Trochanteric bursitis

Trochanteric bursitis is an inflammation of the bursa located over the greater trochanter of the femur. It is a common cause of lateral hip pain, particularly in middle-aged and older adults. Understanding its anatomy, causes, and clinical presentation is essential for effective management.

Anatomy and Physiology

Greater Trochanter

The greater trochanter is a prominent bony projection on the lateral aspect of the femur. It serves as an attachment site for several hip muscles, including the gluteus medius and minimus, which are critical for hip stability and movement.

Bursae of the Hip

Bursae are fluid-filled sacs that reduce friction between bones and soft tissues. The trochanteric bursa is situated between the greater trochanter and the overlying gluteal tendons. Other hip bursae include the iliopsoas bursa, ischial bursa, and gluteal bursae.

• Trochanteric Bursa: Located over the lateral aspect of the greater trochanter, primarily involved in trochanteric bursitis.
• Other Hip Bursae: Provide cushioning for tendons and muscles, contributing to smooth hip movement.

Muscle and Tendon Relations

The trochanteric bursa lies beneath the tendons of the gluteus medius and minimus muscles. The tensor fascia lata also overlays this region. Proper functioning of these muscles is essential to maintain lateral hip stability and prevent excessive friction over the bursa.

• Gluteus medius and minimus
• Tensor fascia lata

Etiology and Risk Factors

Primary Causes

Trochanteric bursitis often results from repetitive trauma or friction over the bursa. Direct pressure from prolonged lying on the affected side or overuse from physical activities can initiate inflammation.

• Repetitive trauma from physical activity or sports
• Direct pressure on the lateral hip during prolonged lying or sitting

Secondary Causes

Secondary trochanteric bursitis develops in response to underlying musculoskeletal conditions that alter hip mechanics or increase stress on the bursa.

• Hip osteoarthritis leading to abnormal joint loading
• Lumbar spine disorders causing altered gait and hip stress
• Leg length discrepancy resulting in asymmetric pressure on the bursa

Predisposing Factors

Certain demographic and lifestyle factors increase susceptibility to trochanteric bursitis.

• Age and gender: More common in middle-aged women
• Obesity contributing to increased hip load
• Overuse in athletes or individuals with repetitive hip movements

Pathophysiology

Inflammatory Mechanisms

Trochanteric bursitis arises from inflammation of the bursa over the greater trochanter. Mechanical stress, repetitive friction, or microtrauma triggers an inflammatory response, leading to swelling, increased vascular permeability, and pain.

Degenerative Changes

Chronic bursitis can result in degenerative changes in both the bursa and adjacent tendons. Fibrosis, thickening of the bursal wall, and calcification may occur, reducing the elasticity of the bursa and prolonging discomfort.

Biomechanical Contributions

Altered gait patterns, muscle weakness, or leg length discrepancies increase pressure on the trochanteric bursa. These biomechanical factors exacerbate inflammation and contribute to persistent symptoms if not addressed.

Clinical Presentation

Symptoms

Patients typically present with lateral hip pain, which may radiate down the thigh. Pain is often aggravated by activity such as walking, climbing stairs, or lying on the affected side at night.

• Lateral hip pain localized over the greater trochanter
• Pain aggravated by walking, stair climbing, or prolonged standing
• Night pain when lying on the affected side

Physical Examination

Clinical examination usually reveals tenderness over the greater trochanter and discomfort during specific movements.

• Tenderness on palpation of the lateral hip over the trochanter
• Pain with resisted abduction of the hip
• Positive Trendelenburg sign indicating gluteal muscle weakness

Diagnosis

Imaging Studies

Imaging is often used to confirm the diagnosis and rule out other causes of lateral hip pain. Different modalities provide complementary information about soft tissue and bone structures.

• X-ray: Useful to identify bony abnormalities, osteoarthritis, or leg length discrepancies.
• MRI: Provides detailed visualization of the bursa, tendons, and surrounding soft tissues, detecting inflammation and degenerative changes.
• Ultrasound: Can confirm fluid accumulation within the bursa and guide therapeutic injections.

Laboratory Tests

Laboratory investigations are generally limited but may be performed if an infectious or systemic inflammatory process is suspected. Routine blood tests can help rule out systemic causes of bursitis.

Differential Diagnosis

Several conditions can mimic trochanteric bursitis, requiring careful evaluation to establish an accurate diagnosis.

• Hip osteoarthritis presenting with lateral hip pain
• Trochanteric tendinopathy causing similar tenderness
• Lumbar radiculopathy with referred pain to the lateral thigh

Management

Conservative Treatment

Initial management of trochanteric bursitis focuses on relieving pain, reducing inflammation, and improving hip function through non-invasive methods.

• Rest and activity modification to reduce stress on the bursa
• Physical therapy emphasizing stretching, strengthening, and posture correction
• Nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation

Interventional Treatment

For patients not responding to conservative therapy, interventional procedures may provide symptom relief.

• Corticosteroid injections into the bursa to reduce inflammation
• Platelet-rich plasma (PRP) therapy to promote tissue healing in chronic cases

Surgical Treatment

Surgery is reserved for refractory cases where conservative and interventional treatments fail to resolve symptoms.

• Bursa excision to remove chronically inflamed tissue
• Tendon repair for associated gluteal tendon tears contributing to bursitis

Rehabilitation and Prevention

Post-Treatment Rehabilitation

After acute symptoms subside or following surgical intervention, rehabilitation focuses on restoring hip strength, flexibility, and function. A structured program helps prevent recurrence and promotes optimal recovery.

Exercise and Strengthening

Targeted exercises strengthen the hip abductors, gluteal muscles, and core to reduce stress on the trochanteric bursa. Stretching of the iliotibial band and surrounding soft tissues enhances mobility and minimizes friction.

Ergonomic and Lifestyle Modifications

Adjustments in daily activities and ergonomics can prevent exacerbation of symptoms. Recommendations include avoiding prolonged pressure on the lateral hip, using supportive cushions, correcting gait abnormalities, and maintaining a healthy body weight.

Prognosis and Complications

Expected Recovery

Most patients with trochanteric bursitis respond well to conservative treatment, achieving symptom relief within weeks to months. Early intervention and adherence to therapy improve outcomes.

Potential Complications

In some cases, untreated or chronic bursitis can lead to ongoing pain and functional limitations. Awareness of potential complications helps guide long-term management.

• Chronic lateral hip pain resistant to therapy
• Recurrence of bursitis with continued mechanical stress
• Hip instability due to associated tendon or muscle dysfunction

References

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