Treatment of Trochanteric Bursitis

Trochanteric bursitis is a common disorder occurring over the lateral aspect of the proximal femur at the level of the greater trochanter. The main symptoms are pain, aching or pulling over the lateral aspect of the trochanteric area and lateral thigh.

The most prominent area of the lateral thigh, the lateral aspect of the trochanter can cause irritation of the bursa overlying it. The bursa surrounds the gluteus medius insertion on to the greater trochanter of the femur. Additionally, since the tensor fascia lata overlies the gluteus maximus insertion at the level of the greater trochanter, the interface between the tensor fascia lata and gluteus medius insertion can also become inflamed.

Bursitis refers to painful inflammation of the potential spaces surrounding these tendon structures. Trochanteric bursitis can result from overuse and/or traumatic inflammation of the trochanteric bursa. Direct falls on the lateral aspect of the hip, repetitive athletic overuse or multiple traumatic impacts of a lesser severity can cause acute inflammation of the trochanteric bursa and lead to chronic trochanteric bursitis. The acute inflammatory process can cause reactive tissue to form within the bursa and, with repetitive insults, the bursa may become an active inflammatory center aggravated by any activity involving the surrounding muscles.

Etiology

Trochanteric bursitis may be occupation-related, such as a cashier or wallpaper hanger whose multiple repetitive actions lead to trauma to the lateral thigh area. Also, patients who must lie on one side of their bodies for extended periods due to an injury, may develop pain over the trochanteric bursa. Walking, moving the involved extremity, and lying on the involved trochanter may increase pain.

Limiting mobility of the lumbar spine, hip, knee or ankle may contribute to trochanteric bursitis by increasing the irritation over the greater trochanter. Injury to any of these areas may cause a limp and an alteration in gait which may lead to irritation of the structures overlying the greater trochanter. Additionally, leg length discrepancy and scoliosis similarly disrupts the normal mechanics of gait.

Symptoms

Although trochanteric bursitis occurs commonly in middle-aged or elderly persons, and more often in women than men, it can occur at any age. All patients complain of aching over the trochanteric area and lateral thigh. Although pain is usually acute in onset, it may increase gradually as a symptom. It may last for many months. In chronic cases, the patient's complaints may be more vague and they may not be able to adequately describe the location of their pain.

The pain can have a radiating quality which must be distinguished from that associated with lumbosacral spine disease or sciatica. Lumbosacral spine disease is particularly suspect if the pain radiates down to the knee and throughout the extent of the iliotibial band.

Patients generally present with a limp and, rarely, may not be able to walk due to the intensity of the pain.

Physical Examination

Trochanteric bursitis is diagnosed by direct physical examination. With the patient lying on his or her side or back, pressure is placed over the vastus ridge of the greater trochanter. Pain is usually elicited with this maneuver. The pain is usually lateral and/or posterior to the greater trochanter and is exacerbated with external rotation of the hip. Abduction against resistance may be difficult without pain.

A careful history of previous surgery over the involved trochanter is important as surgical scars, previous trauma or prosthetic implants may indicate the cause of the trochanteric bursitis.

Underlying surgical wire, implants or scar tissue can be a nidus for the formation of the trochanteric bursitis.

Diagnostic Studies

Radiographs of the involved hip may help determine if spur formation or underlying surgical hardware may be causing the bursitis. A rheumatological evaluation for fibromyalgia may be necessary if the patient has a history of multiple tendon disorders such as shoulder bursitis, low back pain, Achilles tendinitis, plantar fasciitis, pes anserine bursitis, costochondritis and/or multiple trigger points in addition to depression, sleep disorders, or other psychiatric history. Although bursitis is generally considered to be the main problem, the disorder can actually be present at the insertion of the tendons involved and may involve an enthesopathy or other systemic condition rather than merely a localized trochanteric bursitis.

Treatment

The first step in treatment of trochanteric bursitis is rest. The activities which cause the problem need to be modified and the area needs to be relieved and treated. Ice, nonsteroidal anti-inflammatory drugs, stretching of the gluteus medius and tensor fascia lata, weight loss and pelvic tilt exercises may help in the overall management of trochanteric bursitis.

Physical therapy interventions may also be helpful. In addition to icing the affected area for 15 to 2() minutes two to three times a day, other modalities including iontophoresis, ultrasound and deep massage may be effective. In addition, the physical therapist can demonstrate gluteus medius strengthening exercises, stretching exercises for the tensor fascia lata and pelvic tilt exercises.

If rest, ice, anti-inflammatory drugs and physical therapy are not successful, then the patient may be a candidate for a local injection of corticosteroid. A 22 gauge needle may be inserted directly over the vastus ridge at the site of the patient's pain to deposit a preparation of local anesthetic and corticosteroid within the bursa. Several injections may be necessary over a several month period to completely resolve this problem. Occasionally, if this treatment regimen does not work and there is an underlying cause which has been elucidated, surgery may be indicated to relieve trochanteric bursitis. In properly selected patients, the success rate for surgery still is not high and is to be avoided if at all possible unless a very obvious offending agent is found within the trochanteric bursa on preoperative workup.

Clinical Features

• Pain over the lateral thigh at the level of the vastus ridge of the greater trochanter
• Pain when tying on side
• Tenderness with palpation over the lateral aspect of the greater trochanter

Treatment

• Rest
• Anti-inflammatory medication
• Ice
• Stretching exercises
• Physical therapy
• Steroid injection
• Surgery as a last resort