Trochanteric Bursitis: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


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. The only cardinal sign of inflammation that is present is pain. Trochanteric bursitis is an element of a greater term, hip bursitis, that envelopes 4 different types
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.
# Trochanteric bursitis
# [[Iliopsoas Bursitis]]
# [[Gluteal Bursitis]]
# [[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)  but is in fact a component of GTPS that also includes other conditions that cause lateral-sided hip pain.
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" />.  


== Clinically Relevant Anatomy ==
In the rarer cases of isolated trochanteric bursitis, the causes could include:
[[File:Trochanteric_Bursitis.jpg|right|150x150px]]
A bursa is a double - membrane sac filled with fluid located near a joint. It forms a sort of cushion between to minimize friction between the soft tissue/bone interface and acts as a shock absorber during the movement of muscles and joints.  <sup></sup>For the mechanism of injury or the pathological process of bursitis: refer to the page&nbsp;[[Bursitis]]<br>


In case of Trochanteric Bursitis, two bursae are commonly involved:
* [[Sepsis|Septic]] trochanteric [[bursitis]]
# Subgluteus Medius bursa - located above the greater trochanter and underneath the insertion of the gluteus medius.
# Subgluteus Maximus bursa - located between the greater trochanter and the insertion of the gluteus medius and gluteus maximus muscles.<sup></sup><sup></sup><sup></sup><sup></sup><sup></sup><sup></sup><sub></sub><sup></sup><sup></sup>
== Epidemiology /Etiology  ==


Inflammation of the bursa is a slow process, which progresses over time. This bursitis most often occurs because of friction, overuse, direct trauma or too much pressure.<br>
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" />.


There are two types of bursitis
* Other causes of  trochanteric 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.
# 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 predisposing factors that can cause Trochanteric Bursitis:
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" />.
* Gender: Women more commonly affected than men.
* Overweight/Obesity
* 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 Iliotibial band)
* 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 (Iliotibial Band Syndrome)
* Bacterial infection
* Other inflammatory diseases
* Hip prosthesis


== Characteristics/Clinical Presentation  ==
== 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" />.


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


* Chronic pain and/or hip tenderness in the lateral aspect of the hip that may radiate down the thigh<ref name=":0">Snider RK. Essentials of musculoskeletal care. Rosemont (IL): American Academy of Orthopaedic Surgeons. 1997.</ref>
* direct trauma
* A snap felt in the lateral aspect of the hip<ref name=":0" />
* 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>
* Ascending stairs is a painful activity
* overuse<ref name=":10" />
* Patient is unable to lie down on the affected side
* compression of the tendon (and bursa)<ref name=":0" />
* Development of pain-related sleep disturbance
* female gender<ref name=":13" />
* Lower back pain (Trochanteric Bursitis can present as lumbago)<ref>Margo K, Drezner J, Motzkin D. [https://www.mdedge.com/jfponline/article/60172/pain/evaluation-and-management-hip-pain-algorithmic-approach/page/0/2 Evaluation and management of hip pain: an algorithmic approach.](Applied evidence: new research findings that are changing clinical practice). Journal of family practice. 2003 Aug 1;52(8):607-18.</ref><br>
* 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>


== Diagnostic Procedures  ==
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" />.


Diagnosing lateral hip pain is very complex since clinical presentations are variable and sometimes inconclusive. To be sure to diagnose the right affection the examination has to follow a stepwise approach, including thorough history, inspection, palpation, range of motion, stability and strength in all planes.
Septic bursitis occurs when bacteria is introduced into the bursa<ref name=":1" /> and can occur due to:


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.
* [[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" />


As additional test you can also perform the [[Ober's_Test]]. It was originally conceived for abductor muscle contracture, but it was found that the pain reproduction or the reduced range of motion was significant to diagnose trochanteric bursitis.
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).


If there is still any doubt about the diagnosis it’s favorable to make an MRI, which will give more specific information.
== Characteristics/Clinical Presentation  ==


== Physical Examination ==
* 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>
Physical examination is performed based upon the history of previous injuries and it is used to confirm the source of the pain 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 Observation, Palpation, Range of motion, Muscle Strength, Gait Assessment and the execution of special tests.<ref name=":1">Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010 May;2(3):191-6.</ref>  
* Pain to the lateral thigh and knee<ref name=":8" /><ref name=":13" /><ref name=":3" />
* Local tenderness over the greater trochanter<ref name=":8" /><ref name=":13" /><ref name=":3" />
* 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" />
* Pain with weight-bearing activities<ref name=":8" /><ref name=":13" /><ref name=":3" />
* Pain with sitting crossed-legged<ref name=":3" />
* Pain with prolonged sitting<ref name=":8" /><ref name=":13" />


The first part is the observation. The most important aspect of observation is the patient’s posture in a seated and upright position.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.<ref>Byrd JT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953301/ Evaluation of the hip: history and physical examination]. North American journal of sports physical therapy: NAJSPT. 2007 Nov;2(4):231.</ref>  
== Diagnostic Procedures ==


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 bellies and the pubic symphysis. They can determine a potential source of hip symptoms or pain.<ref name=":1" />  
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" />.


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.  
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" />.


