Introduction

Trochanteric bursitis, also known as greater trochanteric bursitis (GTB) or greater trochanteric pain syndrome (GTPS), is a prevalent condition that frequently causes lateral hip pain due to the inflammation of the hip bursa. The bursa is a small, fluid-filled sac that acts as a lubricant for the nearby gluteus tendons, allowing them to glide smoothly during the physiological range of motion. The trochanteric bursa is located on the lateral aspect of the hip, lying above the hip abductor muscles and beneath the iliotibial band (ITB). Due to its superficial location and proximity to sizable tendons, the trochanteric bursa is susceptible to inflammation, often causing pain and leading to frequent consultations with orthopedic surgeons or family physicians.[1]

Inflammation of the bursa can arise from various factors, including repetitive microtraumas such as running or exercise, tendinopathy of surrounding musculature, and gross trauma such as a fall from a height with direct compression to the bursa. In addition, inflammation can occur idiopathically without a discernible cause. The diagnostic process primarily relies on clinical assessment, which involves reviewing the patient's medical history and conducting a physical examination. However, imaging, including plain film radiographs, is essential to rule out other potential causes of hip discomfort.

Treatment modalities are nearly exclusively nonoperative and include nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, stretching, and corticosteroid injections. Surgical excision of the trochanteric bursa is reserved for refractory cases that do not respond to nonoperative treatment.[2][3]

Etiology

Trochanteric bursitis can result from various factors, such as repetitive microtrauma, blunt trauma, or idiopathic causes. Overuse of the surrounding musculature can lead to tendinopathies of the gluteus medius and gluteus minimus, making it a common contributing factor. Repetitive hip abduction, as seen in stair climbing or cycling activities, can trigger an inflammatory cascade within the bursa. In older patients, sustaining falls directly over the bursa can initiate an inflammatory cascade within the tissue. Sedentary or bed-bound patients are also at risk of developing trochanteric bursitis, as the continuous pressure over the greater trochanter of the proximal femur can provoke an inflammatory response in the bursa.[2][4]

Epidemiology

Trochanteric bursitis affects individuals across different age groups and distribution patterns. GTB is notably prevalent, affecting approximately 15% of women and 8% of men.[5] Although middle-aged women are the most commonly affected group, young female athletes are also susceptible to developing GTB. This vulnerability can be attributed to increased Q angles in females, leading to tighter ITBs. Such tightness strains the bursa during repetitive movements, such as running and jumping.[6]

In a retrospective cohort analysis conducted by Shemesh et al, 990 primary total hip joint arthroplasties (THAs) were examined, comprising 377 direct anterior and 613 posterior approaches. In this group, the incidence of trochanteric bursitis after primary THA was 5.4% (ie, 54 out of 990). The study revealed that there was no significant difference in incidence between the posterior and direct anterior approaches (5% versus 6.1%, respectively; P = .47). Patients with trochanteric bursitis were substantially more likely to have lumbar spinal stenosis and a history of smoking (P = .03 and P = .01, respectively).[7] 

In a study by Farmer et al involving 689 cases who underwent initial THAs, 32 patients (4.6%) developed postsurgical trochanteric bursitis. The study indicated that corticosteroid injections can effectively treat postoperative trochanteric bursitis. Moreover, nonoperative treatments may yield lower success rates in younger patients and those with leg length discrepancies.[8]

History and Physical

Patients often complain of unilateral lateral hip pain. A strong suspicion of trochanteric bursitis should be considered if the pain develops gradually, the patient can ambulate, and the pain responds positively to over-the-counter anti-inflammatory medication. Patients can often localize the pain to a specific area directly over the greater trochanter of the proximal femur. Younger patients may have a history of repetitive athletic activities such as running, cycling, or sports involving jumping. In contrast, older patients may have a history of direct compression from sustained immobilization or low-energy trauma, such as ground-level falls.[9]

Physical examination is the gold standard for diagnosing trochanteric bursitis. In this evaluation, it is crucial to rule out the possibility of a hip fracture. Patients should be able to perform a straight leg raise without pain, and the execution of a log roll (internal and external rotation of the leg at the hip joint with the hip flexed to 90°) should not elicit hip joint pain. Deep palpation over the greater trochanter on the lateral aspect of the proximal femur usually elicits localized pain. This discomfort frequently worsens with prolonged activity or movements that require pelvic stabilization, such as standing on one leg.[10] The skin typically appears normal upon examination, with no signs of erythema or increased warmth, as the underlying cause is non-infectious. Pain is frequently induced by femur adduction and alleviated by abduction, as these movements create and relieve tension on the overlying ITB.

Evaluation

Imaging Evaluation

After performing a thorough physical examination on patients with a strong clinical suspicion of trochanteric bursitis, it is advisable to obtain plain film radiographs, including a 2-view of the hip and pelvis, to rule out any associated fractures or osseous abnormalities. Plain films typically appear unremarkable and show no notable abnormalities in trochanteric bursitis cases.

