Trochanteric hip bursitis
The inflamed, fibrotic trochanteric bursa on the right side of the hip bone

Definition

Trochanteric bursitis is the inflammation of the bursa, a fluid filled sack that is located on the great trochanter of the femur, beneath the tendons and muscles of the buttocks.

The trochanteric bursa (red circle) can become inflamed from the pressure of the ilio-tibial band seen posteriorly and laterally

Pathology

Trochanteric bursitis is a disease mostly caused by the friction to the bursa that is located between the great trochanter (the side tip of the femur) and the iliotibial band (tendon) that runs along the external thigh. Numerous gluteal muscles insert at the great trochanter. They are used for activities such as walking, running, climbing and jumping. In particular the contraction of the gluteus maximus, which is attached to the iliotibial band, exerts a significant pressure to the bursa as it forces the sliding of the band around the great trochanter. Weakness of the gluteus medius may also lead to the irritation of the bursa. This pathology is frequent in older individuals and athletes due to muscles weakness and repetitive activities that pose a strong pressure on the bursa. In elderly individuals the iliotibial band can become tight causing pressure on the bursa, thus triggering its inflammation and swelling. A trauma to the hip side may also provoke bleeding and formation of a haematoma within the bursa, leading to inflammation, thickening of the bursal capsule and trochanteric bursitis.

Arm abduction is restricted by the inflamed bursa and tendons, reducing the joint space
Cross section of the shoulder depicting the compression of the bursa (red) above the rotator cuff (white) and below the deltoid muscle

Classification

There are various classification systems for a shoulder impingement syndrome.

Stages of subacromial impingement in athletes - Jobe’s Classification
(1989):

Pure impingement with no instability

Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement

Primary instability due to intrinsic ligament laxity with secondary impingement

Pure instability with no impingement.

Grading of impingement changes - Milgrom’s Ultrasound Classification:

Stage 1 Bursal thickness from 1.5 to 2.0 mm

Stage 2 Bursal thickness over 2.0 mm

Stage 3 Partial or full thickness tear of the rotator cuff.

Impingement lesions - Copeland Levy Classification:

This is based on the location of the impingement, either on the acromial or the bursal side.

Acromial side

A0 normal - smooth surface

A1 minor deterioration, haemorrhage or local inflammation

A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament

A3 exposed bone areas.

Bursal side

B0 normal - smooth surface

B1 minor deterioration, haemorrhage, inflammation

B2 major deterioration of the cuff, partial thickness tear

B3 full thickness tear of the rotator cuff

B4 massive cuff tear.

Two-part proximal humerus fracture

According to the Habermeyer Classification the fractures to the proximal humerus are divided into:

Type 0 one fractured part without dislocation

Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion

Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities

Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.

These are defined further as:

One-part fractures are non-displaced fractures or fractures with minimal displacement

Two-part fractures only involve a single segment

Three-part fractures involve two segments

Four-part fractures occur when all humeral segments are involved (see image in pathology section)

The injury severity is proportional to the increasing number of fractures.

Three-part proximal humerus fractures

A traumatic impact on the hip side can cause a trochanteric bursitis

Causes

There is a number of causes leading to trochanteric bursitis but in some cases the origin of the disease is unknown. These are:

Trauma

Fall

Lack of training, muscle weakness

Excessive training

Leg length discrepancy

Joint stiffness

Muscle tightness

Strenuous and prolonged physical activity can lead to a trochanteric bursitis

Risk factors

Leading risk factors for a trochanteric bursitis include:

Excessive or inadequate training

Elderly age predisposed to falls

Runners (especially on hard surface)

Female gender

Previous hip replacement or other hip surgeries 

Pain on the hip side also radiating along the external thigh is a common symptom

Symptoms

The most frequent symptoms of trochanteric bursitis are:

Pain to the lateral hip side (initially)

Pain radiating along the outer thigh up to the knee (when chronic)

Pain when touching the bursa

Pain when sleeping on the side

Stiffness of the hip joint

Difficulty in walking, limp

Weakness of the lower limbs

‍MRI of the hip showing a normal bursa (red circle)

Diagnosis

Clinical examination begins with medical history to acquire information on injuries or activities that may have caused a trochanteric bursitis. Usually medical examination is sufficient to confirm the diagnosis. An MRI or ultrasound may reveal the characteristics of the bursitis prior to local injections of drugs or surgical removal. X-ray imaging is only performed to rule out any degenerative changes of the hip bone and joint that may contribute to the symptoms.

Injection of anaesthetics (novocaine) into the bursa is an additional method for the diagnosis, whereby cessation of pain confirms a trochanteric bursitis. 

Treatment

Prolonged symptoms of a trochanteric bursitis are treated with steroid injection into the bursa

Nonoperative treatment

Management of trochanteric bursitis begins with conservative treatment, which is mostly successful although with a lengthy prognosis. This approach involves:

Anti-inflammatory therapy with NSADs

Local injection of steroids

Reduction of physical activity and extreme sport

Physiotherapy

When conservative treatment fails the bursa is surgically removed (open technique)
Diagram of a hip arthroscopy

Surgical Treatment

Surgery is recommended only rarely when a chronic bursitis fails to resolve with conservative treatment. Different methods are available that vary between open surgery and less invasive arthroscopic surgery. The ultimate goal is the removal of the inflamed, sclerotic bursa and excise any bone spurs that may have formed. The surgeon may choose to lengthen the tendon of the gluteus maximus that has caused the pathology or remove part of the tendon covering the bursa to prevent local frictions and recidivism of the pathology.

Manipulation and massage are used for rehabilitation of the trochanteric bursitis

Rehabilitation

Physical therapy is mostly successful in resolving trochanteric bursitis. It focuses on restoring the flexibility of the iliotibial tendon and strengthening the gluteal and thigh muscles. The prognosis is usually between 4 and 8 weeks although it may take longer particularly in older patients or after surgery. Physiotherapy treatment includes:

Rest

Ice/heat treatment

Antiinflammatory therapy (NSAIDs)

Use of crutches (after surgery)

Manipulation

Massage

Stretching

Activity modifying regime

Return to activity plan

Strengthening the hip and gluteal muscles is useful to prevent trochanteric bursitis

Prevention

A trochanteric bursitis is prevented by adhering to a number of recommendations:

Maintain muscular strength of the hip muscles, pelvic muscles and buttocks

Maintain flexibility muscles and tendons of hip and glutei

Improve mobility of the hip joint

Reduce extreme sport

Avoid hard surfaces when jogging

Wearing orthotics to reduce leg length discrepancy

Modify daily habits to prevent falls