Trochanteric Bursitis: Difference between revisions

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<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
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'''Original Editors ''' - [[User:Emy Van Rode|Emy Van Rode]]  
'''Original Editors ''' - [[User:Emy Van Rode|Emy Van Rode]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}   
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== Search Strategy  ==


<u>'''Databases'''</u><br>
== Definition/Description  ==


*Pubmed
Trochanteric [[bursitis]] was first described in 1923 <ref name=":7">Hilligsøe M, Rathleff MS, Olesen JL. [https://vbn.aau.dk/ws/files/312074292/Study_Protocol_Ultrasound_Definitions_and_Findings_in_Greater_Trochanteric_Pain_Syndrome_A_Systematic_Review_Version_2.pdf Ultrasound definitions and findings in greater trochanteric pain syndrome: a systematic review.] Ultrasound in Medicine & Biology. 2020 Jul 1;46(7):1584-98.</ref><ref name=":8">Board TN, Hughes SJ, Freemont AJ. [https://www.researchgate.net/profile/Tim-Board/publication/265419776_Trochanteric_Bursitis_The_Last_Great_Misnomer/links/54d285120cf25017917e624c/Trochanteric-Bursitis-The-Last-Great-Misnomer.pdf Trochanteric bursitis: the last great misnomer]. Hip international. 2014 Nov;24(6):610-5.</ref>and was used to describe lateral [[hip]] [[Pain Behaviours|pain]]<ref name=":8" /><ref name=":9">Lange J, Tvedesøe C, Lund B, Bohn MB. [https://ugeskriftet.dk/files/scientific_article_files/2022-06/a09210714_web.pdf Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain]. Danish medical journal. 2022 Jun 15;69(7):A09210714.</ref> thought to be caused by inflammation of the trochanteric bursa.
*Web of Knowledge
*Google scholar
*Medscape


<u>'''Search words'''</u>
The continued use of trochanteric bursitis for lateral hip pain is however unsuitable as bursitis implies [[Inflammation Acute and Chronic|inflammation]] yet three of the four cardinal inflammatory signs, namely rubor, tumour and calor<ref name=":7" /><ref name=":8" /> <ref name=":10">Reid D. T[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761624/ he management of greater trochanteric pain syndrome: a systematic literature review.] Journal of Orthopaedics. 2016 Mar 1;13(1):15-28.</ref>are rarely present<ref name=":7" /><ref name=":8" />.  Studies have revealed that trochanteric bursitis is rarely present in isolation <ref name=":9" /><ref>Long SS, Surrey DE, Nazarian LN. [https://www.researchgate.net/publication/258067149_Sonography_of_Greater_Trochanteric_Pain_Syndrome_and_the_Rarity_of_Primary_Bursitis Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis]. American Journal of Roentgenology. 2013 Nov;201(5):1083-6.</ref> and that there is a low prevalence of trochanteric bursa inflammation<ref name=":9" /><ref name=":11">Koulischer S, Callewier A, Zorman D. [http://actaorthopaedica.be/assets/2500/02-Koulisher.pdf Management of greater trochanteric pain syndrome: a systematic review.] Acta Orthop Belg. 2017 Jun 1;83(2):205-14.</ref> in patients with lateral hip pain. More recently it has become clear that gluteal tendon pathology ([[Gluteal Tendinopathy|gluteal tendinopathy]] or gluteal tendon tears<ref name=":7" /><ref name=":8" /><ref name=":9" /><ref name=":12">Speers CJ, Bhogal GS. [https://bjgp.org/content/bjgp/67/663/479.full.pdf Greater trochanteric pain syndrome: a review of diagnosis and management in general practice]. British Journal of General Practice. 2017 Oct 1;67(663):479-80.</ref><ref name=":13">Lin CY, Fredericson M. [https://www.researchgate.net/profile/Michael-Fredericson/publication/272409750_Greater_Trochanteric_Pain_Syndrome_An_Update_on_Diagnosis_and_Management/links/5b16dc4e45851547bba30c6b/Greater-Trochanteric-Pain-Syndrome-An-Update-on-Diagnosis-and-Management.pdf Greater trochanteric pain syndrome: an update on diagnosis and management.] Current Physical Medicine and Rehabilitation Reports. 2015 Mar;3(1):60-6.</ref>or [[Snapping Hip and Trochanteric Bursitis|external coxa saltans]] <ref name=":14">Khoury AN, Brooke K, Helal A, Bishop B, Erickson L, Palmer IJ,  et al. [https://academic.oup.com/jhps/article/5/3/296/5068229?login=true Proximal iliotibial band thickness as a cause for recalcitrant greater trochanteric pain syndrome]. Journal of Hip Preservation Surgery. 2018 Aug;5(3):296-300.</ref><ref name=":10" /> is more likely the primary cause of the lateral hip pain and that associated trochanteric bursitis can be present<ref name=":7" /><ref name=":8" /><ref name=":9" /><ref name=":12" /><ref name=":13" />.  The gluteal tendon pathology or external coxa saltans with the possible associated trochanteric bursitis is now referred to as [[Greater Trochanteric Pain Syndrome|greater trochanteric pain syndrome (GTPS)]]<ref name=":8" /><ref name=":11" /><ref name=":12" /><ref name=":13" />. If there is GTPS and an associated bursitis, the bursitis can occur in the subgluteus maximus (trochanteric bursa), subgluteus medius or subgluteus minimus bursa but it most commonly occurs in the trochanteric bursa<ref name=":13" />.


