What Is A Bursa?
A bursa is a closed fluid-filled sac that functions as a gliding surface in the body. Existing to reduce friction between moving tissues, acting as a cushion between soft tissues such as muscles, tendons, and skin and the uncompromising hardness of bones. All major bursae of the body are located near large joints like the shoulders, elbows, hips and knees knees… Lying adjacent to the tendons around these large joints and inflamed, the resulting condition is known as “bursitis”. Whereby an individual with an inflamed bursa at the hip would be referred to as having hip bursitis, the most common of which is a trochanteric bursitis also referred to as greater trochanteric pain syndrome (GTPS).
Presentation Of Pain With A Trochanteric Bursitis
There are other common bursitis conditions in the hip and pelvic area including ischial bursitis, and iliopsoas bursitis which present as literally a pain in the butt and a pain in the front of the hip respectively. Where as a trochanteric bursitis causes pain around the lateral (outside) hip area. Trochanteric bursitis is one of the most commonly diagnosed bursitis in the body and the most commonly diagnosed in the hip. Anatomically the superficial trochanteric bursa which is the pain source in this condition is positioned over the prominent greater trochanter a part of the femur near the ball and socket that is your hip joint. This bursa can become irritated if the hip is “overused” or traumatically injured and frequently causes resting, and activity related discomfort, as well as and local tenderness on palpation of the outer hip area.
Other than the pain pattern and the area being sensitive to palpation there are other signs someone may have a hip bursitis.
- Pain lying on the affected side is a common sign, this can be significant enough to disturb sleep.
- Rising from a deep chair following a period of prolonged sitting, or moving folloing sitting with leg crossed can both trigger pain in someone with a trochanteric bursitis.
- Hip bursitis pain may also be aggravated with simply walking, if not walking commonly negotiating stairs and exercise will trigger pain during, or after.
- Active adults regularly involved in among others running or cycling activities can be susceptible to developing greater trochanteric pain, potentially due in some part to the iliotibial band (ITB) mechanics. Your ITB is a long band of connective tissue which runs from the hip to the knee down the outside of the thigh crossing the greater trochanter and can in turn compress against the trochanteric burs. This compression/rubbing against the greater trochanter and overlying bursa potentially causes irritation when performing repetitive activities like running. It is therefore postulated a “tight” ITB as being a potential trigger or hip bursitis due to friction against the trochanteric bursa.
Diagnosing Hip Bursitis
Diagnosis with a trochanteric bursitis is usually based on clinical evaluation. At the Movement Centre our physiotherapists will start by taking a medical history, including any history of previous relevant injuries, or medical condition and the specific history of the hip discomfort. They will then will perform a physical examination of your hip, and as appropriate the spine, pelvis, feet or other areas deemed relevant to your history.
The use of medical investigations including ultrasound imaging and MRI can help confirm diagnosis, as well as ruling out of other conditions that could cause a similar presentation. An X-ray of the hip can highlight any areas of calcium deposits in neighboring tendons as well as highlight indications of osteoarthritis. All these investigations are sometimes used to assist in the diagnosis and management of hip bursitis, however as previously mentioned with a trochanteric bursitis diagnosis is typically a clinical one, without the need for investigations to proceed with any treatment planning or implementation.
Causes Of Trochanteric Bursitis
A trochanteric bursitis can be the result of both local trauma, or tissue overload. Local trauma causing injury to the trochanteric bursa could be the result of falling off a push bike, falling off a bike, or any fall onto your side where the individual lands on their lateral hip area impacting the bursa at the side of the hip can cause blunt trauma to the bursa and trigger an acute bursitis. More commonly in our
Randwick physio practice we see trochanteric bursitis with its onset being more gradual in nature. Repetitive load to the hip and bursa associated with activities involving running, or cycling are frequent causes.
Friction to the bursa over time can lead to irritation, should cycling or running activities be performed with poor muscle control, technique or even improper equipment such as an ill fitted bike any pressure, or friction to the bursa with activity may be amplified.