Advanced imaging is seldom required for trochanteric bursitis diagnosis, although it is commonly ordered if there is a suspicion of an occult femoral neck fracture. Although trochanteric bursitis may appear as an area of increased signal on T2 sequence magnetic resonance imaging (MRI), it is not necessary for diagnosis.[11] Although ultrasound is not routinely used for diagnosis, it can detect increased fluid within the trochanteric bursa.

Laboratory Evaluation

In cases with a strong clinical suspicion of trochanteric bursitis and the absence of constitutional symptoms, routine laboratory investigations are typically unnecessary. However, if patients exhibit associated symptoms such as fevers, chills, or signs of systemic infections, a complete blood cell count (CBC) with differential can be obtained to check for leukocytosis. If there is clinical suspicion of an underlying septic hip joint, acute inflammatory markers may be obtained, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).[9]

Treatment / Management

The primary approach to managing trochanteric bursitis is initially nonoperative, and antibiotics should not be used in treating this condition. 

Pharmaceutical Treatment

Oral NSAIDs are crucial for inhibiting the inflammatory cascade and providing symptomatic pain relief for trochanteric bursitis symptoms. However, before initiating NSAIDs, it is essential to confirm that patients have no contraindications. Individuals currently taking blood thinners or at high risk of gastrointestinal (GI) bleeding should avoid NSAID therapy.

Physical Therapy

Physical therapy focused on quadriceps strengthening and ITB stretching is important for addressing the underlying pathology. In addition, hip abduction exercises should be incorporated to enhance the stretching and strengthening of the gluteus medius and gluteus minimus muscles.[12][13] Instructing adolescent athletes on proper running and jumping techniques is crucial to preserve hip mobility and flexibility during trochanteric bursitis treatment.

Corticosteroid Injections

Trochanteric bursitis can be effectively managed with steroid injections. These injections administer a localized dose of cortisone, frequently combined with a local anesthetic such as lidocaine or Marcaine. This treatment offers relief and directly targets local inflammation; orthopedic surgeons and primary care providers can administer it. These are minor outpatient procedures conducted using standard sterile techniques. Long-term outcomes are comparable between individuals who receive corticosteroid injections and those who undergo physical therapy.[14]

Platelet-Rich Plasma Injections

The application of platelet-rich plasma (PRP) injections continues to be a subject of ongoing discussion within orthopedics and sports medicine.[15] A recent level I systematic review, which examined 3 randomized clinical trials (RCTs) and 2 case series from the literature, demonstrated patient improvement at 3- and 12-month follow-ups. However, the review's authors recognized the limited availability of high-quality evidence conclusively favoring PRP injections over the nonoperative approaches mentioned earlier.[16] As a result, PRP is not considered the standard of care for GTB.

Extracorporeal Shock Wave Therapy

Extracorporeal shock wave therapy (ESWT) is an effective treatment for GTPS, especially in cases where high signals are evident on MRI. According to a study, ESWT is more effective than corticosteroid injections or home exercises in treating the condition. Combining ESWT with a specific exercise regimen has demonstrated a success rate of 86.8% in just 2 months after therapy, proving its safety and effectiveness in addressing GTPS.[17]

Surgical Management

Surgical intervention for trochanteric bursitis remains an uncommon approach reserved for refractory cases unresponsive to standard conservative therapy. Surgical management includes sharp excision and debridement of the bursa.[18] Arthroscopic bursectomy has demonstrated notable success, with Fox reporting excellent outcomes in 88% of patients in a study involving 27 individuals.[19] After a straightforward longitudinal release of the iliotibial tract across the greater trochanter and removal of the subgluteal bursa, Slawski et al observed improvements in Harris hip scores and gait.[18] Brooker emphasizes the significance of removing the gluteus maximus bursa, reducing the lateral prominence of the greater trochanter, and releasing the iliotibial tract across the prominent portion of the trochanter as crucial steps in treating refractory trochanteric bursitis.[20] 

In cases involving traumatic, idiopathic, and primary THAs, Baker et al have reported success rates of 100%, 88%, and 64%, respectively. However, all attempts to treat refractory trochanteric bursitis following revision were unsuccessful. The author made an 'H-shaped' incision in the fascia lata over the greater trochanter. The resulting flaps were then folded over and sutured together.[21] According to Govaert et al, addressing the ITB is essential, as GTPS is often related to it.[22] Under local anesthetic, Pretell et al lengthened the distal "Z" of the fascia lata,[23] whereas Chirputkar lengthened the proximal ITB to treat GTPS.[24]

Differential Diagnosis

The differential diagnosis for trochanteric bursitis includes femoroacetabular impingement, fractures involving the greater trochanter, femoral neck or intertrochanteric hip fracture, hamstring avulsion injuries, or simple muscle strains or sprains.[25] Femoroacetabular impingement should also be considered in athletic patients presenting with hip pain and must be ruled out.[26] Trochanteric bursitis can be easily differentiated from the abovementioned conditions through detailed patient history, thorough physical examination, localized pain over the trochanter, and negative findings on plain film radiographs.