*Hip bursitis
In the rarer cases of isolated trochanteric bursitis, the causes could include:
*Trochanteric Bursitis
*Greater trochanteric pain syndrome


== Definition/Description<br> ==
* [[Sepsis|Septic]] trochanteric [[bursitis]]


For the definition of bursitis: [[Bursitis|Bursitis]].<br>There are 4 different types of hip bursitis: Trochanteric bursitis, [[Iliopsoas Bursitis|iliopsoas bursitis]], [[Gluteal_Bursitis|gluteal bursitis]] and&nbsp;[[Ischial Bursitis|ischial bursitis]]. Trochanteric bursitis is more common. The term greater trochanteric pain syndrome is now often substituted for trochanteric bursitis.[2] The condition is more prevalent in women than men. [3] (level of evidence A1)<br>• In this article, the condition trochanteric bursitis will be treated<br>&nbsp;
If inflammatory signs such as redness, swelling and warmth are present, [[Septic (Infectious) Arthritis|septic arthritis]] should be suspected<ref name=":13" /><ref name=":15">Truong J, Mabrouk A, Ashurst JV. [https://www.ncbi.nlm.nih.gov/books/NBK470331/ Septic Bursitis.] InStatPearls [Internet] 2021 Sep 14. StatPearls Publishing.</ref>.  Sometimes septic bursitis can be present without these inflammatory signs and then aspiration is needed to confirm the diagnosis<ref name=":15" />. It can be acute, sub-acute or chronic<ref name=":15" />.


<br>
* Other causes of  trochanteric bursitis


== Clinically Relevant Anatomy  ==
Certain auto-immune diseases such as [[Rheumatoid Arthritis|rheumatoid arthritis (RA)]] can lead to trochanteric bursitis<ref>Suh JY, Park SY, Koh SH, Lee IJ, Lee K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446489/ Unusual, but important, peri-and extra-articular manifestations of rheumatoid arthritis: a pictorial essay]. Ultrasonography. 2021 Oct;40(4):602.</ref> as well as crystal arthropathies such as [[gout]]<ref name=":13" />. Direct trauma could potentially also lead to isolated trochanteric bursitis. Isolated trochanteric bursitis due to repetitive rubbing/friction is possible<ref name=":14" /> but is very rare<ref name=":9" />.


add text here
== Clinically Relevant Anatomy ==
[[File:Trochanteric_Bursitis.jpg|right|150x150px]]
A bursa is a sac that usually contains a small amount of fluid and functions as a friction-reducing structure between two anatomical structures, e.g. bone and tendon<ref name=":13" /><ref name=":16">Ivanoski S, Nikodinovska VV. [https://sciendo.com/it/article/10.15557/jou.2019.0032 Sonographic assessment of the anatomy and common pathologies of clinically important bursae]. Journal of Ultrasonography. 2019 Jan 1;19(78):212-21.</ref>. Bursitis is characterised by soft-tissue swelling, localised pain, synovial thickening and increased fluid in the bursa<ref name=":16" />.
 
The trochanteric bursa covers the posterior facet and lies deep into the gluteus maximus muscle. It also lies over the trochanter attachments of gluteus medius, gluteus minimus and vastus lateralis<ref name=":13" />. The sub gluteus medius bursa is situated at the lateral and superolateral facets deep to the gluteus medius tendon insertion while the sub gluteus minimus bursa is located between the anterior facet and gluteus minimus tendon<ref name=":13" />.


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==
When there is GTPS with associated  trochanteric bursitis, the following are possible causes/contributing factors:


add text here <br>  
* direct trauma
* mechanical overload<ref name=":10" /><ref name=":0">Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. [https://www.researchgate.net/profile/Bill-Vicenzino/publication/276362252_Gluteal_Tendinopathy_A_Review_of_Mechanisms_Assessment_and_Management/links/555db77208ae8c0cab2af237/Gluteal-Tendinopathy-A-Review-of-Mechanisms-Assessment-and-Management.pdf Gluteal tendinopathy: a review of mechanisms, assessment and management.] Sports Medicine. 2015 Aug;45(8):1107-19.</ref>
* overuse<ref name=":10" />
* compression of the tendon (and bursa)<ref name=":0" />
* female gender<ref name=":13" />
* poor pelvic control or weak hip abductors<ref name=":0" />
* external coxa saltans<ref name=":10" /><ref name=":14" />
* [[Gluteus Medius|Gluteus medius]] <ref name=":1">Pascual-Garrido C, Schwabe MT, Chahla J, Haneda M. [https://www.sciencedirect.com/science/article/pii/S2212628719301549 Surgical treatment of gluteus medius tears augmented with allograft human dermis]. Arthroscopy techniques. 2019 Nov 1;8(11):e1379-87.</ref> and [[Gluteus Minimus|minimus]] tears (degenerative or traumatic)
* [[Obesity]]<ref>Bird PA, Oakley SP, Shnier R, Kirkham BW. [https://onlinelibrary.wiley.com/doi/epdf/10.1002/1529-0131%28200109%2944%3A9%3C2138%3A%3AAID-ART367%3E3.0.CO%3B2-M Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome]. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2001 Sep;44(9):2138-45.</ref>


== Characteristics/Clinical Presentation  ==
GTPS is more common in women in their 4th to 6th decades of life<ref name=":7" /><ref name=":12" />. A recent study found that only 2% of women had isolated trochanteric bursitis, while 25% had hip abductor tendon pathology with an associated trochanteric bursitis<ref name=":9" />.


