Trochanteric bursitis

The trochanteric bursa is a small fluid-filled sac which lies on the outer aspect of the hips. A bursa helps to smooth the movement between two surfaces.

The trochanteric bursa lies directly over a bony protuberance named the greater trochanter, so sometimes they are called greater trochanteric bursae. A strong band of soft tissue (the iliotibial tract) and the tendons of the gluteal muscles also lie over the hip bursae. The area of the greater trochanter is the one which we can feel directly at the top and outside of the thigh.

When this sac filled with a synovial fluid becomes inflamed and causes pain, the condition is called trochanteric bursitis. In recent years it has been found that alongside trochanteric bursitis there may be tears and inflammation to the gluteal tendons as well. For this reason, some healthcare professionals now use the term greater trochanteric pain syndrome or greater trochanteric bursitis.

Trochanteric bursitis causes pain in the outer side of the hip although the pain may also travel down through the upper thigh. The pain may also be localised on the lateral side of the hip.

If you have this condition then you may find walking difficult. The pain may be the result of an injury, although it can also be caused by repetitive movements, such as when running. People who have had hip surgery may also be prone to this type of pain.

The trochanteric bursa can become inflamed due to infection or injury. Should this happen, the inflamed bursa will put increased pressure on nearby structures and tissues, causing pain and swelling.

Normally there is a gradual onset of a hip trochanteric bursitis. This is thought to be the result from excessive friction between the greater trochanter and the gluteal tendons or the iliotibial band (a long piece of connective tissue that runs down the outside of your leg from the hip to the knee).

The following factors are the main causes behind developing excessive friction:      

• Direct trauma to the hips and the side of the pelvis.  
• Weak hip abductor muscles.        
• Sudden increase in activity levels, such as taking up cycling or running.     
• Prolonged standing while at work.    
• High Body Mass Index (BMI).

Associated low back pain or arthritis of the lower limb can also result in weakness and fatigue to the hip muscles, which can lead to more pressure on the trochanteric bursa.

The main symptom of trochanteric bursitis is pain directly over the greater trochanteric region. In some cases this pain radiates down the thigh to the outer aspect of the knee. In severe cases there may be an audible clunking sound when the hip is moved as the iliotibial tract rubs over the bony trochanter.

Once inflamed, pain from trochanteric bursitis may be felt during a range of static postures or activities for several reasons. The most common complaint is pain when lying directly on the painful side. However, many sufferers also feel pain when lying down with their painful side uppermost. This is due to the iliotibial tract being under tension and compressing the inflamed bursa.

Sitting for sustained periods is another common complaint for the same reason. Sitting cross-legged places the iliotibial tract under considerable tension and often significantly aggravates the pain.

Activities that aggravate trochanteric bursa symptoms may include climbing stairs or walking for unaccustomed periods of time. The repetitive forward motion of the hip and knee may cause repetitive friction of the iliotibial tract over the bursa.

Symptoms are aggravated by any posture that places direct pressure over the trochanteric region or activities that require repeated flexion and extension of the hip joint.

Although the above factors may aggravate symptoms once the bursa or tendons are inflamed, the underlying cause for trochanteric bursitis often lies in abnormal biomechanics. A correct diagnosis will require expertise during a physical examination and sometimes specialist diagnostics.

Your doctor or physiotherapist will be able to diagnose trochanteric bursitis by conducting a physical examination and by taking a history of your condition.

Although trochanteric bursitis symptoms, hip bursitis symptoms and greater trochanteric pain syndrome symptoms are very similar, an experienced consultant will be able to determine the precise cause of the pain.

Most cases of trochanteric bursitis will be resolve without the need for any invasive intervention. Symptoms will normally settle following a period of activity modification and home exercises. The use of anti-inflammatory medications will help reduce pain and swelling.

Activity modifications to reduce pain may include:        

• Reducing the time spent walking        
• Modifying technique for walking upstairs (in severe cases)     
• Stopping sleeping on the painful side and placing a pillow between the knees if sleeping on the non-painful side        
• Stopping sitting in a crossed-legged position and raising the seat

However, in persistent cases your clinician may consider a referral for a course of physical therapy. Your physical therapist will be able to help you with a list of trochanteric bursitis exercises that will reduce pain, strengthening your muscles and improve your range of motion.

Physiotherapy exercises to treat trochanteric bursitis are mainly aimed at strengthening the buttock muscles (gluteal muscles). By strengthening the gluteal muscles, this helps to prevent excessive rotation of the hips and knees, which helps to prevent trochanteric bursitis from developing.

Some cases of trochanteric bursitis may not settle entirely even with appropriate physiotherapy management. As such, ultrasound-guided corticosteroid injections may be advised in specific circumstances by an orthopaedic consultant.

Trochanteric bursa injections aim to reduce the inflammation of the bursa and manage the pain. Corticosteroid injections are a simple and effective method as part of a trochanteric bursitis treatment course. You can read more about local steroid injections here.

In rare circumstances when physiotherapy and trochanteric bursitis injections have failed, an orthopaedic hip consultant may be able to offer a surgical procedure to remove the trochanteric bursa, which will give some pain relief.

In these circumstances there may be associated tears seen to the gluteal tendons on diagnostic imaging which may be repaired during the same procedure.