Bursitis: A real pain in the hip?

Introduction:

Hip bursitis or, Greater Trochanteric Bursitis now formally recognised as Greater Trochanteric Pain Syndrome (GTPS) is a common musculoskeletal condition that physiotherapists encounter in clinical practice. It can present with pain and superficial swelling on the outside of the hip, but it's often not the only thing going on. The best estimates of prevalence are from a large, community-based study with over 3000 adults aged 50 to 70 years, in which unilateral GTPS was present in 15 percent of females and 6.6 percent of males (Segal et al., 2007). The aim of this blog is to introduce you to the anatomy surrounding the hip and this condition and give some sneaky little insights on how you and we can try and manage it.

Anatomy and Function of the Hip Joint Complex:

The hip joint is a ball-and-socket joint comprising the acetabulum of the pelvis and the femoral head. The stability of this joint is enhanced by a complex network of ligaments, tendons, and muscles. The synovial lining ensures smooth articulation, while the surrounding bursae play a crucial role in minimising friction between various structures. A Bursa, is a thin connective tissue sac filled with lubricating liquid. They are located in regions where skin, ligaments, muscles, or muscle tendons can rub against each other, usually near a body joint. Bursae tend to lie adjacent structures and between them, preventing them from rubbing directly against each other. 

Key components of the hip complex involved in this condition, include the iliotibial (IT) band, trochanteric bursa, and the gluteal tendons. The trochanteric bursa, situated on the outside aspect of the hip, is particularly susceptible to inflammation, resulting in trochanteric bursitis. This condition often coexists with other hip pathologies and merits detailed examination. This is why GTPS is now commonly used to describe it. 

Mechanisms of Injury Leading to Hip Bursitis:

Trochanteric bursitis is commonly associated with repetitive friction or trauma. Overuse injuries, such as those seen in long-distance runners, cyclists, and footballers, can lead to inflammation of the trochanteric bursa due to surpassing one’s tolerance to friction between the IT band and the greater trochanter. 

Traumatic events, such as a fall onto the hip or direct impact, this can be an innocuous fall, or impact in a contact sport, the inflammatory response can be triggered for a variety of reasons which can sometimes not feel like they are representative of the magnitude of the insult.

Recent studies, including those by Fearon et al. (2020) and Grimaldi et al. (2018), highlight the multifactorial nature of hip bursitis. Anatomical variations, muscle imbalances, and altered biomechanics can contribute to increased stress on the trochanteric bursa. Considering these factors when formulating a diagnosis and a subsequent comprehensive management plan is obviously important.

Early Stage Management:

As always a thorough patient history and examination, focusing on identifying aggravating factors, biomechanical abnormalities, and associated incidents is vital here. GTPS is multifactorial, which is not just to say there are a combination of reasons why it can happen, but there can be, and often is, a combination or irritated structures (Long et al., 2013). 

Diagnostic imaging, such as ultrasound or magnetic resonance imaging (MRI), may be employed for a more accurate diagnosis. While imaging is often overused in the world of musculoskeletal injury, this can be a time where it’s useful to help quickly confirm or deny or differentiate signs and symptoms from pathology. An US is very effective, quick and the cost is significantly less (Long et al., 2013). An MRI can be used if the US is inconclusive or the Hip joint itself requires further investigation. 

Pain Management:

Initially it would be wise to consider the use of over the counter non-steroidal anti-inflammatory drugs (NSAIDs) , always checking with your Dr about your suitability. If the bursa remains unresponsive, your Dr can prescribe stronger over the NSAID’s which are only available by prescription.  A last resort could be localised corticosteroid injections under the guidance of a medical professional, but usually the condition settles before this is necessary. 

Manual Therapy:

Traditional “manual therapy techniques” aimed at addressing muscular imbalances and improving joint mobility. Soft tissue mobilisation, myofascial release, and joint mobilisations are often not beneficial in alleviating pain and restoring normal function when it is true Bursitis. It may help with surrounding musculature that may be being negatively impacted from altered mechanics or use. 

Exercise Prescription:

A progressive rehabilitation program focusing on strengthening the hip abductors, external rotators, and core stabilisers is a sensible and practical approach. Incorporating functional exercises that mimic the patient's daily activities to enhance carryover is helpful as often these are the first things to begin improving and helps with patient adherence to physiotherapeutic programs. A sensible approach looks to include exercises which do not irritate symptoms and are functionally achieved and not inhibited by range of motion limitations or pain, you will quickly lose interest in your rehab if this is the case and talking this through with your physiotherapist is important, they should want to hear what you like/don’t like about the exercises you’re doing.

Patient Education:

Empowering the patient with knowledge about their condition, emphasising the importance of compliance with prescribed exercises and activity modifications is so important, and probably where a lot of time should be spent, but so often is not. Educating on self-management strategies, including any self applicable modalities such as heat or ice, or strategies to overcome any limitations imposed by the condition will make life just that bit easier.

Conclusion:

Hip bursitis poses a multifaceted challenge for physiotherapists, requiring a comprehensive understanding of the hip joint complex, injury mechanisms, and evidence-based early stage management. By understanding and gleaning information from such studies by Fearon et al. (2020) and Grimaldi et al. (2018), we can refine our clinical approach and optimise outcomes for our patients. We can understand that sometimes one condition is not all it's always the only thing that's going on. This holistic and detailed approach ensures that physiotherapists are well-equipped to address the complexities of hip bursitis and contribute to the overall well-being of their patients.

References:

Alfredson, H., Örskov, A. C., & Piehl, L. D. (2015). Gluteal tendinopathy: A review of mechanisms, assessment and management. Sports Medicine, 45(8), 1107-1119.

Long, S. S., Surrey, D. E., & Nazarian, L. N. (2013). Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology, 201(5), 1083-1086. doi:10.2214/AJR.12.10038.

Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, Nevitt MC. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988-992. doi:10.1016/j.apmr.2007.04.014

UpToDate. (2023) 'Greater trochanteric pain syndrome (formerly trochanteric bursitis)'. Available at: https://www.uptodate.com/contents/greater-trochanteric-pain-syndrome-formerly-trochanteric-bursitis (Accessed: 24 Oct 2023).