tendon scars have been performed for both adductor and hamstring injuries that fail to resolve. These surgeries are usually reserved for high-level athletes whose conditions fail to improve and who return to activity with prolonged courses of physical therapy. After surgery, such a prolonged physical therapy is needed to return athletes to their full ROM and strength. 
• Large avulsion fractures of the rectus, hamstring, and iliopsoas should be internally fixated. Likewise, large apophyseal avulsions (greater than 2 cm) should be repaired. Intra-articular disorders, such as labral tears, and intra-articular loose bodies need hip arthroscopy to improve an individual's symptoms and level of activity.

Recovery Phase

Rehabilitation Program

Physical Therapy

See Treatment, Acute Phase.

Tendinopathy treatment can often be frustrating for clinicians and patients alike. The degenerative tendon must be lengthened with aggressive and constant stretching. Eccentric exercises have been proven to decrease pain and return patients to a full level of activity in both hamstring and patellar tendinopathy.

Consultations

The treatment of hip overuse syndrome (traction tendinitis) is never a short-term proposition; thus, treating this condition effectively requires a team approach. Optimally, medical resources are available to include a physical therapist and a fitness trainer who are skilled in laddered, progressive exercise following an individual's injury.

Chronic hip pain often goes undiagnosed, leading to psychologic difficulties from the debilitating nature of the pain itself and the frustration of being unable to return to a sport or exercise in a timely fashion. A psychology consultation may be indicated in such cases.

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Other Treatment (Injection, manipulation, etc.)

• The treatment of greater trochanteric bursitis involves lengthening the tensor fasciae latae/iliotibial band complex. Additionally, an injection of corticosteroid into the affected bursa can be added if necessary. Likewise, injections into the iliopsoas bursa can be performed by experienced clinicians using ultrasound guidance.  
• Interventional treatments for chronic tendinopathy have met with varied success. The goal of all of these therapies is to restart the healing process by increasing inflammation and blood flow into an area, thereby allowing new progenitor cells to come into the area, lay down healthier collagen, and improve the organization of collagen. Any patients who undergo these treatments should not use anti-inflammatory medications because these drugs will prevent the inflammation that is being sought. 
• Prolotherapy (also called proliferative therapy) involves injecting 3% NaCl or 10% dextrose into and around the affected tendon to restart the inflammatory cascade. 
• Injections of autologous whole blood and platelet-rich plasma concentrations have also been attempted for the treatment of tendinopathy in other parts of the body. Using these injections under ultrasound guidance will likely increase their effectiveness. Likewise, performing percutaneous needling of the tendon by fenestration with an 18- or 21-gauge needle before administration of the injection will improve the flow of blood and inflammation into the tendon.

Medication

For patients with hip overuse syndrome, medications are used primarily to decrease pain and inflammation. These agents are best used for short time periods in the acute setting after an injury to prevent further swelling and pain. 

Inflammation is part of the normal healing response and may be necessary to allow for complete tissue recovery. Some theories regarding tendinopathy involve the belief that stopping the healing response by halting all inflammation prevents the eventual recovery of tendons by interfering with normal collagen deposition and alignment. By preventing new blood-vessel formation into an injured area, complete healing does not occur.

In patients without known contraindications, nonsteriodal anti-inflammatory medications (NSAIDS) are preferred for short time periods for pain and inflammation control. Providers can decide which NSAIDS are the ones they are most comfortable using.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

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Ibuprofen (Motrin, Excedrin IB, Ibuprin, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprosyn, Anaprox, Aleve, Naprelan)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Ketoprofen (Actron, Orudis, Oruvail)

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

Nabumetone (Relafen)

Nonacidic NSAID that is rapidly metabolized after absorption to a major active metabolite that inhibits cyclooxygenase enzyme, which in turn inhibits inflammation.

Cyclooxygenase-2 (COX-2) Inhibitors

COX-2 inhibitors are a class of NSAIDs that have a decreased incidence of adverse GI effects, such as gastritis and ulcers. COX-2 inhibitors may be indicated in patients with a history of gastric ulcers, who require anti-inflammatory medications.

Celecoxib (Celebrex)

Inhibits primarily COX-2, an isoenzyme that is induced during pain and with inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme not inhibited; therefore, GI toxicity may be decreased. Seek the lowest dose for each patient.

Analgesics

Simple analgesics like acetaminophen may be preferred for conditions in which NSAID use is not advised or in which there is little suspicion of an underlying inflammatory process.

Tramadol hydrochloride is an opioid analgesic that has noradrenergic and serotonergic properties that may contribute to its analgesic activity. Tramadol is used for moderate to severe pain or in cases wherein NSAIDs cannot be taken. The potency of this agent is less than that of traditional opioids, and there is less (but not zero) addiction potential.

Acetaminophen (Aspirin-free Anacin, Tylenol, Feverall, Tempra)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Tramadol (Ultram, Ultram ER)

Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.

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