> Table of Contents > Trochanteric Bursitis (Greater Trochanteric Pain Syndrome)
Trochanteric Bursitis (Greater Trochanteric Pain Syndrome)
David W. Kruse, MD
Joann Y. Chang, MD
image BASICS
Trochanteric bursitis is the historical term referring to lateral hip pain and tenderness over the greater trochanter. Because many patients lack an inflammatory process within the trochanteric bursa, this condition has been more recently referred to as greater trochanteric pain syndrome (GTPS) (1).
DESCRIPTION
  • Bursae are fluid-filled sacs found primarily at tendon attachment sites with bony protuberances:
    • Multiple bursae are in the area of the greater trochanter of the femur.
    • These bursae are associated with the tendons of the gluteus muscles, iliotibial band (ITB), and tensor fasciae latae.
    • The subgluteus maximus bursa is implicated most commonly in lateral hip pain (1).
  • Other structures of the lateral hip include the following:
    • ITB, tensor fasciae latae, gluteus maximus tendon, gluteus medius tendon, gluteus minimus tendon, quadratus femoris muscle, vastus lateralis tendon, piriformis tendon
  • Bursitis refers to bursal inflammation.
  • Tendinopathy refers to any abnormality of a tendon, inflammatory or degenerative. Enthesopathy refers to abnormalities of the zones of attachment of ligaments and tendons to bones.
EPIDEMIOLOGY
Incidence
  • 1.8/1,000 persons/year
  • Peak incidence in 4th to 6th decades
Prevalence
  • Predominant sex: female > male
  • More common in running and contact athletes
    • Football, rugby, soccer
ETIOLOGY AND PATHOPHYSIOLOGY
  • Acute: abnormal gait or poor muscle flexibility and strength imbalances lead to bursal friction and secondary inflammation
    • Tendon overuse and inflammation
    • Direct trauma from contact or frequently lying with body weight on hip can cause an inflammatory response (“hip pointer”) as well.
  • Chronic
    • Fibrosis and thickening of bursal sac due to chronic inflammatory process
    • Tendinopathy due to chronic overuse and degeneration: gluteus medius and minimus most commonly involved (1,2)
Genetics
No known genetic factors
RISK FACTORS
Multiple factors have been implicated (1,3):
  • Female gender
  • Obesity
  • Tight hip musculature (including ITB)
  • Direct trauma
  • Total hip arthroplasty
  • Abnormal gait or pelvic architecture
    • Leg length discrepancy
    • Sacroiliac (SI) joint dysfunction
    • Knee or hip osteoarthritis
    • Abnormal foot mechanics (e.g., pes planus, overpronation)
    • Neuromuscular disorder: Trendelenburg gait
GENERAL PREVENTION
  • Maintain ITB, hip, and lower back flexibility and strength.
  • Avoid direct trauma (use of appropriate padding in contact sports).
  • Avoid prolonged running on banked or crowned surfaces.
  • Wear appropriate shoes.
  • Appropriate bedding and sleeping surface
  • Maintain appropriate body weight loss.
COMMONLY ASSOCIATED CONDITIONS
  • Biomechanical factors (1)
    • Tight ITBs, leg length discrepancy, SI joint dysfunction, pes planus
    • Width of greater trochanters greater than width of iliac wings (4)[B]
  • Other associated pathology (1):
    • Low back pain
    • Knee and hip osteoarthritis
    • Obesity
image DIAGNOSIS
PHYSICAL EXAM
  • Observe gait.
  • Point tenderness with direct palpation over the lateral hip is characteristic of GTPS (1)[B].
  • Other exam features have lower sensitivity (1)[B]:
    • Pain with extremes of passive rotation, abduction, or adduction
    • Pain with resisted hip abduction and external or internal rotation
    • Trendelenburg sign
  • Other tests to rule out associated conditions:
    • Patrick-FABERE (flexion, abduction, external rotation, extension) test for SI joint dysfunction
    • Ober test for ITB pathology
    • Flexion and extension of hip for osteoarthritis
    • Leg length measurement
    • Foot inspection for pes planus or overpronation
    • Lower extremity neurologic assessment for lumbar radiculopathy or neuromuscular disorders
    • Hip lag sign (5)
DIFFERENTIAL DIAGNOSIS
  • ITB syndrome
  • Piriformis syndrome
  • Osteoarthritis or avascular necrosis of the hip
  • Lumbosacral osteoarthritis/disc disease with nerve root compression
  • Fracture or contusion of the hip or pelvis—particularly in setting of trauma
  • Stress reaction/fracture of femoral neck—particularly in female runners
  • Septic bursitis/arthritis
DIAGNOSTIC TESTS & INTERPRETATION
No routine lab testing is recommended.
Initial Tests (lab, imaging)
  • Diagnosis can be made by history and exam (6).
  • If imaging is ordered:
    • US can aid in diagnosis and guide aspiration and/or injection.
    • Anteroposterior and frog-leg views of affected hip to rule out specific bony pathology (OA, stress fracture, etc).
    • Consider lumbar spine radiographs if back pain is thought to be a contributing factor.
    • MRI is image of choice in recalcitrant pain or to formally exclude stress fracture.
Follow-Up Tests & Special Considerations
  • If there is a concern for a septic bursitis, then aspiration or incision and drainage may be necessary.
  • Advanced imaging rarely necessary; detection of abnormalities on MRI is a poor predictor of GTPS (7)[B].