When the trochanteric bursa is inflammated, the patient will indicate chronic pain and/or point tenderness in the lateral aspect of the hip, more specifically while palpating superior posterior of the greater trochanter. The maximal tenderness is found at the insertion of the M. Gluteus maximus. Tenderness and pain can also be felt over the iliotibial tract.[4] Patients may report that the pain limits their strength and makes their legs feel weak. In some of the cases the patient is not able to lie down the affected side, so pain-related sleep disturbance could develop. [2] Lower back pain can be related to trochanteric bursitis. [6]
Septic bursitis occurs when bacteria is introduced into the bursa<ref name=":1" /> and can occur due to:


<br>In most of the cases there is a weakness of the hip-abductors noticed. So when resisting hip abduction, symptoms of pain and tenderness may be reproduced. This symptoms could also perform while resisting external rotation. It is possible that a snap can be felt in the lateral hip with flexion or extension. [1] <br>(level of evidence A1)<br>
* [[Tuberculosis]] infection (less than 2% of musculoskeletal tuberculosis presents as septic trochanteric bursitis)<ref name=":10" /><ref name=":13" /><ref name=":2">Vlaic J, Pavic I, Batos AT, Zmak L, Kruslin B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343840/ Neglected tuberculous trochanteric bursitis in an adolescent girl: A case report and literature review]. Joint diseases and related surgery. 2021 Aug;32(2):536.</ref>
* Direct puncture of the skin<ref name=":15" />
* Micro-trauma<ref name=":15" />
* [[Cellulitis]] of the skin that is adjacent to the bursa<ref name=":15" />


== Differential Diagnosis  ==
Most cases of acute septic bursitis involve Staphylococcus aureus, followed by Streptococcus<ref name=":15" /> . Atypical mycobacteria or fungi are associated with chronic septic bursitis<ref name=":15" />. Septic bursitis, in general, is more common in men around the age of 50 years<ref name=":15" />. People who are more susceptible to septic arthritis, in general, include those with inflammatory arthritis (e.g. RA) and those with crystal arthropathies like [[gout]] (19).


Trochanteric bursitis is one of the pathologies that can cause lateral hip pain. The other pathologies that are involved could be:
== Characteristics/Clinical Presentation  ==


*Gluteal tendonitis
* Lateral hip pain<ref name=":8" /><ref name=":13" /><ref name=":3">Grimaldi A, Fearon A. [https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5829 Gluteal tendinopathy: integrating pathomechanics and clinical features in its management.] journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):910-22.</ref>
*Gluteal muscle dysfunction (atrophy, tear,…)  
* Pain to the lateral thigh and knee<ref name=":8" /><ref name=":13" /><ref name=":3" />
*Iliotibial band disorders ([[Snapping Psoas / Snapping Hip|_Snapping_Hip]] syndrome)
* Local tenderness over the greater trochanter<ref name=":8" /><ref name=":13" /><ref name=":3" />
*[[Femoral Fractures|Femoral_Fractures]] (Femoral neck stress fractur)
* Pain with side-lying on the affected side<ref name=":8" /><ref name=":13" /><ref name=":3" /> and sometimes when lying on the unaffected side too due to hip adduction on the affected side<ref name=":3" />
*Lumbar spine disease and ipsilateral hip pain.
* Pain with weight-bearing activities<ref name=":8" /><ref name=":13" /><ref name=":3" />
 
* Pain with sitting crossed-legged<ref name=":3" />
[6],[7](level of evidence A1)<br>
* Pain with prolonged sitting<ref name=":8" /><ref name=":13" />


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


• Gluteus medius tendonitis [3]<br>• Iliotibial band disorders ([[Snapping Psoas / Snapping Hip|_Snapping_Hip]]): <br>Confirmed with positive [[Ober's Test|Ober's_Test]]. [6]<br>• Gluteal medius muscle disfunction&nbsp;: <br>Confirmed with positive [[Trendelenburg Test|Trendelenburg_Test]]. Tenderness involving the whole muscle instead of point tenderness. A tear of the muscle can be revealed with an MRI.[7]
There is no one specific test to confirm GTPS. Please see the [[Greater Trochanteric Pain Syndrome|GTPS]] page for a complete list of the tests that can be used. Concerning imaging, ultrasound can be used but is only indicated if conservative management has failed<ref name=":13" /><ref name=":3" />; if the diagnosis is unclear<ref name=":13" /><ref name=":3" /> or if the primary pathology is thought to be a gluteal tear<ref name=":13" />. MRI can be used for differential diagnosis<ref name=":7" /><ref name=":3" />.
 
