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.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

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