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image TREATMENT
GENERAL MEASURES
  • Physical therapy to address underlying dysfunction and rebuild atrophic muscle
  • Correct pelvic/hip instability.
  • Correct lower limb biomechanics.
  • Low-impact conditioning and aquatic therapy
  • Gait training
  • Weight loss (if applicable)
  • Minimize aggravating activities such as prolonged walking or standing.
  • Avoid lying on affected side.
  • Runners
    • May need to decrease distance and/or intensity of runs during treatment. Some need to stop running. Amount of time is case specific but may range from 2 to 4 weeks.
    • Avoid banked tracks or roads with excessive tilt.
MEDICATION
First Line
  • NSAIDs (1)[B]: Treat for 2 to 4 weeks.
    • Naproxen: 500 mg PO BID
    • Ibuprofen: 800 mg PO TID
  • Corticosteroid injection is effective for pain relief (8)[C] and can be considered first-line therapy for selected cases:
    • Dexamethasone: 4 mg/mL or
    • Kenalog: 40 mg/m, useL 1 to 2 mL
    • Consider adding a local anesthetic (short- and/or long-acting) for more immediate pain relief.
    • Can be repeated with similar effect if original treatment showed a strong response
    • Goal is pain relief (9)[A].
ISSUES FOR REFERRAL
  • Septic bursitis
  • Recalcitrant bursitis
ADDITIONAL THERAPIES
  • Ice
  • Low-energy shock wave therapy has been shown to be superior to other nonoperative modalities (8)[A].
  • Focus on achieving flexibility of hip musculature, particularly the ITB.
  • Address contributing factors:
    • Low back flexibility
    • If leg length discrepancy, consider heel lift.
    • If pes planus or overpronation, consider arch supports or custom orthotics.
SURGERY/OTHER PROCEDURES
  • Surgery rare but effective in refractory cases (10)[A]
  • If surgery is indicated, potential options include:
    • Arthroscopic bursectomy
    • ITB release
    • Gluteus medius tendon repair
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture
  • Prolotherapy
  • Growth factor injection techniques
  • Platelet-rich plasma injection
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
4 weeks posttreatment, sooner if significant worsening
PATIENT EDUCATION
  • Maintain hip musculature flexibility, including ITB.
  • Correct issues that may cause abnormal gait:
    • Low back pain
    • Knee pain
    • Leg length discrepancy (heel lift)
    • Foot mechanics (orthotics)
  • Gradual return to physical activity
PROGNOSIS
Depends on chronicity and recurrence, with more acute cases having an excellent prognosis
REFERENCES
1. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-1670.
2. Domb BG, Carreira DS. Endoscopic repair of fullthickness gluteus medius tears. Arthrosc Tech. 2013;2(2):e77-e81.
3. Farmer KW, Jones LC, Brownson KE, et al. Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment. J Arthroplasty. 2010;25(2):208-212.
4. Viradia NK, Berger AA, Dahners LE. Relationship between width of greater trochanters and width of iliac wings in trochanteric bursitis. Am J Orthop (Belle Mead NJ). 2011;40(9):E159-E162.
5. Kaltenborn A, Bourg CM, Gutzeit A, et al. The hip lag sign—prospective blinded trial of a new clinical sign to predict hip abductor damage. PLoS One. 2014;9(3):e91560.
6. Chowdhury R, Naaseri S, Lee J, et al. Imaging and management of greater trochanteric pain syndrome. Postgrad Med J. 2014;90(1068):576-581.
7. Blankenbaker DG, Ullrick SR, Davis KW, et al. Correlation of MRI findings with clinical findings of trochanteric pain syndrome. Skeletal Radiol. 2008;37(10):903-909.
8. Stephens MB, Beutler AI, O'Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. 2008;78(8):971-976.
9. Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care. Ann Fam Med. 2011;9(3):226-234.
10. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447-453.
Additional Reading
&NA;
  • Baker CL Jr, Massie RV, Hurt WG, et al. Arthroscopic bursectomy for recalcitrant trochanteric bursitis. Arthroscopy. 2007;23(8):827-832.
  • Barnthouse NC, Wente TM, Voos JE. Greater trochanteric pain syndrome: endoscopic treatment options. Oper Tech Sports Med. 2012;20:320-324.
  • Hugo D, de Jongh HR. Greater trochanteric pain syndrome. SA Orthopaedic Journal. 2012;11(1):28-33.
  • McMahon SE, Smith TO, Hing CB. A systematic review of imaging modalities in the diagnosis of greater trochanteric pain syndrome. Musculoskeletal Care. 2012;10(4):232-239.
  • Pretell J, Ortega J, García-Rayo R, et al. Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis. Int Orthop. 2009;33(5):1223-1227.
Codes
&NA;
ICD10
  • M70.60 Trochanteric bursitis, unspecified hip
  • M70.62 Trochanteric bursitis, left hip
  • M70.61 Trochanteric bursitis, right hip
Clinical Pearls
&NA;
  • Patients with GTPS often present with an inability to lie on the affected side.
  • Femoral neck stress fractures are a do-not-miss diagnosis, particularly in young female runners.
  • Corticosteroid injection helps as an initial therapy, particularly for pain relief to allow for aggressive physical therapy.
  • Physical therapy is treatment mainstay for correcting biomechanical imbalances and restoring proper function.