 Iliotibial band disorders, Gluteal muscle atrophy and hip tendonitis are hard to differentiate with a trochanteric bursitis because they could be in relation with, or even be the cause of this disorder. For instance, while testing for Iliotibial band disorders or gluteal muscle atrophy, symptoms will also occur when suffering from a bursitis. MRI must give more specific information. [6]
 
• Femoral neck stressfracture: <br>The hop test on one leg will cause pain in the ipsilateral groin region in case of a femoral neck stressfracture. [1]<br>• Lumbar spine disease and ipsilateral hip pain&nbsp;:<br>Differentiated with the [[FABER Test|FABER_Test]]&nbsp; [1]<br>(level of evidence A1)<br>
 
== Outcome Measures  ==
 
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])
 
== Physical Examination  ==
 
The first part of the physical examination is to observe the person’s gait for abnormalities like asymmetry of the waist and hips, a favored side while walking. Further, an examination of the hip is important to establish any limitations or deficits that the patient may have. It is possible that there is an underlying disorder or anatomical impairment present that may cause a bursitis or tendonitis. A weakness of the Mm. Gluteï, a unilateral tilt of the pelvis because of a leg length difference and lumbar spine disorders like scoliosis could be responsible for a bursitis or tendonitis. [1] (level of evidence A1)<br>


An examination of the lumbar spine and knee is also required when the patient complains about pain in this area’s. This pain can refer to the patient’s hip pain. In general, it is important to observe, to palpate, to check the range of motion and to test the strength of the muscles and other anatomic structures that are involved in this issue. The range of motion can be checked with several tests: The faber test, trendelenbrug test, Ober’s test, Thomas test [1] and the snapping hip maneuver could be helpful in diagnosing the cause of lateral hip pain.[6] <br><br>
In septic arthritis, [[antibiotics]] should only be started after blood cultures and inflammatory marker investigations have been done and should include white blood count, C-reactive protein and erythrocyte sedimentation<ref name=":15" />. Currently, the gold standard for diagnosis is aspiration and analysis of the bursal fluid<ref name=":15" />. Uric acid and rheumatoid factor should be ordered if one of these is suspected<ref name=":15" />. Imaging does not help diagnose septic arthritis and should only be conducted if other pathology, such as septic arthritis, is suspected<ref name=":15" />.


== Medical Management <br>  ==
== Differential Diagnosis ==
Multiple structures can present as lateral hip pain. In the absence of inflammatory signs, differential diagnosis can include:


add text here <br>  
* GTPS, including external [[Snapping Hip Syndrome|coxa saltans]]<ref name=":10" /><ref name=":14" />, [[Gluteal Tendinopathy|gluteal tendinopathy]]<ref name=":7" /><ref name=":8" /><ref name=":9" />and gluteal tears<ref name=":7" /><ref name=":8" /><ref name=":9" />.
* [[Referred Pain|Referred pain]] from the lumbar spine<ref name=":13" /><ref name=":3" />
* [https://www.physio-pedia.com/Hip_Osteoarthritis?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Hip osteoarthritis]<ref name=":13" /><ref name=":3" />
* [[Femoroacetabular Impingement|Femoroacetabular impingement]]<ref name=":13" /><ref name=":3" />
* Femoral head stress fracture<ref name=":13" />
* [[Labral Tear|Labral tears]]<ref name=":13" /><ref name=":3" />
* Bony metastasis<ref name=":3" />
* [[Femoral Neck Fractures|Neck-of-femur fracture]]<ref name=":3" />
* [[Rheumatoid Arthritis|Rheumatoid arthritis]]<ref name=":3" />
* [[Avascular Necrosis Femoral Head|Femoral head avascular necrosis]]<ref name=":13" />


== Physical Therapy Management <br>  ==
If inflammatory signs are present:


Physical therapy is given to improve flexibility, muscle strengthening and joint mechanics. When these aspects are improved, pain will decrease. [4] The therapy consists of stretching the M. Tensor fasciae latae and the Iliotibial band because these aspects are often shortened and causes an increased friction with the bursa. [1] Iliotibal band syndrome can be confirmed with a positive Ober’s test.[6] When physical examination shows weakness of the hip abductors, the physical therapist must give exercises for strengthening the hip abductors. Weakness of these group of muscles can be noticed while testing the patient on trendelenbrug gait. Other physical therapy interventions are the use of ultrasound, moist heat, patient education regarding activity modification and correcting possible training errors. [3]  
* [[Cellulitis]]<ref name=":15" />
* [[Gout]]<ref name=":15" />
* [[Rheumatoid Arthritis|RA]]<ref name=":15" />


To heal trochanteric bursitis it is necessary to proceed to infiltration of the bursa with antiphlogistic medication (Corticosteroid-injections). In case of a persistent bursitis surgery has to be considered as well. [8]<br>  
== Outcome Measures ==
• VISA-G - GTPS-specific outcome measure<ref>Fearon AM, Ganderton C, Scarvell JM, Smith PN, Neeman T, Nash C, et al. [https://www.sciencedirect.com/science/article/abs/pii/S1356689X15000624?via%3Dihub Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G]. Manual therapy. 2015 Dec 1;20(6):805-13.</ref>
== Physiotherapy Management ==


(levels of evidence A1, C)
If trochanteric bursitis is associated with GTPS, the primary problem will need to be addressed. Please see the Physiopedia pages [[Greater Trochanteric Pain Syndrome|GTPS]], [[Gluteal Tendinopathy|gluteal tendinopathy]] and [[Snapping Hip and Trochanteric Bursitis|coxa saltans]] on how to manage the primary problems of the associated trochanteric bursitis.  For the management of specifically the associated bursitis, please see the medical and surgical management below. The videos below simplifies  Trochantric bursitis and it's physiotherapy management
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|Ue9EL8C4R5Y|400}} <div class="text-right"><ref>Zero To Finals. Understanding Trochanteric Bursitis. Available from: http://www.youtube.com/watch?v=Ue9EL8C4R5Y [last accessed 20/01/2024]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|lRTEnTT4vlY|400}} <div class="text-right"><ref>HT Physio - Over-Fities- Specialist Physio. 5 Best Exercises to FIX Hip Bursitis (Pain on Outside of Hip). Available from: http://www.youtube.com/watch?v=lRTEnTT4vlY [last accessed 20/01/2024]</ref></div></div>
</div>
== Medical Management ==


