Trochanteric bursitis is one of the most common causes of pain originating from the periarticular structures of the hip . It often goes unnoticed, being diagnosed as non-specific coxalgia, mainly in older patients with coxarthrosis , or as root irradiation.
Trochanteritis, as such, is the inflammation of the serous bursae that are located in the proximal extremity of the femur . Patients often complain of lateral hip pain , although the hip joint itself is not involved. The pain can radiate to the side of the thigh. Because these bursae are filled with synovial fluid , they are exposed to all those inflammatory processes that affect the hip, such as rheumatoid arthritis . However, most trochanteritis is caused by recurrent microtrauma.
The hip joint is made up of a ball and a cup that surrounds it. The hip cup is called the acetabulum forms and surrounds the ball of the upper part of the femur (femoral head). The thick muscles of the buttock in the back and the thick muscles of the thigh in the front surround the hip.
The greater trochanter is the large bulge on the outside of the upper end of the femur. This bulge is the point where the large muscles in the buttocks that move the hip connect with the femur. The gluteus maximus is the largest of these muscles and inserts lower on the femur.
When friction occurs between muscles, tendons, and bones, there is usually a structure called a bursa. A bursa is a thin tissue sac that contains fluid to lubricate the area and reduce friction. The bursa is a normal structure. The body even produces bursae in response to friction.
The hip is an area especially rich in serous bursae. Of the four bursae that generally exist around the greater trochanter, three are constant: two major and one minor. The minor is located between the greater trochanter and the gluteus minimus; the second, between the gluteus medius and the greater trochanter and, finally, the largest and most important, is located between the gluteus maximus and the gluteus medius tendon. This last bursa is shaped like an almond and is about 5 cm long by 3 cm wide.
Its function is to allow the gliding of the anterior portion of the gluteus maximus tendon and the tensor fascia lata, when they pass over the greater trochanter, to continue with the iliotibial ligament. Consequently, any inflammatory process of this bursa will result in the symptoms of trochanteric bursitis.
It is the inflammation of the bursa located between the greater trochanter and the gluteus medius / iliotibial tract and can be caused by acute trauma or repetitive (cumulative) trauma. Acute injuries include concussions from falls, contact sports, and other sources of impact. Repetitive trauma includes irritation of the bursa resulting from friction of the iliotibial band, which is an extension of the tensor fasciae latae muscle. These repetitive traumas often produce irritation, which generally occurs in corridors, but can also be seen in less active people. Other predisposing factors include lower extremity length discrepancy and lateral hip surgery.
Trochanteric bursitis is relatively common in physically active patients, as well as in sedentary people. Unilateral and bilateral major trochanteric pain syndrome (GTPS) have a prevalence of 15.0% and 8.5% in women, and 6.6% and 1.9% in men, respectively.
Morbidity includes chronic pain, lameness, and pain related to sleep disturbances that occur when the patient is lying on the affected side.
Age and Sex
Trochanteric bursitis can occur in adults of any age, but the majority of patients are women, generally with some degree of obesity, in a 4: 1 ratio, in the middle age of life or older (40-60 years). In the sports field, it is a very common condition in soccer goalkeepers and in those athletes who suffer, as a result of their sporting activity, excessive friction in the region, as occurs, for example, in marathon runners.
Most cases of trochanteric bursitis appear gradually with no apparent underlying causes, but it is usually caused by constant friction of the tensor fasciae lata muscle as it passes over the trochanteric bursa during flexion-extension movements of the hip. Bursa friction can occur when walking if the long tendon on the side of the thigh, the iliotibial band, is tight. It is not clear what causes this tendon tightness. The gluteus maximus attaches to this long tendon. When walking, the gluteus maximus pulls this tendon on the greater trochanter with each step.
When the tendon is tight, it rubs against the bursa. Rubbing causes irritation and inflammation of the bursa. There may also be friction if another muscle in the area (gluteus medius) is weak, if one leg is longer than the other, or if you run on uneven (inclined) surfaces.
On the other hand, alterations in the biomechanics of the lower limb (hip, knee or foot), sacrum, lumbar spine, or alterations in the adjacent structures of the hip can lead to inflammation of the bursa in a significant proportion, as occurs in rheumatoid arthritis, lumbar spondylosis or asymmetries caused by nerve paralysis.
Trochanteric bursitis can appear after total hip replacement or other types of hip surgery. The cause can be a combination of changes in the way the hip joint works, the way the prosthesis is placed, that is, the alignment, or the way the scar tissue has remained after the incision has healed.
A fall on the hip can cause bleeding into the bursa and the formation of a bruise . The bleeding is not serious, but the bursa can react to the bleeding with inflammation. The inflammation causes the bursa to thicken over time. This thickening, constant irritation and inflammation can lead to it becoming chronic, or long lasting.
Deep trochanteric bursitis occurs in runners and ballet dancers, as a form of overuse injury, or in other athletes from acute trauma.
The onset can be acute or insidious. If there is an acute trauma, patients can recall specific details of the impact. The classic symptom is chronic and intermittent pain in the greater trochanter region of the hip that can radiate to the lateral part of the ipsilateral thigh, in more than 40% of cases, however the irradiation should not reach the foot. There is local pain (more posterior in the case of deep bursa involvement).
Symptoms are aggravated when the patient lies on the affected bursa (ie, when lying in the lateral decubitus position). Pain can awaken the patient during the night.
