History
The classic symptom is pain at the greater trochanteric region of the lateral hip. The pain may radiate down the lateral aspect of the ipsilateral thigh; [5] however, it should not radiate all the way into the foot. Onset may be either insidious or acute. 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.
Symptoms are often related to increased activity or exercise. With acute trauma, patients may recall specific details of the impact.
A cross-sectional study by Plinsinga et al indicated that, compared with healthy controls, patients with persistent, clinically diagnosed greater trochanteric pain syndrome (GTPS) tend to have significantly poorer quality of life, a reduced local pressure-pain threshold, poorer health status, impaired physical function, lower conditioned pain modulation, reduced hip abductor/extensor strength, greater levels of depression and anxiety, and a lower local cold-pain threshold. Moreover, they tend to spend less time engaged in vigorous physical activity. According to the investigators, depression, hip abductor strength, and time to complete stairs accounted for 26% of pain and disability in the study. [30]
Physical Examination
The most classic physical finding is point tenderness over the greater trochanter, which reproduces the presenting symptoms. Palpation may also reproduce pain that radiates down the lateral thigh. Additionally, it has been reported that tenderness to areas that are either superior or posterolateral to the trochanter can be identified. [6] Bursal swelling may be present, but this may be difficult to appreciate in many patients. With recent trauma, overlying skin changes of ecchymosis with abrasions may be apparent.
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.
Lateral hip pain can often be elicited by carrying out passive external rotation of the hip without provoking such symptoms by internal rotation or performing end-range adduction. [7] In addition, the external rotation can be combined with passive hip abduction. Lateral hip pain can be reproduced with flexion of the hip followed by resisted hip abduction. Groin pain or referred knee pain provoked by passive internal rotation of the hip may indicate hip joint pathology (eg, osteoarthritis). Performing other specific musculoskeletal examinations, such as the Trendelenberg test and Ober test, can help to identify other structural derangements that may lead to lateral hip pain. [7, 8]
A study by Ganderton et al indicated that in women, the most diagnostically accurate clinical tests for greater trochanteric pain syndrome included palpation of the greater trochanter, resisted hip abduction, the resisted external derotation test, and the Patrick, or FABER (flexion, abduction, external rotation), test. [31]
To assess for sciatica or lumbosacral radiculopathy, perform a detailed neurologic examination of both lower extremities, including assessment of strength, reflexes, and sensation, as well as dural stretch maneuvers (eg, the straight leg raise).
Complications
Complications of trochanteric bursitis may include the following:
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Progressive or persistent pain
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Reduced mobility
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Limited activity level
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Limping (antalgic gait)
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Sleep disturbance, which is especially problematic for a patient who usually sleeps in the side-lying position
Potential complications resulting specifically from focal corticosteroid injection include the following:
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Bleeding, bruising, infection, and allergic reactions occurring after the injection
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Necrotizing fasciitis – This has been observed from a single steroid injection of the greater trochanteric bursa [32]
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Transient elevation of blood glucose levels occurring after corticosteroid injection in a diabetic patient
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Cardiac arrhythmia occurring after intravascular injection of a local anesthetic
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Subcutaneous skin atrophy occurring with more superficial administration of corticosteroids
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Peripheral nerve dysfunction if the injection is administered very close to or within a major nerve
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Tr B = trochanteric bursa; G Med B = subgluteus medius bursa; G Min B = subgluteus minimus bursa.
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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.
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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.
Tables
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. |
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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. |
