AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Background

Trochanteric bursitis is characterized by painful inflammation of the bursa that is located just superficial to the greater trochanter of the femur. Patients typically complain of lateral hip pain, although the hip joint itself is not involved, because pain may radiate down the lateral aspect of the thigh.

Pathophysiology: Inflammation of the affected bursa between the femoral trochanteric process and the gluteus medius/iliotibial tract may be due to acute or repetitive (cumulative) trauma. Acute trauma includes contusions from falls, contact sports, and other sources of impact. Repetitive trauma includes bursal irritation due to friction by the iliotibial band (ITB), which is an extension of the tensor fascia lata (TFL) muscle. Such repetitive, cumulative irritation often occurs in runners, but it can also be seen in less-active individuals. Other predisposing factors include leg-length discrepancy, hip abductor weakness, and lateral hip surgery. (See also the eMedicine article Iliotibial Band Syndrome.)

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Bursitis.

Frequency

United States

Trochanteric bursitis is relatively common among physically active and sedentary patients and can occur as a complication of arthroscopic surgery of the hip. The overall complication rate has been estimated to be 1.4%.¹

The prevalence of unilateral greater trochanteric pain syndrome (GTPS) is 15.0% in women and 8.5% in men and that of bilateral GTPS is 6.6% in women and 1.9% in men.²

Race: No racial predilection has been reported.

Sex: A study published in a British journal reported that trochanteric bursitis there appeared to be a female preponderance (80%) relative to males.³ 

Age: Trochanteric bursitis can occur in adults of any age.

International

Lievense et al reported the annual incidence of trochanteric pain in primary care settings was 1.8 patients per 1000.³ 

Sport-specific Biomechanics

Athletic activities that are potentially associated with trochanteric bursitis include those involving running or sports that are associated with the possibility of falls and/or physical contact. Other contributing factors may include running on banked surfaces, which essentially produces a functional leg-length discrepancy because the contact surface of the downhill foot is lower.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

History

• In cases of acute trauma, patients may recall the specific details of the impact that caused the injury.
• The classic symptom is pain at the greater trochanteric region at the lateral hip.
• The pain may radiate down the lateral aspect of the ipsilateral thigh but usually does not radiate all the way into the foot.
• Typically, symptoms worsen when the patient is lying on the affected bursa (eg, lying in the lateral decubitus position on the affected side).
• Pain may awaken the patient at night.

Physical

• The most classic finding is the elicitation of point tenderness over the greater trochanter, which reproduces the presenting symptoms.
• Palpation may also reproduce pain that radiates down the lateral thigh.
• Bursal swelling may be present, but this finding may be difficult to appreciate in many patients.
• In obese patients, direct location of the trochanter may be difficult. Consider using the iliac crest as a landmark and assessing for the trochanter approximately 8 inches (20 cm) below the pelvic brim. Attempt to palpate the region while passively circumducting the affected hip.
• If recent acute trauma has occurred, skin changes may include ecchymosis, abrasions, or both.
• Lateral hip pain can often be elicited with passive external rotation of the affected hip, whereas such symptoms are not provoked by internal rotation. External rotation can also be combined with passive hip abduction.
• Lateral hip pain can also be reproduced with either passive hip adduction or active hip abduction.
• Groin pain produced through passive internal rotation of the hip may indicate hip joint pathology, such as osteoarthritis. (See also the eMedicine article Osteoarthritis.)
• To assess for sciatica or lumbosacral radiculopathy, perform a careful neurologic examination in the bilateral lower limbs, including assessment of strength, reflexes, sensation, and dural stretch maneuvers (eg, straight-leg raise). (See also the eMedicine article Lumbosacral Radiculopathy.)

Causes

• Acute trauma
• • A fall or tackle with the patient landing on the lateral hip region
• Repetitive (cumulative) trauma
• • More common involvement than acute trauma
  • Caused when patients with tightness of the ITB run or even walk
• Other diagnostic considerations
• • Osteoarthritis of the hip, although this diagnosis generally manifests as groin or knee pain rather than lateral hip pain (See eMedicine topic Osteoarthritis.)

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Other Problems to Be Considered

Osteoarthritis of the hip
Gluteus medius tendinitis
Gluteus medius partial tear

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Lab Studies

• Generally, laboratory studies are unnecessary.