Hip movements (internal and external rotation), walking, running, weight bearing, stair climbing, and other vigorous activities can exacerbate symptoms.
Patients may report leg weakness and loss of strength from pain. Symptoms are usually related to increased activity or exercise.
- Chronic pain
- Activity level limitation
- Lameness (Antalgic gait
- Sleep disturbance, which is especially troublesome for patients who generally sleep in the lateral decubitus position.
The diagnosis of trochanteric bursitis begins with a history and physical exam. This is usually all that is necessary to make the diagnosis.
In general, laboratory studies are not necessary for the diagnosis of trochanteric bursitis. In rare cases, it may be necessary to rule out infection or a connective tissue disease.
Treatment of trochanteric bursitis usually begins with simple measures. The treatment becomes more complex if the simple measures. The vast majority of patients with trochanteric bursitis do not require surgery.
Trochanteric bursitis generally does not require surgical treatment. Younger patients who have this condition due to mechanical overload can usually be treated by reducing their activities or changing the way they do them. Combining this with a stretching and strengthening exercise program and perhaps a short course of anti-inflammatories can usually solve the problem.
Oral anti-inflammatories can help decrease pain and inflammation and can be used for several weeks. The choice of an anti-inflammatory is largely a matter of convenience (the frequency of taking and the appropriate dose to achieve an analgesic and anti-inflammatory effect) and cost.
It can also be combined with physiotherapy sessions. These physical therapy treatments are used to decrease inflammation and may include applications of heat or ice.
Physical therapy will help, with massages and stretches, to restore the hip’s full range of motion. Improving strength and coordination in the gluteal muscle and hip muscles is also favored by allowing the femur to move more smoothly, helping to reduce friction on the bursa. Physical therapy may be needed for four to six weeks before full mobility and recovery of functional capacity are achieved.
If rehabilitation does not reduce symptoms, a cortisone injection into the bursa can relieve symptoms and provide temporary relief from the condition. Cortisone is a powerful anti-inflammatory. Swelling and pain can be reduced when injected directly into the bursa. The injection probably does not cure the problem. However, you can control symptoms for months.
Corticosteroid injection into the trochanteric bursa
Many authors consider that infiltrations can play an important role in the treatment plan for trochanteric bursitis. Several randomized controlled clinical trials have shown that infiltration of corticosteroids and lidocaine for trochanteric bursitis is an effective therapy with long-term benefit.
Since the 60s, the infiltration of glucocorticoids has been the treatment of choice for trochanteric bursitis. Gordon, in 1961, compared the response of a series of patients to one or more injections with local anesthetic versus a single injection with a mixture of anesthetic and corticosteroid.
The results were excellent in the latter case, although the study follow-up was too short for long-term evaluations (only 21 days!). In 1976, Swezey et al reported a 50% positive response with a 3-month follow-up and a single 40-mg triamcinolone injection. The studies by Ege Rassmusen and Fano, in 1985 and by Schapira et al, in 1986, provide us with positive response ranges of 70-90% with one or more corticosteroid injections, but they also record a 25% relapse within 10 months of follow up.
The 1996 study by Shbeeb and Matteson for the Mayo Clinic1 is the most recent of the longitudinal studies of trochanteric bursitis. In it, after a 6-month follow-up, more than 60% of the patients noted relief of their symptoms with a single infiltration. Doses of 6, 12 and 24 mg of dexamethasone dissolved in 4 cc of lidocaine were used. The patients who received the highest dose of corticosteroids were those who experienced the most evident improvement.
The infiltration technique of the trochanteric bursa should be performed with the patient in lateral decubitus on the healthy side and with the affected hip semi-flexed. They are commonly performed without radiographic orientation. However, some preliminary data suggest that radiological confirmation (for example, with fluoroscopy) is necessary for the exact location of the trochanteric bursa, especially in obese patients, who have a history of trauma, who suffer from chronic inflammation, or who have had previous surgery, as well as when repeat injections are necessary. This radiographic confirmation may also be necessary in patients with chronic pain who, therefore, have developed a peripheral sensitization, which can lead to infiltration in sensitive areas,
The diagnostic infiltration procedure consists of using local anesthesia, without epinephrine (eg, 5 ml of 1–2% lidocaine), which is injected into the affected trochanteric bursa using a 22-G needle. A 3.8 cm needle. it may be suitable for a thin patient, but an overweight patient may require an 8.9 cm needle. to get to the bursa.
The needle is inserted up to the greater trochanter (in contact with the bone to confirm depth and proper placement) and then slightly withdrawn to bring it into the bursa. The local anesthetic can be injected directly into the bursa. If the patient has rapid pain relief, this is considered confirmation of trochanteric bursitis as the etiology of the pain.
This injection of local anesthetic can be followed by the administration of steroids (by using the needle that is already in place and changing to a syringe containing the corticosteroid). Injection of 40-80 mg. Methylprednisolone acetate, triamcinolone acetonide, or a mixture of sodium phosphate and betamethasone acetate (12 mg0 6 + 6) is adequate. This infiltration can be repeated in 4-6 weeks if pain relief has been less than 50%. In most cases, the diagnosis of trochanteric bursitis is clear. In these cases, the diagnostic test with lidocaine is not necessary and infiltration will be performed with a mixture of a local anesthetic and the corticosteroid.