Trochanteric Bursitis

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  • Hip bursitis
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Trochanteric bursitis is an inflammation of the trochanteric bursa. The fact that it’s a Bursitis, implicates it has an inflammatory component but we have to take into account that 3 of the 4 elements of an inflammation named rubor, calor and tumor aren’t present. Only the sign of pain is present.
Trochanteric bursitis is an element of a greater term, hip bursitis, that envelopes 4 different types:trochanteric bursitis, Iliopsoas BursitisGluteal Bursitis and Ischial Bursitis
It’s often used as a general term to describe pain around the greater trochanteric region of the hip. Trochanteric bursitis is frequently confused with Greater Trochanter Pain Syndrome(GTPS). Trochanteric bursitis is in fact a component of GTPS that’s also including other conditions that cause lateral-sided hip pain.
Trochanteric bursitis most commonly results from friction of the overlying iliotibial band.

Clinically Relevant Anatomy

A bursa is a double membrane filles with fluid located near a joint. A bursa is filled with synovial fluid, which lessens friction between tissues. It forms a sort of cushion between bones and muscles and acts as a shock absorber and lubricant during the movement of muscles and joints.
For the mechanism of injury or the pathological process of bursitis: see page of Bursitis

Trochanteric Bursitis.jpg

When you have a trochanteric bursitis two bursae can ignited. The first one is the subgluteus medius bursa. This bursa is located above the greater trochanter. It also lies underneath the insertion of the gluteus medius. The second one is the subgluteus maximus bursa. This bursa is situated between the greater trochanter and the insertion of the gluteus medius and gluteus maximus muscle.

Epidemiology /Etiology

Inflammation of the bursa is a slow process, which progresses over time. This bursitis most often occurs because of friction, overuse, trauma or too much pressure.
The etiology of a bursitis isn’t entirely known.
There are two types of bursitis. Acute bursitis occurs because of trauma or a massive overload. After a few days’ symptoms like pain, swelling and a warm feeling when touching the affected area can be noticed. It will also be very painful to move the joint. The second one is chronic bursitis which is caused by overuse, too much pressure on the structures or by extreme movements. Wrong muscle strain can also be a cause of chronic bursitis. The main symptom – which is always present – is pain.

There are many factors that may cause trochanteric bursitis:
• Sex: there are more women with problems of the bursa trochanterica than men;
• Overweight;
• Trauma: e.g. injury of the greater trochanter: this can deface the bursa.
• Overuse of the muscles around the bursa or the joint underneath the bursa.
• Incorrect position: this can cause an increase in pressure.
• Too much pressure on the bursa (caused by friction of the ITB)
• Dysfunction of the insertion of the muscle gluteus medius.
• Hip osteoarthritis
• Lumbar spondylosis
• Excessive or rapidly increased mileage
• Repetitive strain: e.g. frequent training with too much weight or training in a bad position
• Poorly cushioned shoes: results in increased pressure on the muscles, joint and bursa
• Excessive pronation/ extreme movement
• Leg length differences
• ITBS (iliotibiale band sydrome)
• Bacterial infection
• Other inflammatory diseases
• Hip prosthesis

Characteristics/Clinical Presentation

Following characteristics may occur:
- Chronic pain and/or hip tenderness in the lateral aspect of the hip that may radiate down the thigh.22
 More specifically while palpaiting superior and posterior of the greater trochanter.
 Maximum tenderness at the insertion of the M. Gluteus maximus
 Can also be felt over the iliotibial tract 4
- Pain limits the strength and makes the legs feel weak
- Pain in the area of the greater trochanter whilst walking or running. It can be felt over the lateral aspect of the leg until the knee
- Stair-climbing is most painful 11
- Patient is not able to lie down on the affected side
 Development of pain-related sleep disturbance 2
- Lower back pain can be related to Trochanteric Bursitis 6
- Weakness of the hip-abductors
 Resistance test can cause tenderness - Pain and tenderness can arise while resisting external rotation
- A snap felt in the lateral aspect of the hip 1
1 Level of Evidence: 1A 
22 Level of Evidence: 5