Imaging Studies

• If significant trauma is present, obtain radiographs of the hip and femur to assess for possible fracture(s).
• If metastatic cancer is suspected (even in the setting of normal femur radiographic findings), a bone scan can be used to assess for lesions in the proximal femur.
• Magnetic resonance imaging (MRI) and ultrasonography (US) can potentially be used to differentiate between gluteus medius tendinitis and trochanteric bursitis in patients with GTPS.⁴

Procedures

• Occasionally, diagnostic injection of local anesthetic into the trochanteric bursa may be helpful, particularly in an obese individual in whom the diagnosis is not yet certain.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Management of the patient during the acute phase can include icing of the affected regions for 20-30 minutes every 2-3 hours. The proper use of the various treatment modalities can be taught to patients during physical therapy sessions; subsequently, the patient can perform them independently. These modalities should be goal-directed as part of a comprehensive plan to facilitate active patient participation in the rehabilitation program. The physical therapist can instruct the patient in a home exercise program, emphasizing stretching of the ITB and TFL and strengthening of the hip abductors, especially the gluteus medius. The use of phonophoresis and soft-tissue massage may also be helpful. Transcutaneous electrical nerve stimulation (TENS) can be considered in cases that prove resistant to the rehabilitation program.

Stretching of the ITB and TFL can be achieved with a program that incorporates passive adduction of the knee of the affected limb across the midline as far as possible and maintenance of this position for at least 10-20 seconds. This exercise can be repeated in various degrees of hip flexion, thus theoretically stretching the various ITB and TFL fibers. To avoid exacerbation of trochanteric bursitis and/or its symptoms, stretching should not be performed in a ballistic, jerking fashion. Instead, stretches should be performed in a controlled and sustained fashion.

Medical Issues/Complications

• Chronic pain

• Limited activity level

• Limping (antalgic gait)

• Sleep disturbance, which is especially problematic for patients who usually sleep on their sides

Surgical Intervention

Surgical intervention is generally not required for trochanteric bursitis. Patients with this condition rarely need a bursectomy and partial resection of the greater trochanteric process.

Consultations

If the patient does not respond to appropriate treatments, or if the treating physician does not have the skill or supplies to perform corticosteroid injections, the patient may be referred to a musculoskeletal specialist. Usually, no other consultations are required.

Other Treatment

• Corticosteroid injection into the trochanteric bursa
• • A mixture of a corticosteroid and a local anesthetic (eg, 40-80 mg of long-acting methylprednisolone [eg, Depo-Medrol; Pharmacia & Upjohn Co, Kalamazoo, Mich] and 5 mL of 1% lidocaine) can be injected into the affected trochanteric bursa with a 22-gauge needle.
  • A 1.5-inch (3.8-cm) needle may be adequate for a slim patient. A heavier patient may require a 3.5-inch (8.9-cm) needle to reach the bursa.
  • The needle is advanced to the greater trochanter and then is withdrawn slightly so that it is located within the bursa before the injection is made.
  • Further specifics of the injection procedure and potential complications are beyond the scope of this text. Interested clinicians are encouraged to read other appropriate sources.
  • Lievense et al found that, depending on the treatment setting, the rates of corticosteroid injections were 34% for primary care, 37% for specialist, and 34% for hospital, resulting in improvement rates between 60% 1-year follow-up and 66% at 5-year follow-up.³ Patients who had received a corticosteroid injection had a 2.7-fold higher chance of recovery after 5 years relative to those patients who had not received such an injection. Having had a corticosteroid injection was predictive for improvement within 5 years.³

Recovery Phase

Rehabilitation Program

Physical Therapy

The physical therapy program should be advanced to include gradual resumption of sports-related activities.

Medical Issues/Complications

See Acute Phase, Medical Issues/Complications.

Other Treatment (Injection, manipulation, etc.)

• Corticosteroid injections may be repeated, if necessary.
  