Muscle strength needs to be tested for all the major muscle groups acting on the hip joint which can be assessed with resisted contraction. Hip abductor weakness is a common finding and testing the abductors can provoke lateral hip pain during the examination.
== Differential Diagnosis ==
Multiple structures can present as lateral hip pain. In the absence of inflammatory signs, differential diagnosis can include:


While assessing the gait, one should look for any limb length discrepancy, weakness and heel strike which contributes to the function of the gluteus maximus.<ref>Woodley SJ, Nicholson HD, Livingstone V, Doyle TC, Meikle GR, Macintosh JE, Mercer SR. [[Lateral hip pain: findings from magnetic resonance imaging and clinical examination]]. journal of orthopaedic & sports physical therapy. 2008 Jun;38(6):313-28.</ref>  
* 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" />


== Differential Diagnosis ==
If inflammatory signs are present:
There are many conditions which can present as lateral hip pain in a patient. This is why it is crucial to rule out other possible causes to accurately arrive at a diagnosis of Trochanteric Bursitis. 


Common conditions that can cause lateral hip pain are:
* [[Cellulitis]]<ref name=":15" />
* [[Iliotibial Band Syndrome]]
* [[Gout]]<ref name=":15" />
* [[Snapping Hip Syndrome]]
* [[Rheumatoid Arthritis|RA]]<ref name=":15" />
* [[Gluteal Tendinopathy|Gluteus Medius Tendon Dysfunction and Tears]]
* Meralgia Paresthetica
* [[Referred Pain]]  


== Outcome Measures ==
== Outcome Measures ==
• [[Visual Analogue Scale|VAS-scale for pain]]&nbsp;<br>• International Hip Outcome Tool (iHot) <ref name=":2">Enseki K, Harris-Hayes M, White DM, Cibulka MT, Woehrle J, Fagerson TL, Clohisy JC. [https://www.jospt.org/doi/full/10.2519/jospt.2014.0302?code=jospt-site Nonarthritic Hip Joint Pain: Clinical Practice Guidelines Linked to the International Classifiation of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association]. Journal of Orthopaedic & Sports Physical Therapy. 2014 Jun;44(6):A1-32.</ref><sup></sup><br>• [[Oswestry Disability Index]] <ref>Lustenberger DP, Ng VY, Best TM, Ellis TJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3689218/ Efficacy of treatment of trochanteric bursitis: a systematic review.] Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine. 2011 Sep;21(5):447.</ref><br>• Harris Hip score <ref>Furia JP, Rompe JD, Maffulli N. [http://www.fysiosupplies.nl/media/PDF/Low-Energy_Extracorporeal_Schock_Wave_Therapy.pdf Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome]. The American journal of sports medicine. 2009 Sep;37(9):1806-13.</ref><br>• [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walk Test]]<br>• [[Hip Disability and Osteoarthritis Outcome Score]]<br>• Copenhagen Hip and Groin Outcome Score <ref name=":2" />
• 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>
== Medical Management   ==
== Physiotherapy Management ==
 
There are various approaches in the treatment of 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. <br>


=== Aseptic Trochanteric Bursitis ===
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
* In most cases trochanteric bursitis is treated without surgery. If the pain results from overuse, it is recommended to reduce the activities or modify the body mechanics in which those specific activities are performed<ref name=":3">Firestein, G.S., et al. Kelley's Textbook of Rheumatology, 9th ed. Philadelphia, Pa: Saunders Elsevier, 2012</ref>.
<div class="row">
* 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.<ref name=":4">Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. New York: Springer and Arthritis Foundation, 2008</ref>  
  <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>
* 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.
  <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 ==


=== Septic Trochanteric Bursitis ===
[[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.
* Infectious trochanteric bursitis does occur, but only in exceptional cases.<ref name=":3" />
* 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.<ref name=":4" />


== Surgical treatment ==
[[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" />.
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 elongate the tendon surgically.<ref>Farmer KW, Jones LC, Brownson KE, Khanuja HS, Hungerford MW. [https://www.sciencedirect.com/science/article/pii/S0883540309000552 Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment]. The Journal of arthroplasty. 2010 Feb 1;25(2):208-12.</ref>


== Physical Therapy Management  ==
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>.


There are several treatments that can be used to reduce pain and swelling on a patient with trochanteric bursitis<ref name=":5">Alvarez-Nemegyei, J., & Canoso, J. J. (2004). ''Evidence-Based Soft Tissue Rheumatology. JCR: Journal of Clinical Rheumatology, 10(3), 123–124.''</ref>. There is not a lot of evidence detail the benefits of physiotherapy or the modalities used but it is a common intervention when pain is a predominant factor.<ref name=":6">Reid, D. (2016). ''The management of greater trochanteric pain syndrome: A systematic literature review. Journal of Orthopaedics, 13(1), 15–28''</ref> When pain is the main complaint, it is important to assess for any underlying disorders so as to treat the client more effectively. Physical therapy can improve flexibility, muscle strengthening and joint mechanics. When these aspects are improved, pain will decrease<ref name=":6" />. To heal trochanteric bursitis it is necessary to proceed to infiltration of the bursa with antiphlogistic medication (Corticosteroid-injections)<ref name=":5" /><ref name=":6" />. In case of a persistent bursitis, surgery has to be considered as well. <ref name=":6" />Other physical therapy interventions are the use of ultrasound, moist heat and educating the patient on activity modification and correcting possible training errors.
== 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:


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. 
* 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" />


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 through a supervised and thorough exercise rehabilitation program.
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:


The next phase of rehabilitation is the restoration of all functions. Many patients develop Trochanteric Bursitis due to their common daily activities like running, walking etc. 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 with less difficulty.  
* 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)
* [[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>
* ITT bursectomy<ref name=":6" />


The final phase is to prevent a relapse. It may be as simple as training your core muscles or fabricating foot orthotics to address any biomechanical faults in the lower limbs. 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.  
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 ==
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[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Sports Injuries]]
[[Category:Bursitis]]
[[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, Wanda van Niekerk, Vidya Acharya, 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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