== Key Research  ==
[[Corticosteroid Medication|Corticosteroid]] injections can be used to manage the associated bursitis in GTPS but they only provide short-term relief<ref name=":11" />. Platelet-rich plasma (PRP) has also been found to be a feasible option<ref>Jacobson JA, Yablon CM, Henning PT, Kazmers IS, Urquhart A, Hallstrom B, et al. [https://pubmed.ncbi.nlm.nih.gov/27663654/ Greater trochanteric pain syndrome: percutaneous tendon fenestration versus platelet‐rich plasma injection for the treatment of gluteal Tendinosis]. ''Journal of Ultrasound in Medicine'', 2016; ''35''(11):2413-2420.</ref><ref>Ali M, Oderuth E, Atchia I, Malviya A. [https://academic.oup.com/jhps/article/5/3/209/5087803?login=true The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review]. Journal of Hip Preservation Surgery. 2018 Aug;5(3):209-19.</ref>, but it is unknown whether corticosteroid injections or PRP are more effective.


add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
[[NSAIDs|Non-steroidal anti-inflammatory drugs]] (NSAIDs) may provide analgesia in the acute phase of GTPS or primary [[bursitis]]. Still, if the GTPS is chronic, NSAIDs are not advised as they may have a detrimental effect on tendon healing<ref name=":13" />.


• Pubmed<br>• Medscape<br>• Web of Knowledge<br>• Google scolar<br>• Book: Meeusen R. Heup- en liesletsels, reeks sportrevalidatie. 90-5583-724-5, 2000.
Septic bursitis is managed with [[antibiotics]] and if pain management is needed, NSAIDs can be used<ref name=":15" />. If the NSAIDs are insufficient, corticosteroid injection can be used<ref name=":15" />. [[Tuberculosis|TB]] trochanteric bursitis is also managed with antibiotics but treatment continues for much longer, usually 6-18 months<ref name=":5">Ramos-Pascua LR, Carro-Fernández JA, Santos-Sánchez JA, Ramos PC, Díez-Romero LJ, Izquierdo-García FM. [https://synapse.koreamed.org/articles/1050379 Bursectomy, curettage, and chemotherapy in tuberculous trochanteric bursitis.] Clinics in Orthopedic Surgery. 2016 Mar 1;8(1):106-9.</ref>.


== Clinical Bottom Line  ==
== Surgical Management ==
Indications for surgery for septic arthritis include<ref name=":15" /> significant swelling, severe cases that aren’t responding to antibiotics alone or chronic or recurrent cases. Operative interventions include:


add text here <br>  
* Suction irrigation<ref name=":15" />
* Needle aspiration in conjunction with systemic antibiotics<ref name=":15" />
* If aspiration fails, incision and drainage<ref name=":15" />
* Bursectomy<ref name=":15" /><ref name=":2" /><ref name=":5" />


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
In GTPS, surgical intervention is only indicated if conservative management has failed<ref name=":12" /> or if there is a significant tendon tear<ref name=":3" />. Surgical options for GTPS, without a tendon tear, that are safe and effective include:


see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]  
* Bursectomy<ref>Wiese M, Rubenthaler F, Willburger RE, Fennes S, Haaker R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456940/pdf/264_2004_Article_569.pdf Early results of endoscopic trochanter bursectomy.] International orthopaedics. 2004 Aug;28(4):218-21.</ref> <ref>Fox JL. [https://www.sciencedirect.com/science/article/abs/pii/S0749806302000397 The role of arthroscopic bursectomy in the treatment of trochanteric bursitis]. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2002;18(7):1-4.</ref>(arthroscopic)
<div class="researchbox">
* [[Iliotibial Tract|Iliotibial tract]] (ITT) release<ref name=":6">Mitchell JJ, Chahla J, Vap AR, Menge TJ, Soares E, Frank JM, et al. [https://www.sciencedirect.com/science/article/pii/S2212628716300755 Endoscopic trochanteric bursectomy and iliotibial band release for persistent trochanteric bursitis.] Arthroscopy Techniques. 2016;5(5):e1185-9.</ref>
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>  
* ITT bursectomy<ref name=":6" />
</div>  
== References  ==


see [[Adding References|adding references tutorial]].  
For gluteal tendon tears, a reconstruction/repair<ref name=":4">Ebert JR, Bucher TA, Mullan CJ, Janes GC. [https://journals.sagepub.com/doi/pdf/10.5301/hipint.5000525 Clinical and functional outcomes after augmented hip abductor tendon repair.] Hip International. 2018 Jan;28(1):74-83.</ref> <ref>Ebert JR, Brogan K, Janes GC. [https://www.researchgate.net/publication/338755889_A_Prospective_2-Year_Clinical_Evaluation_of_Augmented_Hip_Abductor_Tendon_Repair A prospective 2-year clinical evaluation of augmented hip abductor tendon repair.] Orthopaedic Journal of Sports Medicine. 2020 Jan 22;8(1):2325967119897881.</ref>is done. Please see [https://journals.sagepub.com/doi/pdf/10.5301/hipint.5000525 this reference]<ref name=":4" /> for the rehabilitation protocol after abductor tendon repair.