  
  • Many authors and clinicians consider corticosteroid injections an important option within the comprehensive treatment plan for trochanteric bursitis. A randomized, controlled clinical trial demonstrated that corticosteroid and lidocaine injection for trochanteric bursitis was an effective therapy with prolonged benefits.⁵
  • Trochanteric bursa injections are commonly performed without any radiographic guidance. However, some preliminary data suggest that radiologic confirmation (eg, with fluoroscopy) is necessary for accurate trochanteric bursa injections, especially in the following patients with⁶:
  • • Heavy body habitus or obesity
    • A history of repeated injections
    • A history of chronic inflammation
    • A history of previous surgery
    • Pain for long periods, with the development of peripheral sensitization, which may lead to the injection of medicine into tender areas rather than the areas involved in pain generation
• For a diagnostic injection, local anesthetic without epinephrine (eg, 5 mL of 1-2% lidocaine) can be injected into the affected trochanteric bursa with a 22-gauge needle. A 1.5-inch (3.8-cm) needle may be adequate for a slim patient, but a heavier patient may require a 3.5-inch (8.9-cm) needle to reach the bursa. The needle is advanced to the greater trochanter (making contact with the bone as confirmation of depth and appropriate placement) and then withdrawn slightly so that it is located within the bursa. The local anesthetic can then be injected directly into the bursa; if the patient receives appropriate pain relief, this is considered confirmation of trochanteric bursitis as the source of the pain.
  
  
  • The injection of local anesthetic can be followed by the administration of steroids through the same needle; the syringe is then switched to one containing the corticosteroid. Injection of 40-80 mg of methylprednisolone acetate or triamcinolone acetonide should be adequate. This injection may be repeated after 4-6 weeks if pain relief has been less than 50%.
  • In most cases (ie, the diagnosis of trochanteric bursitis seems straightforward from the clinical evaluation), a diagnostic injection (or local anesthetic injection) is not necessary before the corticosteroid injection. In these cases, the most straightforward approach is to perform the same needle approach as outlined above, followed by delivery of a mixture of a corticosteroid and a local anesthetic (eg, 40-80 mg of long-acting methylprednisolone [eg, Depo-Medrol] and 5 mL of 1% lidocaine).
  • Further specifics of the injection procedure and potential complications are beyond the scope of this text. Interested clinicians are encouraged to read other appropriate sources.
• Relative rest includes restriction of activities, such as climbing stairs or getting in and out of chairs. Direct pressure on the affected site should also be avoided.
• Evaluation and correction of any underlying gait abnormalities are important and may be addressed with assistive devices (eg, cane, walker, orthotics, shoe lift, knee brace).
• Use of deep-heating modalities (eg, US, TENS) should be considered in cases in which conventional therapy has failed in the patient (10-12 wk).

Maintenance Phase

Rehabilitation Program

Physical Therapy

Ideally, by the time the patient is on maintenance therapy, he or she is independently performing a home exercise program to prevent recurrence of trochanteric bursitis.

MEDICATION

Section 7 of 12  

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• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Medications are used primarily to decrease the pain and inflammation of trochanteric bursitis; thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and focal corticosteroid injections that are used in conjunction with the rehabilitation plan.

Drug Category: Nonsteroidal anti-inflammatory drugs

Oral NSAIDs can help decrease pain and inflammation. Various oral NSAIDs can be used, and none holds a clear distinction as the drug of choice. The choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Drug Category: Corticosteroid preparations for focal injection

In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. When corticosteroid injections are used, there are a variety of corticosteroid preparations to choose from. Commonly, the corticosteroid is mixed with one of several local anesthetic agents before injection.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Return to Play

The athlete may be expected to return to play without restrictions when the following goals have been achieved:

• Resolution of symptoms
• Resolution of any positive physical examination findings (eg, limping, tenderness to palpation)
• Adequate performance of sports-specific practice drills, without recurrence of symptoms or physical examination findings

Complications

• Complications due to trochanteric bursitis include progressive or persistent pain, with associated limping and decreased mobility.
• Potential complications due to focal corticosteroid injection include bleeding, bruising, infection, and allergic reactions. Necrotizing fasciitis from a single steroid injection of the greater trochanteric bursa has been reported.⁷ (See also the eMedicine article Necrotizing Fasciitis.)
• In patients with diabetes, transient elevation of blood glucose levels may occur after a corticosteroid injection.
• Intravascular injection could potentially cause cardiac arrhythmia due to the local anesthetic.
• Peripheral nerve dysfunction is possible if the injection is administered very near or within a major nerve.

Prevention

Prevention may include emphasis on an appropriate training schedule for the patient and avoidance of constant unidirectional activities on banked surfaces. For example, if running must be done on a banked surface, ideally, the athlete should spend half the time running each way on the embankment to avoid always overloading the same tissues on one side of the body. Athletes who participate in contact sports (eg, hockey) should be educated regarding the appropriate use and size of protective padding. Athletes in endurance sports should be educated in the importance of ITB stretching and hip abductor strengthening.

