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 thighbone (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.
Surgery for Trochanteric Bursitis of the Hip
Introduction
The bump of bone on the outside of the hipbone is called the greater trochanter. When the tissue or bursa in this area becomes thickened and inflamed causing pain, surgery may be needed to remove the bursa and to reduce tension on the tendon that glides over it.
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.
The trochanteric bursa lies over the greater trochanter of the hip, the bump on the outer part of the femur. The gluteus maximus is the largest of three gluteal muscles of the buttock. This muscle spans over the side of the hip and joins the iliotibial band. This long tendon passes over the bursa on the outside of the greater trochanter, runs along the side of the thigh, and attaches just below the outside edge of the knee.
Walking causes the gluteus maximus to pull on the tendon. If the tendon is tight, it will start to press and rub against the greater trochanteric bursa. It is unclear why the tendon becomes tight. The rubbing causes friction to build in the bursa, leading to irritation and inflammation in the bursa.
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.
Rationale
Surgery is indicated for this condition only after conservative treatments have failed including anti-inflammatory medications, cortisone injections and physical therapy. The primary goal of surgery is removing the thickened bursa, removing any bone spurs (knobby outgrowths) that may have formed on the greater trochanter, and relaxing the large tendon of the gluteus maximus. Some surgeons prefer to simply lengthen the tendon a bit, and some prefer to remove a section of the tendon that rubs directly on the greater trochanter. Both procedures result in taking pressure off the bursa.
Surgical Procedure
Before surgery begins, you will be given anesthesia. There are two basic options: a general anesthetic (one that puts you to sleep) or a regional block (one that numbs the area to be worked on). For hip surgery the most common type of regional anesthetic available is either a spinal block or an epidural block. Both of these regional blocks numb the body from the waist down.
An incision is made in the side of the thigh over the area of the greater trochanter. The surgeon continues the incision through the tissues that lie over the bursa.
The tendon is split so the trochanteric bursa and the bone of the greater trochanter can be seen. The tendon is split lengthwise.
The surgeon then removes the bursa sac.
The bone of the greater trochanter is smoothed, and any bone spurs are removed.
At this point the tendon may be lengthened or released and not repaired. If the surgeon chooses not to repair the tendon, scar tissue will eventually heal the loose edges of the tendon. As it heals, it will be looser than before surgery, so it won’t rub on the greater trochanter quite so much. The skin is closed with stitches.
As with any major surgery, complications are possible during the operation and after. Some of the most common complications following surgery for trochanteric bursitis are infection, nerve or blood vessel injury, and failure of the operation.
After Surgery
After surgery, your hip will be covered over with a padded dressing. You will probably be advised to avoid a great deal of activity within the first week after surgery. Support your outer hip with a pillow when you sit or recline. During this time, you may also be instructed to use crutches to keep from placing weight on your hip while standing or walking. Your stitches will be removed ten to fourteen days after surgery. If your surgeon chooses to use dissolvable stitches, these will not need to be removed.
Rehabilitation
Rehabilitation after surgery can be a slow process. You will probably need to attend therapy sessions for several weeks, and you should expect full recovery to take several months. Getting the hip moving as soon as possible is important. However, this must be balanced with the need to protect the healing muscles and tissues.
Ice and electrical stimulation treatments may be used during your first few physical therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.
Treatments include range-of-motion exercises and gradually work into active stretching and strengthening. Active therapy starts two to three weeks after surgery. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.
At about four weeks you may start doing more active strengthening. Exercises focus on improving the strength and control of the buttock and hip muscles. Your therapist will help you retrain these muscles to keep the ball of the femur moving smoothly in the socket.
Some of the exercises you’ll do are designed get your hip working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your hip. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
