A bursa is a fluid-filled sac of soft tissue that acts as a lubricating medium between different structural components throughout the body. They can be found near all of the body’s major joints, including the knee, shoulder, and elbow; bursitis occurs when these sacs get inflamed and cause pain and irritation to the very tissues they are tasked with helping freely move.
There are two bursae in the hip: the greater trochanteric bursa, which lines the greater trochanter of the hip and allows the iliotibial band to move freely across the bony prominence, and the iliopsoas bursa, which is located near the groin. However, trochanteric bursitis is far more common than iliopsoas bursitis, as this bursa is more likely to be damaged or injured. In any case, trochanteric bursitis and iliopsoas bursitis are diagnosed and treated in the same way, so much of what is discussed herein applies to both conditions.
Trochanteric bursitis is caused by inflammation and damage to the bursae, either through overuse, injury or comorbid disease processes. While the condition can happen to anyone, it is most common in female and older patients. Females are more predisposed to trochanteric bursitis because of the shape of their hips and pelvis. There are a number of associated risk factors for the condition, including repetitive stress from running, cycling or extended periods of standing; low back pain; unequal leg lengths; rheumatoid arthritis; and prior surgery in the hip.
One of the strongest correlations for trochanteric bursitis is with low back pain, specifically degenerative disc disease. The pain from these conditions weakens and destabilizes the lumbar and pelvic musculature, which places excessive stress on the abductor muscles and unbalances the pelvis. This loss of hip stability tightens the iliotibial band, which begins to irritate the trochanteric bursa, ultimately leading to bursitis. This bursitis can damage the areas on the side of the hip and ultimately lead to tearing of the abductor tendons. This is very similar to the way that shoulder bursitis leads to rotator cuff tears. Because this disease progresses from bursitis to abductor tendinitis and finally abductor tearing, the medical term encompassing all of these diagnoses is Greater Trochanteric Pain Syndrome.
The primary symptom of trochanteric bursitis is pain and inflammation at and surrounding the site of the inflamed bursae. This pain is generally located on the outer and lateral sections of the hip in trochanteric bursitis where the Iliotibial (IT) band rubs over the side of the greater trochanter. This pain is typically described as localized and sharp, but over time it can transition to a constant, dull ache spreading across a larger area of the hip. It is also generally worse at night when patients lie on the affected hip, when walking up stairs, and when standing from a seated position. In addition to the pain, hip bursitis can lead to functional shortcomings, including gait issues and can worsen concomitant back pain. Long-standing and untreated trochanteric
The hip musculature includes a critical group of muscles called the abductors, which include the gluteus medius, gluteus minimus, and tensor fascia latae. The abductors are often referred to as the rotator cuff of the hip, as they serve a similar anatomical and mechanical purpose. These muscles come together to move the leg away from the body and rotate the leg at the hip joint and are absolutely essential for maintaining stability will walking or in a single-leg stance (running, cutting, dancing, etc.). The symptomology of abductor tears closely mimic those of trochanteric bursitis, so it is a critical differential diagnosis for an orthopaedic surgeon to investigate if treatment for hip bursitis is unsuccessful.
Diagnosis and Treatment
In order to diagnose the cause of your hip pain, your physician will first conduct a comprehensive physical examination and discuss your medical and family history. The will evaluate your range of motion and palpate (press firmly) over the anatomical sites of the hip bursae to evaluate your level of tenderness. In some cases, your physician may order additional diagnostic tests like x-ray or magnetic resonance imaging (MRI) to better visualize the bone and soft tissue structures of the hip. Generally speaking, a physical examination and medical history will be sufficient to diagnose bursitis; the additional testing is simply to rule out more severe underlying issues. To diagnose abductor tendon tears, generally, an MRI is required.
Hip bursitis is generally treated non-operatively with activity modification and physical therapy aimed at improving hip strength and flexibility. You may also receive steroid or numbing injections directly into the affected bursa, which can provide immediate and, in some cases, long-lasting relief. Often, conservative treatment fails and patients require surgical intervention to get relief from hip bursitis. During this procedure, the bursa will be entirely removed (excised) from the hip using an arthroscopic approach. The bursa is a vestigial structure so the hip can function perfectly fine without it. Often, the Iliotibial band is also lengthened to help prevent recurrence of symptoms and pain.
Abductor tendon tears are usually treated non-operatively initially. Steroid injections may not help the symptoms with abductor tendon tears.