Differential Diagnosis

It may be difficult to diagnose lateral hip pain because clinical presentations are variable and sometimes inconclusive. That’s why it’s important to have a thorough history and complete physical examination of the patient. That will be crucial to help the diagnosis of lateral hip pain and to know of it’s a trochanteric bursitis or not.
Another difficult aspect is differentiating intrinsic pain from Referred_Pain. Trochanteric bursitis is one of the pathologies that can cause lateral hip pain.
As already mentioned above trochanteric bursitis most commonly results from friction of the overlying iliotibial band. There is frequently tenderness over the greater trochanter that can be aggravate by external rotation and abduction of the hip. Also a lot of factors have been associated with this affection, including leg-length difference, excessive foot pronation, a wide pelvis. During the physical examination the bursal pain can be detected by palpation.2 We have to note that trochanteric bursitis is frequently associated with gluteal tendon pathology.
Trochanteric bursitis is more present concerning women. It is frequently associated with mechanical back strain and obesity. Furthermore, it is also common with reduced hip internal rotation range of motion.
Other pathologies that can be involved in lateral hip pain are:
• Hip Pointer (contusion of iliac crest or avulsions or fractures of the lateral hip)
• Iliotibial_Band_Syndrome
• Snapping_Hip_Syndrome
• Gluteus Medius Tendon Dysfunction and Tears
• Meralgia Paraesthetica (entrapment of the lateral cutaneous nerve)

Diagnostic Procedures

Diagnosing lateral hip pain is very complex. To be sure to diagnose the right affection the examination has to follow a stepwise approach, including inspection, palpation, range of motion, stability and strength in all planes. 
An important diagnostic test for lateral hip pain, particularly for trochanteric bursitis is without a doubt palpation. You have to palpate in and around the greater trochanter. This is the most provocative clinical test by physical therapists.
As additional test you can also perform the Ober's_Test. It was originally conceived for abductor muscle contracture, but we found that the pain reproduction or the reduced range of motion was significant to diagnose trochanteric bursitis.
If you have any doubt about the diagnosis it’s favorable to make a MRI, which will give more specific information.

Outcome Measures

• VAS-scale for pain 15
• International Hip Outcome Tool (iHot) 33
• Oswestry Disability Index 15
• Harris Hip score 32
• 6 Minute Walk Test
• Hip Disability and Osteoarthritis Outcome Score
• Copenhagen Hip and Groin Outcome Score 33

15 Level of evidence: 3A
32 Level of evidence: 3B
33 Level of evidence: 1A

Physical Examination

Physical examination is performed based upon the history of previous injuries and it is used to confirm the source of the pain23 and establish any limitations or deficits that the patient might have. It also assesses the underlying disorder or anatomical impairment that may cause a bursitis.
The physical examination must have a stepwise approach which includes inspection, gait, palpation, Range of motion, muscle strength and the execution of special tests.23
The first part is the inspection. The most important aspect of inspection is the patient’s posture in a seated and upright position. 24 The patient with an irritated hip will tend to stand with the joint slightly flexed. In a seated position: slouching and leaning to the uninvolved slide allows the hip to seek a slightly less flexed position. The observation is also focused on the asymmetry, the gross atrophy, the spinal alignment or the pelvic skewness.
While observing the gait, one should look at leg length discrepancy, weakness and heel strike which contributes to the function of the gluteus maximus. 25
Bursae pain may be detected by palpation. We perform palpation to assess sources of the hip pain. The palpation starts with joint tenderness on the proximal and distal area of the hip. Also each part of the body that is associated with this injury must be assessed, e.g.: the bone, muscle, ligaments, etc. It is important to check the lumbar spine, sacroiliac joints, ischium, iliac crest, lateral aspect of the greater trochanteric bursa, muscle bellis and the pubic symphysis. They can determine a potential source of hip symptoms or pain. 23
The muscle strength can be assessed by resisted contraction which provokes symptoms.
The range of motion should be checked on the actual injured hip as well as on the contralateral hip. An active hip flexion, an internal and external rotation, an abduction and adduction will reproduce pain in the injured area. The range of motion can be identified with several tests: the faber test, Trendelenburg test, Ober’s test, Thomas test and a test whereby the forced flexion combined with internal rotation could be helpful in diagnosing the cause of lateral hip pain.
23 level of evidence: 1A
24 level of evidence: 1A
25 level of evidence: 4

Medical Management

There are several ways to treat trochanteric bursitis, depending on whether or not the bursitis has an infection, and whether it is necessary to treat the lesion with or without surgery.
Nonsurgical treatment21

Aseptic trochanteric bursitis19,20
In most cases trochanteric bursitis is treated without surgery. If the pain results from overuse, it is recommended to reduce the activities and change the way of doing them.
Furthermore, an exercise program of stretching and strengthening with a physiotherapist will help to bring back full range of motion in the hip, sometimes in combination with anti-inflammatory medications or heat and ice applications to calm inflammation.
Improving strength and coordination in the buttock and hip muscles also enable the femur to move in the socket smoothly and can help reduce friction on the bursa.
If the above treatment fails to reduce the symptoms, an injection of cortisone into the swollen bursa may be required. This anti-inflammatory injection will reduce the symptoms for months, but it will not cure the problem itself.
Septic trochanteric bursitis19,20
Infectious trochanteric bursitis does occur, but only in exceptional cases.
Further examination of the bursa fluid in the laboratory is necessary to assess which bacteria has caused the infection. Once this is known, an (intravenous) antibiotic therapy can be prescribed.
Surgical treatment21
Only when the nonsurgical therapy fails, and when the pain is still unbearable, it is recommended to consider surgery. The aim of surgery is to remove the thickened bursa and bone spurs that have arisen on the greater trochanter. Also the large tendon of the gluteus maximus is treated. Some doctors prefer to remove a part of the tendon that rubs against the greater trochanter while others prefer to lengthen the tendon somewhat.