== References ==
<references />  
<references />  


[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]
<br>  
 
<br>1. J. Rosenberg, R. Patel. Hip tendonitis and bursitis review. http://emedicine.medscape.com/article/87169-overview. '''Level of evidence: 1 (A1)'''
 
2. Patrick M Foye, MD, Todd P Stitik, MD. Trochanteric bursitis review. http://emedicine.medscape.com/article/87788-overview '''Level of evidence: 1 (A1)'''
 
3. Kyndall L. Boyle, MS, Shane Jansa, MS, Chad Lauseng, MS, Cynthia Lewis. Management of a Woman Diagnosed with Trochanteric Bursitis with the Use of a Protonics® Neuromuscular System. Journal of the Section on Women’s Health, volume 27, No.1, March 2003
 
4. Bryan S. Williams, Steven P. Cohen: Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. ANESTHESIA &amp; ANALGESIA, Vol. 108, No. 5, May 2009<br>'''Level of evidence: 1 (A1)'''
 
5. Dina L. Jones, Diagnosis of Trochanteric Bursitis Versus Femoral Neck Stress Fracture, case report. Physical Therapy. Volume 77. No 1. January 1997
 
6. Katherine Margo, MD, Jonathan Drezner, MD, and Daphne Motzkin, MD. Evaluation and management of hip pain: An algorithmic approach. The journal of family practice, vol 52, No 8, august 2003.
 
7. M. Lequesne, P. Mathieu, V. vuillemin-Bodaghi, H. Bard, P. Dijan. Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome: Diagnostic Value of Two Clinical Tests. Arthritis &amp; Rheumatism, Vol. 59, No. 2, February 15, 2008, pp 241–246<br>'''Level of Evidence: 1 (A1)'''


8. Cohen S.P., Narvaez J.C., Lebovits A.H., Stojanovic M.P. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. British Journal of Anaesthesia volume 94 , No 1: 100–6, 2005<br>'''Level of Evidence: 3 (C)'''<br>
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Bursitis]]

Latest revision as of 14:09, 20 January 2024

Original Editors - Emy Van Rode as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Mudra Shah, Emy Van Rode, Gertjan Van Gijsegem, Lionel Geernaert, Lena Vanderaa, Wendy Snyders, Admin, Kim Jackson, Andrea Nees, Rachael Lowe, Uchechukwu Chukwuemeka, Vidya Acharya, Wanda van Niekerk, WikiSysop and Claire Knott

Definition/Description[edit | edit source]

Trochanteric bursitis was first described in 1923 [1][2]and was used to describe lateral hip pain[2][3] thought to be caused by inflammation of the trochanteric bursa.

The continued use of trochanteric bursitis for lateral hip pain is however unsuitable as bursitis implies inflammation yet three of the four cardinal inflammatory signs, namely rubor, tumour and calor[1][2] [4]are rarely present[1][2].  Studies have revealed that trochanteric bursitis is rarely present in isolation [3][5] and that there is a low prevalence of trochanteric bursa inflammation[3][6] in patients with lateral hip pain. More recently it has become clear that gluteal tendon pathology (gluteal tendinopathy or gluteal tendon tears[1][2][3][7][8]or external coxa saltans [9][4] is more likely the primary cause of the lateral hip pain and that associated trochanteric bursitis can be present[1][2][3][7][8].  The gluteal tendon pathology or external coxa saltans with the possible associated trochanteric bursitis is now referred to as greater trochanteric pain syndrome (GTPS)[2][6][7][8]. If there is GTPS and an associated bursitis, the bursitis can occur in the subgluteus maximus (trochanteric bursa), subgluteus medius or subgluteus minimus bursa but it most commonly occurs in the trochanteric bursa[8].

In the rarer cases of isolated trochanteric bursitis, the causes could include:

If inflammatory signs such as redness, swelling and warmth are present, septic arthritis should be suspected[8][10].  Sometimes septic bursitis can be present without these inflammatory signs and then aspiration is needed to confirm the diagnosis[10]. It can be acute, sub-acute or chronic[10].

  • Other causes of  trochanteric bursitis

Certain auto-immune diseases such as rheumatoid arthritis (RA) can lead to trochanteric bursitis[11] as well as crystal arthropathies such as gout[8]. Direct trauma could potentially also lead to isolated trochanteric bursitis. Isolated trochanteric bursitis due to repetitive rubbing/friction is possible[9] but is very rare[3].

Clinically Relevant Anatomy[edit | edit source]

Trochanteric Bursitis.jpg

A bursa is a sac that usually contains a small amount of fluid and functions as a friction-reducing structure between two anatomical structures, e.g. bone and tendon[8][12]. Bursitis is characterised by soft-tissue swelling, localised pain, synovial thickening and increased fluid in the bursa[12].

The trochanteric bursa covers the posterior facet and lies deep into the gluteus maximus muscle. It also lies over the trochanter attachments of gluteus medius, gluteus minimus and vastus lateralis[8]. The sub gluteus medius bursa is situated at the lateral and superolateral facets deep to the gluteus medius tendon insertion while the sub gluteus minimus bursa is located between the anterior facet and gluteus minimus tendon[8].