Weak hip muscles, rheumatoid arthritis,
osteoarthritis (degenerative joint disease) of the hip, calcium deposition in the gluteal tendons as well as leg length discrepancies where an individual has altered biomechanis as a result of having one leg longer than the other, can all increase an individuals risk of developing trochanteric bursitis.
Hip Bursitis Treatment
In the early stages avoidance of aggravating activities and use of remedies to manage pain and inflammation are frequently beneficial. When individuals persist with aggravating activities symptoms may struggle to settle, henceforth some form of activity modification is usually necessary in managing hip bursitis. Physiotherapy as a profession is often called on in both acute early stages and the more chronic ongoing management of hip bursitis. Physiotherapy is used to initially settle the pain and ultimately to address any perceived stability, mobility biomechanical issues of hip and lower limb allowing a return to normal pain free function. Where the goal is ensuring balanced support around the hip joint exists and creating an environment where activity doesn’t irritate the bursa and tissues are conditioned appropriately to take the load required to perform the activities of daily life, employment and sport. The trochanteric bursa in part at least is thought to get irritated as a result of the iliotibial band (ITB) rubbing against the bursa. Your ITB is a long band of connective tissue that runs down the outside of the thigh from the hip to the knee and repetitive activities like going up and down stairs and running can cause the band to friction against the bursa. It is therefore suggested that a “tight” ITB can be a potential trigger/contributor and as a result physiotherapists often where appropriate look at releasing tight structures around the hip including the ITB and the muscles feeding into the ITB and at the ITB interface.
Other treatment approaches someone with hip bursitis may be suggested include:
- Ice: Particularly relevant if a traumatic bursitis where there is local swelling or bruising following the blunt trauma and when this is the case some will find that regular application of ice packs can help to reduce pain and swelling.
- Aspiration: Most likely performed by a specialist is occasionally considered as a treatment option again more likely where there is a significantly enlarged traumatic bursitis than an overload hip bursitis. If the bursa is significantly swollen “draining” the bursa may be recommended, however not something we commonly hear of these days.
- Non-steroidal anti-inflammatory medications (NSAIDs): Topical applied to the area as a cream or oral NSAIDs similar to the application of ice mentioned above can help reduce pain, swelling and inflammation associated with trochanteric bursitis.
- Corticosteroid injections: A cortisone injection in persistent, or severe cases may be recommended. Like using NSAIDs cortisone injection is aimed at reducing the inflammation in that area. The more invasive the treatment the more risk of side effects so cortisone injections as usually reserved for those not coping with the pain and making limited progress.
- Surgery: The use of surgery as a treatment for hip bursitis is not a common path we see taken at our Randwick physio practice. If surgery is opted for then surgical procedures may include a bursectomy (the removal of the bursa), ITB release, gluteus tendon repair, or greater trochanter osteotomy. Surgical relevance and technique selection are the domain of the orthopaedic surgeon and if any chronic hip bursitis condition is failing to respond to conservative treatment we are happy to refer on to some fantastic local hip surgeons.
Regardless the approach be it surgery, injections, medications…Physiotherapy treatment helps make up part of any good rehabilitation and preventative program for trochanteric bursitis and is regularly employed in combination to any of the above mentioned approaches.
Prevention Of Trochanteric Bursitis
Some hip bursitis conditions respond quickly with symptoms settling within only a few weeks. More chronic cases symptoms may persist for several months particularly in overload situations where tendinopathy of gluteal muscles coexists .
A solid rehabilitation and prevention strategy is aiming to achieve good biomechanics and hip muscle control though the guidance of your physiotherapist or similarly skilled practitioner. Where the goal is addressing postural control, mobility, strength and the endurance of hip muscles as necessary, to promote both the settling of symptoms and avoid any recurrence of hip bursitis once load is reintroduced into daily life.