19 Level of Evidence: 5
20 Level of Evidence: 5
21 Level of Evidence: 3A

Physical Therapy Management 30, 31

There are several treatments that can be used to reduce pain and swelling on a patient with trochanteric bursitis. When pain is the main complaint, we can relieve the pain for other underlying disorders so as to treat them more effectively.
Physical therapy is given to improve flexibility, muscle strengthening and joint mechanics. When these aspects are improved, pain will decrease. 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. Other physical therapy interventions are the use of ultrasound, moist heat and educating the patient on activity modification and correcting possible training errors.
The pain of this injury can be reduced in different phases: The first phase is to manage the pain and the inflammation. Pain being the main reason for treatment of the trochanteric bursitis, we can use two common treatments to decrease the pain: the use of ice and non-steroidal anti-inflammatory drugs (NSAIDs). The bursa inflammation can be treated with ice therapy and techniques or exercises that reduce the inflammation structures. There are also other treatments that a physiotherapist can use, e.g.: electrotherapy, acupuncture, taping techniques, soft tissue massage and the temporary use of a mobility aid to off-load the affected side.
The second phase is to reinforce the patient’s strength and to restore the normal ROM. The physiotherapist will also to improve the muscle length and resting tension, the proprioception, balance and gait.
The next phase of rehabilitation is the restoration of all functions. Many patients catch TB due to their common daily activities like running, walking, … . The goal of the physiotherapist is to provide a specialized program for the patient to improve the movement and to reduce the pain, so that the patient can perform his daily activities.
The final phase is to prevent a relapse. It may be as simple as training your abdomines or performing some foot orthotics to address any biomechanical faults in the legs or feet. The therapist will examine your hip stability and function by addressing any deficits in the core strength and balance. Furthermore, he will also teach the patient some self-management techniques. The ultimate goal is to see the patient safely returning to his former sporting or leisure activities!
30 level of evidence: 5A
31 level of evidence: 1A

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1. J. Rosenberg, R. Patel. Hip tendonitis and bursitis review. Level of evidence: (A1)
2. Patrick M Foye, MD, Todd P Stitik, MD. Trochanteric bursitis review. 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. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment.Anesth Analg. May 2009, 108(5), 1662-70. Level of evidence: 1 A
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 & Rheumatism, Vol. 59, No. 2, February 15, 2008, pp 241–246
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
Level of Evidence: 3 (C)
9. Woodley S.J., Nicholson H.D., Livingstone V., Doyle T.C., Meikle G.R., Macintosh J.E., Mercer S.R. Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination. Journal of orthopaedic & sports physical therapy, Vol 38, No. 6, June 2008, pp 313 - 328
10. Paluska S.A., An overview of Hip Injuries in Running. Sports Med 2005; 35, pp 991 – 1014
11. Ombregt L., Bisschop P., ter Veer H.J., Van de Velde T., A System of Orthopaedic Medicine. 1999.
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12. Seong-Tae K. , Myung-Sang M. , Min-Geun Y. , Woo-Sung P. Jee-Hyun H. , Tuberculosis of the trochanteric bursa: a case report , 2009.
Level of Evidence 3 B
13. Christian W. A. Pfirrmann, MD Christine B. Chung, MD Nicolas H. , Theumann, MD Debra J. Trudell, RA Donald Resnick, MD, Greater Trochanter of the Hip: Attachment of the Abductor Mechanism and a Complex of Three Brusae - MR Imaging and MR Bursogrphy in Cadavers and MR Imaging in Asymptomatic Volunteers, 2001. Level of Evidence 5

14. Ramand D., Haslock I., Trochanteric bursitis - a frequent cause of 'hip' pain in rheumatoid arthritis, 1982. Level of Evidence 2 C

15.David P Lustenberger, BS*, Vincent Y Ng, MD*, Thomas M Best, MD, PhD†, and Thomas J Ellis, MD* Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sport Med. 2011 September ; 21(5): 447–453. Level of Evidence 3 A

16. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92.

17. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. Jan 2003;84-8.

18. Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. Mar 2005;55(512):199-204.

19. Firestein, G.S., et al. Kelley's Textbook of Rheumatology, 9th ed. Philadelphia, Pa: Saunders Elsevier, 2012. Level of Evidence 5

20. Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. New York: Springer and Arthritis Foundation, 2008. Level of Evidence 5

21. Farmer KW, Jones LC, Brownson KE, et al. Trochanteric bursitis after total hip arthroplasty incidence and evaluation of response to treatment. J Arthroplasty. Mar 3 2009;[Medline]. Level of Evidence 3 A
22. Trochanteric bursitis. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:299-303.
Level of Evidence 5
23. Robert C. Grumet, MD, Rachel M. Frank, BS, Mark A. Slabaugh, MD, Walter W. Virkus, MD,Charles A. Bush-Joseph, MD, and Shane J. Nho, MD, MS*, lateral Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options. Level of Evidence 1A
24. Evaluation of the hip: history and physical examination; J.W. Thomas Byrd, MDa Level of evidence 1A
25. Stephanie J.Woodley, BPhty, MSc, PhD¹; Helen D. Nicholson BSc (Hons), MBChB, MD²; Vicki Livingstone, BSc, MSc, PhD³ ; Terence C. Doyle MBChB, MD4; Grant R. Meikle MBChB, FRANZCR5; Janet E. Macintosh BSc (Hons), BMed, PhD6; Susan R. Mercer BPhty (Hons), MSc, PhD7; Lateral Hip Pain: Findings FromMagnetic Resonance Imaging and Clinical Examination. Level of Evidence 4
26. Neil A. Segal, MD, David T. Felson, MD, James C. Torner, PhD, Yanyan Zhu, MSc, Jeffrey R. Curtis, MD, MPH, Jingbo Niu, DSc, and Michael C. Nevitt, PhD for the Multicenter Osteoarthritis (MOST) Study Group From the Department of Orthopaedics & Rehabilitation, University of Iowa and VA Medical Center, Iowa City, IA (Segal); Clinical Epidemiology, Boston University, Boston, MA (Felson, Zhu, Niu); Department of Epidemiology, University of Iowa, Iowa City, IA (Torner); Dept of Rheumatology, University of Alabama, Birmingham, AL (Curtis); and Dept of Clinical Epidemiology, University of California, San Francisco, CA (Nevitt). Greater Trochanteric Pain Syndrome: Epidemiology and Associated Factors. Level of evidence 1A
27. Firestein, G.S., et al. Kelley's Textbook of Rheumatology, 9th ed. Philadelphia, Pa: Saunders Elsevier, 2012.
Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. New York: Springer and Arthritis Foundation, 2008.
Ruddy, Shaun, et al., eds. Kelley's Textbook of Rheumatology, 6th ed. Philadelphia: Saunders, 2001. ; ; Hip bursitis

28. Michael T. Cibulka, DPT; Douglas M. White, DPT; Judith Woehrle, PT, PhD, Marcie Harris-Hayes, DPT; Keelan Enseki, PT, MS, Timothy L. Fagerson, DPT, MS; James Slover, MD, MS; Joseph J. Godges, DPT; Hip Pain and Mobility Deficits – Hip Osteoarthritis:Clinical Practice Guidelines Linked to the International Classification of Functioning,Disability, and Health from the Orthopaedic Section of the American Physical TherapyAssociation Level of evidence: 5A
29. David P Lustenberger, BS*, Vincent Y Ng, MD*, Thomas M Best, MD, PhD†, and Thomas JEllis, MD**Department of Orthopaedic Surgery, The Ohio State University Sports Medicine Center, TheOhio State University, Columbus, Ohio†Department of Family Medicine, The Ohio State University Sports Medicine Center, The OhioState University, Columbus, Ohio; Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review Level of Evidence: 1A
30. E. C. Falvey, R. A. Clark, A. Franklyn-Miller, A. L. Bryant, C. Briggs.Iliotibial band syndrome: an examination of the evidence behind a
number of treatment options.Scandinavian journal of medicine & science in sport,2009:8
31. Lavine R. Iliotibial band friction syndrome. Current Reviews in Musculoskeletal Medicine,2010;volume 3:18–22
32. Furia J, Rompe J, Maffulli N. Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome. Am J Sports Med. 2009;37:1806–1813. Level of evidence: 3 B
33. ENSEKI K, HARRIS-HAYES M, WHITE DM, et al. Non-arthritic Hip Joint Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. The Journal of orthopaedic and sports physical therapy. 2014;44(6):A1-32. doi:10.2519/jospt.2014.0302. Level of evidence 1A