Epidemiology /Etiology[edit | edit source]

When there is GTPS with associated  trochanteric bursitis, the following are possible causes/contributing factors:

GTPS is more common in women in their 4th to 6th decades of life[1][7]. A recent study found that only 2% of women had isolated trochanteric bursitis, while 25% had hip abductor tendon pathology with an associated trochanteric bursitis[3].

Septic bursitis occurs when bacteria is introduced into the bursa[14] and can occur due to:

  • Tuberculosis infection (less than 2% of musculoskeletal tuberculosis presents as septic trochanteric bursitis)[4][8][16]
  • Direct puncture of the skin[10]
  • Micro-trauma[10]
  • Cellulitis of the skin that is adjacent to the bursa[10]

Most cases of acute septic bursitis involve Staphylococcus aureus, followed by Streptococcus[10] . Atypical mycobacteria or fungi are associated with chronic septic bursitis[10]. Septic bursitis, in general, is more common in men around the age of 50 years[10]. People who are more susceptible to septic arthritis, in general, include those with inflammatory arthritis (e.g. RA) and those with crystal arthropathies like gout (19).

Characteristics/Clinical Presentation[edit | edit source]

  • Lateral hip pain[2][8][17]
  • Pain to the lateral thigh and knee[2][8][17]
  • Local tenderness over the greater trochanter[2][8][17]
  • Pain with side-lying on the affected side[2][8][17] and sometimes when lying on the unaffected side too due to hip adduction on the affected side[17]
  • Pain with weight-bearing activities[2][8][17]
  • Pain with sitting crossed-legged[17]
  • Pain with prolonged sitting[2][8]

Diagnostic Procedures[edit | edit source]

There is no one specific test to confirm GTPS. Please see the GTPS page for a complete list of the tests that can be used. Concerning imaging, ultrasound can be used but is only indicated if conservative management has failed[8][17]; if the diagnosis is unclear[8][17] or if the primary pathology is thought to be a gluteal tear[8]. MRI can be used for differential diagnosis[1][17].

In septic arthritis, antibiotics should only be started after blood cultures and inflammatory marker investigations have been done and should include white blood count, C-reactive protein and erythrocyte sedimentation[10]. Currently, the gold standard for diagnosis is aspiration and analysis of the bursal fluid[10]. Uric acid and rheumatoid factor should be ordered if one of these is suspected[10]. Imaging does not help diagnose septic arthritis and should only be conducted if other pathology, such as septic arthritis, is suspected[10].

Differential Diagnosis[edit | edit source]

Multiple structures can present as lateral hip pain. In the absence of inflammatory signs, differential diagnosis can include:

If inflammatory signs are present:

Outcome Measures[edit | edit source]

• VISA-G - GTPS-specific outcome measure[18]

Physiotherapy Management[edit | edit source]

If trochanteric bursitis is associated with GTPS, the primary problem will need to be addressed. Please see the Physiopedia pages GTPS, gluteal tendinopathy and coxa saltans on how to manage the primary problems of the associated trochanteric bursitis. For the management of specifically the associated bursitis, please see the medical and surgical management below. The videos below simplifies Trochantric bursitis and it's physiotherapy management

[19]
[20]

Medical Management[edit | edit source]

Corticosteroid injections can be used to manage the associated bursitis in GTPS but they only provide short-term relief[6]. Platelet-rich plasma (PRP) has also been found to be a feasible option[21][22], but it is unknown whether corticosteroid injections or PRP are more effective.

Non-steroidal anti-inflammatory drugs (NSAIDs) may provide analgesia in the acute phase of GTPS or primary bursitis. Still, if the GTPS is chronic, NSAIDs are not advised as they may have a detrimental effect on tendon healing[8].

Septic bursitis is managed with antibiotics and if pain management is needed, NSAIDs can be used[10]. If the NSAIDs are insufficient, corticosteroid injection can be used[10]. TB trochanteric bursitis is also managed with antibiotics but treatment continues for much longer, usually 6-18 months[23].

Surgical Management[edit | edit source]

Indications for surgery for septic arthritis include[10] significant swelling, severe cases that aren’t responding to antibiotics alone or chronic or recurrent cases. Operative interventions include:

  • Suction irrigation[10]
  • Needle aspiration in conjunction with systemic antibiotics[10]
  • If aspiration fails, incision and drainage[10]
  • Bursectomy[10][16][23]

In GTPS, surgical intervention is only indicated if conservative management has failed[7] or if there is a significant tendon tear[17]. Surgical options for GTPS, without a tendon tear, that are safe and effective include:

For gluteal tendon tears, a reconstruction/repair[27] [28]is done. Please see this reference[27] for the rehabilitation protocol after abductor tendon repair.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Hilligsøe M, Rathleff MS, Olesen JL. Ultrasound definitions and findings in greater trochanteric pain syndrome: a systematic review. Ultrasound in Medicine & Biology. 2020 Jul 1;46(7):1584-98.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: the last great misnomer. Hip international. 2014 Nov;24(6):610-5.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Lange J, Tvedesøe C, Lund B, Bohn MB. Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain. Danish medical journal. 2022 Jun 15;69(7):A09210714.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Reid D. The management of greater trochanteric pain syndrome: a systematic literature review. Journal of Orthopaedics. 2016 Mar 1;13(1):15-28.
  5. ↑ Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology. 2013 Nov;201(5):1083-6.
  6. ↑ 6.0 6.1 6.2 Koulischer S, Callewier A, Zorman D. Management of greater trochanteric pain syndrome: a systematic review. Acta Orthop Belg. 2017 Jun 1;83(2):205-14.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Speers CJ, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. British Journal of General Practice. 2017 Oct 1;67(663):479-80.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 8.23 8.24 8.25 8.26 Lin CY, Fredericson M. Greater trochanteric pain syndrome: an update on diagnosis and management. Current Physical Medicine and Rehabilitation Reports. 2015 Mar;3(1):60-6.
  9. ↑ 9.0 9.1 9.2 9.3 Khoury AN, Brooke K, Helal A, Bishop B, Erickson L, Palmer IJ, et al. Proximal iliotibial band thickness as a cause for recalcitrant greater trochanteric pain syndrome. Journal of Hip Preservation Surgery. 2018 Aug;5(3):296-300.
  10. ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 10.13 10.14 10.15 10.16 10.17 10.18 10.19 10.20 10.21 10.22 Truong J, Mabrouk A, Ashurst JV. Septic Bursitis. InStatPearls [Internet] 2021 Sep 14. StatPearls Publishing.
  11. ↑ Suh JY, Park SY, Koh SH, Lee IJ, Lee K. Unusual, but important, peri-and extra-articular manifestations of rheumatoid arthritis: a pictorial essay. Ultrasonography. 2021 Oct;40(4):602.
  12. ↑ 12.0 12.1 Ivanoski S, Nikodinovska VV. Sonographic assessment of the anatomy and common pathologies of clinically important bursae. Journal of Ultrasonography. 2019 Jan 1;19(78):212-21.
  13. ↑ 13.0 13.1 13.2 Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine. 2015 Aug;45(8):1107-19.
  14. ↑ 14.0 14.1 Pascual-Garrido C, Schwabe MT, Chahla J, Haneda M. Surgical treatment of gluteus medius tears augmented with allograft human dermis. Arthroscopy techniques. 2019 Nov 1;8(11):e1379-87.
  15. ↑ Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2001 Sep;44(9):2138-45.
  16. ↑ 16.0 16.1 Vlaic J, Pavic I, Batos AT, Zmak L, Kruslin B. Neglected tuberculous trochanteric bursitis in an adolescent girl: A case report and literature review. Joint diseases and related surgery. 2021 Aug;32(2):536.
  17. ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 17.12 17.13 17.14 17.15 17.16 17.17 Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):910-22.
  18. ↑ Fearon AM, Ganderton C, Scarvell JM, Smith PN, Neeman T, Nash C, et al. Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G. Manual therapy. 2015 Dec 1;20(6):805-13.
  19. ↑ Zero To Finals. Understanding Trochanteric Bursitis. Available from: http://www.youtube.com/watch?v=Ue9EL8C4R5Y [last accessed 20/01/2024]
  20. ↑ HT Physio - Over-Fities- Specialist Physio. 5 Best Exercises to FIX Hip Bursitis (Pain on Outside of Hip). Available from: http://www.youtube.com/watch?v=lRTEnTT4vlY [last accessed 20/01/2024]
  21. ↑ Jacobson JA, Yablon CM, Henning PT, Kazmers IS, Urquhart A, Hallstrom B, et al. Greater trochanteric pain syndrome: percutaneous tendon fenestration versus platelet‐rich plasma injection for the treatment of gluteal Tendinosis. Journal of Ultrasound in Medicine, 2016; 35(11):2413-2420.
  22. ↑ Ali M, Oderuth E, Atchia I, Malviya A. The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. Journal of Hip Preservation Surgery. 2018 Aug;5(3):209-19.
  23. ↑ 23.0 23.1 Ramos-Pascua LR, Carro-Fernández JA, Santos-Sánchez JA, Ramos PC, Díez-Romero LJ, Izquierdo-García FM. Bursectomy, curettage, and chemotherapy in tuberculous trochanteric bursitis. Clinics in Orthopedic Surgery. 2016 Mar 1;8(1):106-9.
  24. ↑ Wiese M, Rubenthaler F, Willburger RE, Fennes S, Haaker R. Early results of endoscopic trochanter bursectomy. International orthopaedics. 2004 Aug;28(4):218-21.
  25. ↑ Fox JL. The role of arthroscopic bursectomy in the treatment of trochanteric bursitis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2002;18(7):1-4.
  26. ↑ 26.0 26.1 Mitchell JJ, Chahla J, Vap AR, Menge TJ, Soares E, Frank JM, et al. Endoscopic trochanteric bursectomy and iliotibial band release for persistent trochanteric bursitis. Arthroscopy Techniques. 2016;5(5):e1185-9.
  27. ↑ 27.0 27.1 Ebert JR, Bucher TA, Mullan CJ, Janes GC. Clinical and functional outcomes after augmented hip abductor tendon repair. Hip International. 2018 Jan;28(1):74-83.
  28. ↑ Ebert JR, Brogan K, Janes GC. A prospective 2-year clinical evaluation of augmented hip abductor tendon repair. Orthopaedic Journal of Sports Medicine. 2020 Jan 22;8(1):2325967119897881.


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