Prognosis

Most patients respond well to a combination of corticosteroid injection and physical therapy. Some patients may require a repeat corticosteroid injection.

A retrospective study of 164 patients who presented with trochanteric pain found that after 1 year, at least 36% affected patients were still symptomatic, and after 5 years, 29% were still symptomatic; thus, many patients developed chronic pain at this site.³ Patients with osteoarthritis in the lower limbs had a 4.8-fold risk of persistent symptoms after 1 year, as compared with patients without osteoarthritis.

Patients who were treated with corticosteroid injection were shown to be 2.7 times less likely to have chronic pain at this site at 5 years relative to those treated without such injections.³

Education

• As with any medical condition, educate the patient regarding the nature of the condition, the causative factors, and the treatment plan.
• As with any injection, educate and instruct the patient to watch for any signs or symptoms of local infection at the injection site.
• As with any corticosteroid injection, inform diabetic patients that they may experience a transient increase in blood glucose levels. Patients should also be made aware that symptomatic improvement from the corticosteroid usually does not begin to take effect until a few days after the injection. In fact, they may experience a transient mild increase in symptoms during the time in which the local anesthetic has worn off but when the steroid has not yet begun its therapeutic effect.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Medical/Legal Pitfalls

• Never inject corticosteroid into a site that appears infected.
• In the presence of significant trauma, always check radiographs for fractures before proceeding with treatment.
• Strongly consider radiographs before any injection of corticosteroids.
• If there is a clinical suspicion that the pain may be secondary to metastatic cancer, consider performing a bone scan study, even if plain film findings are normal.

Special Concerns

• Pregnancy: A focal corticosteroid injection can be performed during pregnancy. Avoid the use of oral NSAIDs, especially in the third trimester.
• Pediatric patient: Obtain written, informed consent from the parent or legal guardian of any patient who is a minor before proceeding with any injection.
• Geriatric patient: Be cautious when administering oral NSAIDs to elderly patients.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Greg Gazzillo, 4th year medical student, New Jersey Medical School–UMDNJ, Class of 2007, assisted with the 2006 revision of this manuscript.

Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the 2007 revision of this manuscript.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Media file 1:  This picture demonstrates a method of stretching the iliotibial band (ITB) in the standing position. One foot is crossed over the other; the patient leans away from the side being stretched such that the side to be stretched is leaning in toward the wall. The patient should feel the stretching at the lateral aspect of the hip that is closest to the wall. Stretching should be done in a controlled and sustained manner, never in a ballistic manner with sudden, jerking movements.
	View Full Size Image
Media type:  Photo

Media file 2:  This picture demonstrates a method of stretching the iliotibial band (ITB) with the patient in the supine position. The foot ipsilateral to the stretching is crossed over the contralateral knee. Next, the thigh ipsilateral to the area of stretching is pulled across the midline (adduction). The patient should feel the stretching at the lateral aspect of the hip, in the area shown by the dark line. Stretching should be performed in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

1. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. Jan 2003;406:84-8. [Medline].
2. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92. [Medline].
3. Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. Mar 2005;55(512):199-204. [Medline]. [Full Text].
4. Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. Eur Radiol. Jul 2007;17(7):1772-83. [Medline].
5. Shbeeb MI, O'Duffy JD, Michet CJ Jr, O'Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol. Dec 1996;23(12):2104-6. [Medline].
6. Cohen SP, Narvaez JC, Lebovits AH, Stojanovic MP. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth. Jan 2005;94(1):100-6. [Medline]. [Full Text].
7. Hofmeister E, Engelhardt S. Necrotizing fasciitis as complication of injection into greater trochanteric bursa. Am J Orthop. May 2001;30(5):426-7. [Medline].
8. Brinker MR, Miller MD. The adult hip. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:269-85.
9. Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Publishing; 2000:11-2.
10. Lennard TA. Fundamentals of procedural care. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
11. McGee DJ. Hip. Orthopedic Physical Assessment. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1992:333-71.
12. Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
13. Snider RK. Hip and thigh. Essentials of Musculoskeletal Care. 2^nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:264-303.
14. Snider RK. Injection and corticosteroids. Essentials of Musculoskeletal Care. 2^nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:37-9.
15. Steinberg JG, Seybold EA. Hip and pelvis. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3^rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:171-203.
16. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:783-812.

Article Last Updated: Sep 28, 2007