Trochanteric Bursitis

Inflammation of one or more bursae over the greater trochanter of the femur (the subgluteus maximus bursa is the most important, with the subgluteus medius and minimus bursae deeper). It presents as lateral hip pain.

• Most lateral hip pain in adults is actually tendinopathy or tear of the gluteus medius and minimus tendons, and isolated bursitis is much less common than previously thought. The two often coexist, and the combined picture is called greater trochanteric pain syndrome. The condition is described here as it presents clinically, with the bursa as the focus.
• Prevalence of lateral hip pain is about 10 to 25% in adults over 50 years, and women are affected 3 to 4 times more than men. It peaks in the fourth to sixth decades.
• Causes and risk factors: repetitive friction of the iliotibial band over the trochanter (running, stair climbing, cycling), direct trauma or fall onto the hip, leg length discrepancy, wide pelvis, gluteal weakness, hip or lumbar spine osteoarthritis, obesity, rheumatoid arthritis, gout, diabetes, previous hip surgery or prosthesis, and, uncommonly, infection (septic bursitis, tuberculosis) or crystal deposition.
• Prognosis: most cases settle in 3 to 6 months with conservative care, but about 20 to 30% have symptoms lasting a year or more.

• Lateral hip and upper thigh pain, aching or burning, sometimes radiating down the lateral thigh toward the knee (not usually below the knee). It is worse lying on the affected side at night (the commonest complaint), with prolonged standing, climbing stairs, getting up from a chair, walking and running. Sleep is often disturbed.
• Examination: point tenderness over the greater trochanter, reproduced by palpation 2 to 3 cm proximal to the tip of the trochanter, pain on resisted hip abduction and external rotation, pain on single leg stance for 30 seconds (a positive test is very sensitive), and a positive Ober or FABER test. Hip internal rotation range is usually preserved and pain free (unlike hip joint disease). Swelling and warmth are uncommon unless septic.
• Differential diagnosis: gluteus medius or minimus tendinopathy or tear, iliotibial band syndrome, hip osteoarthritis, femoroacetabular impingement, labral tear, referred pain from the lumbar spine (L4 or L5 radiculopathy), sacroiliac joint dysfunction, piriformis syndrome, meralgia paraesthetica, stress fracture of the femoral neck, avascular necrosis, inflammatory arthritis, and septic bursitis, tumour or metastasis.
• Red flags: fever, marked warmth and swelling, severe night pain with weight loss, a history of cancer, inability to bear weight (femoral neck fracture), and neurological deficit.
• Complications: chronic pain, disturbed sleep, gait change, tendon tear, and rarely septic bursitis.

• Clinical, based on the history, lateral tenderness and the positive single leg stance test.
• Imaging is not needed initially. Plain X-ray of the pelvis and hip (osteoarthritis, calcification near the trochanter, fracture, tumour) is done if pain is persistent, or red flags exist.
• Ultrasound shows bursal fluid, tendon thickening, calcification or tears, and can guide injection. MRI is the best test for gluteal tendon tear, occult fracture, stress reaction, tumour or infection, and for unclear or refractory cases.
• Aspirate and culture bursal fluid with cell count and crystals if infection or gout is suspected. Check full blood count, CRP, ESR, urate and, when appropriate, inflammatory arthritis serology.
• Examine the lumbar spine and neurological function to exclude radiculopathy.

• Conservative treatment (successful in most patients):
  • Relative rest from aggravating activities (running, stair climbing, crossing legs, standing with the weight on one leg), and avoid lying on the painful side. Sleep on the opposite side with a pillow between the knees, or on the back.
  • Weight loss when overweight, supportive footwear, and a heel lift for leg length difference of more than 1 cm.
  • Analgesia: paracetamol 1 g orally 6 hourly, with ibuprofen 400 mg orally 8 hourly with food (or naproxen 500 mg 12 hourly, or diclofenac 50 mg 8 hourly) for 1 to 2 weeks if no contraindication, with a proton pump inhibitor in at risk patients. Topical diclofenac 1% gel 4 g up to 4 times daily is an alternative.
  • Ice for 10 to 15 minutes, 3 times daily, in the first days.
  • Physiotherapy: progressive gluteal strengthening (side lying hip abduction, bridging, step ups), hip abductor and external rotator loading, iliotibial band and hip flexor stretching, and gait retraining, for 8 to 12 weeks. Exercise has better long term outcomes than injection.
  • Extracorporeal shock wave therapy, 3 to 4 weekly sessions, has moderate evidence in chronic cases.
• Corticosteroid injection for pain that fails 4 to 6 weeks of conservative treatment: methylprednisolone acetate 40 mg or triamcinolone acetonide 40 mg, mixed with lidocaine 1% 4 to 5 mL (or bupivacaine 0.25 to 0.5% 3 to 5 mL), into the point of maximal tenderness and around the bursa, with a 21 to 22 gauge needle, preferably under ultrasound guidance. About 60 to 75% get relief for 2 to 8 weeks, with sustained benefit in fewer. Limit to 2 to 3 injections per year at intervals of at least 6 to 12 weeks. Risks: tendon weakening or rupture, skin atrophy and depigmentation, infection (rare), and transient hyperglycaemia in diabetes (monitor glucose for 3 to 5 days).
• Platelet rich plasma injection (single or 2 injections, 3 to 5 mL), has emerging evidence for gluteal tendinopathy and may be better than steroid in the long term, but availability and cost vary.
• Surgery for refractory pain (6 to 12 months of failed conservative care): bursectomy, iliotibial band release or lengthening (open or endoscopic), and gluteal tendon repair in the presence of a tear, with about 70 to 90% success in selected patients.
• Septic bursitis: aspirate, culture, and give flucloxacillin 1 to 2 g IV 6 hourly (or oral 500 mg to 1 g 6 hourly) for 2 to 3 weeks, or vancomycin 15 to 20 mg/kg IV 8 to 12 hourly (adjusted to levels) if MRSA is likely, with surgical drainage for failure of antibiotics. Test for tuberculosis if indolent.
• Special groups:
  • Pregnancy: use rest, physiotherapy, paracetamol and sleeping positions. Avoid NSAIDs after 20 weeks and steroid injection unless essential.
  • Elderly: favour exercise and topical agents, assess for fractures and osteoporosis, and use NSAIDs cautiously.
  • Diabetes: watch glucose after steroid injections.
  • Runners and athletes: review training load, running surface and cadence, and shoes, and return to activity gradually over 6 to 12 weeks.
  • Anticoagulation: prefer ultrasound guided injection with a fine needle and prolonged pressure, or defer.
• Follow up: review at 6 weeks. Refer to sports medicine, orthopaedics or rheumatology for no improvement by 3 months, tendon tear, or doubt about the diagnosis.