Introduction

In many areas of the body, muscles and tendons must slide over and against one another during movement. At each of these places, a small sac of lubricating fluid helps the muscles and tendons move properly. One of these places is the hip. Usually these sacs of fluid, called bursae, function to reduce friction, but if they become swollen and irritated they can cause pain.

One common area where this occurs is the bursa on the outside of the hip (trochanteric bursa) creating a condition known as trochanteric bursitis. This condition is common in older individuals, but may occur in younger patients who are extremely active.

Anatomy

The hip socket is called the acetabulum and forms a deep cup surrounding the ball of the upper thigh bone (femur), or femoral head. The hip is surrounded by the thick muscles of the buttock at the back and the thick muscles of the thigh in the front.

On the outside of the upper end of the femur is a large bump (greater trochanter). This bump is the point where the large buttock muscles that move the hip connect to the femur. These muscles help rotate and move the hip outward. Another layer of muscle, the gluteus maximus, slides over this bump and is attached further down on the thigh bone (femur).

Where friction must occur between muscles, tendons, and bones there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains a bit of fluid to lubricate the area where the friction occurs. The bursa is a normal structure, and the body will even produce a bursa in response to friction.

Causes

Sometimes a bursa can become inflamed because of too much friction or because of an injury to the bursa which can result in pain.

Friction can occur in the bursa during walking if the long tendon on the side of the thigh is tight. It is unclear what causes this tightening of the tendon. The gluteus maximus attaches to this long tendon. As you walk the gluteus maximus pulls this tendon over the greater trochanter with each step. When the tendon is tight, it rubs closely against the bursa with each step. The rubbing causes friction to occur in the bursa, leading to irritation and inflammation. Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on banked surfaces.

Most cases of trochanteric bursitis appear gradually with no obvious underlying injury or cause. Trochanteric bursitis can occur after artificial replacement of the hip joint or other types of hip surgery. This may be a combination of changes in the way the hip works, the way it is aligned, or the way scar tissue has formed from the healing incision. Trochanteric bursitis can also occur as a result of repetitive motion injuries from activities such as running.

A fall on the hip can injure the bursa. This may cause bleeding into the bursa. The bleeding is not serious, but the bursa may react to the blood by becoming inflamed. The inflammation causes the bursa to become thickened over time. This thickening, constant irritation, and inflammation may result in the condition becoming chronic, or long lasting.

Symptoms

The first symptom of trochanteric bursitis is usually pain. The pain can be felt in the area of the hip right over the bump that forms the greater trochanter. Eventually the pain may radiate down the outside of the thigh. As the problem progresses, the symptoms include development of a limp when walking and stiffness in the hip joint. Eventually, the pain will also be present at rest and may even cause a problem with sleeping.

Diagnosis

The diagnosis of trochanteric bursitis begins with a history and physical examination. In fact, this is usually all that is necessary to make the diagnosis. Your doctor will want to know when the pain began and which motions cause the pain. A physical examination will be done to determine how much stiffness you have in the hip and if you have a limp. Once this is done, X-rays will most likely be ordered to make sure that there are no other abnormalities in the hip.

Diagnostic Injection

One simple way that the diagnosis of trochanteric bursitis can be made is with an injection of local anesthetic directly into the bursa. This is a procedure that can easily be performed in the office. To perform this procedure you will probably be asked to lay on the examining table on your side with the sore hip up. Once the skin is cleansed with antiseptic, a long needle is used to inject ten to twenty milliliters of a medication such as novocaine directly into the trochanteric bursa. If the injection removes the pain immediately, then the diagnosis is probably trochanteric bursitis. Most physicians will also add a bit of cortisone medication into the novocaine to help treat the condition at the same time.

Treatment 

Conservative Treatment

Conservative treatment can be very successful for trochanteric bursitis. Younger patients who suffer from trochanteric bursitis because of repetitive motion can usually be treated by reducing their activity or changing the way they do their activity. Combining this with an exercise program of stretching and strengthening and a brief course of anti-inflammatory medications will usually resolve the problem.

Your doctor may also prescribe sessions with a physical therapist. Treatments are used to calm inflammation and may include heat or ice applications. Therapists use hands on treatment and stretching to help restore full hip range of motion. Improving strength and coordination in the buttock and hip muscles also enables the femur to move in the socket smoothly and can help reduce friction on the bursa. You may need therapy treatments for four to six weeks before full motion and function return.

If rehabilitation fails to reduce your symptoms, an injection of cortisone into the trochanteric bursa may ease your symptoms and give temporary relief of the condition. Cortisone is an anti-inflammatory medication which when injected directly into the bursa can reduce the inflammation and pain. Injections will probably not cure the problem but may control the symptoms for months. 

Surgery

Surgery is rarely needed to treat trochanteric bursitis. When all else fails and the pain is disabling, your doctor may recommend surgery. Several types of surgical procedures are available to treat trochanteric bursitis.

The primary goal of all procedures designed to treat this condition is to remove the thickened bursa, to remove any bone spurs that may have formed on the greater trochanter, and to relax the large tendon of the gluteus maximus. Some surgeons prefer to lengthen the tendon slightly, and some prefer to remove a section of the tendon that rubs directly on the greater trochanter.

Rehabilitation

Even if surgery is not needed, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical therapist. Your therapist can create a program of stretching and strengthening for your hip. It is very important to maintain a balance of flexibility and strength of the hip. You will probably progress to a home program within four to six weeks.

If surgery is required, physical therapy sessions may be needed for up to two months after surgery. The first few treatment sessions will focus on controlling the pain and swelling after surgery. You will then begin exercises that gradually stretch and strengthen the muscles around the hip joint. Your therapist will help retrain these muscles to keep the ball of the femur moving smoothly in the socket. Your therapist will give you tips on ways to do your activities without straining the hip joint.