A gluteal medius tear manifests as lateral hip pain that intensifies with prolonged sitting, climbing stairs, and walking, often accompanied by Trendelenburg gait. In contrast, trochanteric bursitis pain worsens when sitting with legs crossed. Both conditions cause pain and discomfort when lying on the affected side.[27] 

Snapping hip syndrome is associated with lateral hip pain and the feeling of catching and "giving way" while climbing stairs and running. Confirming the diagnosis involves palpating the snapping sensation over the greater trochanter while flexing the hip joint.[25] 

Piriformis syndrome leads to retrotrochanteric pain that worsens during prolonged sitting and before bedtime. The piriformis stretch test differentiates this condition from other peritrochanteric pain issues. This test includes hip flexion, adduction, and internal rotation, with a positive result indicated by the reproduction of deep gluteal pain.[28]

Prognosis

The prognosis for trochanteric bursitis is generally favorable, with patients expecting complete symptom resolution through conservative management without experiencing any long-term sequelae. Symptom resolution using NSAIDs, possibly along with corticosteroid injections, can usually be anticipated within a few days of treatment initiation. Although refractory cases are rare, some individuals may experience symptom recurrence due to repeated irritation or repetitive trauma.

Many individuals experiencing trochanteric discomfort may have a chronic condition significantly affecting their daily activities. In a cohort study conducted by Lievense et al on the prognosis of trochanteric bursitis,[29] individuals with osteoarthritis in their lower limbs were 4.8 times more likely to continue experiencing symptoms after a year than those without osteoarthritis. After 5 years, patients who received a corticosteroid injection had a 2.7-fold higher likelihood of recovering than those who did not. Approximately 34% of employed individuals reported significant difficulty performing work-related tasks, and approximately 25% had previously taken sick leave due to trochanteric discomfort. Sleep disturbances were observed in around 40% of patients. Among the 60% of patients engaged in sports, 54% reported "greatly impaired" performance in their activities. A study conducted by Schapira et al achieved rapid and sustained pain relief in 90.3% of trochanteric bursitis patients through the use of local corticosteroid and anesthetic injections.[30]

Complications

Complications stemming directly from trochanteric bursitis are rare. Complications are more often associated with NSAID use and, on rare occasions, corticosteroid injections. NSAIDs can cause gastric ulceration and subsequent bleeding, especially in individuals at high risk or those taking anticoagulants. Patients should be informed of signs and symptoms of anemia as GI bleeding can be occult.

Complications associated with corticosteroid injections include elevated blood glucose levels, particularly in individuals with poorly controlled diabetes, as well as irritation and bleeding at the injection site.[31]

Postoperative and Rehabilitation Care

Rehabilitation therapy is crucial in treating and preventing hip bursitis by strengthening the muscles around the hip joints.[32] These muscles provide support and stability to the pelvic girdle, reducing tendon irritation and joint reaction forces. The therapeutic, manual, stretching, and strengthening exercises are performed in 3 phases.

• Phase 1 management focuses on addressing pain and inflammation using strategies such as ice therapy, NSAID use, acupuncture, topical massage, and brief utilization of mobility assistance devices to alleviate strain on the affected side.

• Phase 2 of rehabilitation includes a series of exercises, including side-lying leg raises, standing hamstring stretches, clamshells, proprioception and balance activities, and piriformis stretches. These exercises are designed to improve hip function and stability. 

• Phase 3 of the therapy shifts the focus to core muscle training, along with the analysis of gait and biomechanics, aiming to enhance overall body stability and alignment.

The final phase centers on patient education, promoting postural awareness, and facilitating a gradual return to sports activities.[33][34] These objectives are pivotal in attaining a successful and sustained recovery.

Deterrence and Patient Education

While appropriate stretching, maintaining proper form, and adhering to correct training techniques can aid in preventing trochanteric bursitis in young athletes, many cases are secondary to trauma or idiopathic, rendering them unpreventable. However, educating patients about the favorable prognosis and success of nonoperative management is crucial. Initiation of anti-inflammatories and possible corticosteroid injections, along with reassurance, usually leads to symptom resolution and high patient satisfaction.

Before initiating treatment, clinicians must educate patients about the possible adverse effects of NSAIDs and corticosteroid injections. Patients should understand the risk-to-benefit ratio when deciding on treatment options. Individuals undergoing THA or joint replacement should receive counseling about the incidence of trochanteric bursitis, which ranges from 5% to 6%.

Conservative management options are always the initial choice for treatment. Although surgical interventions have become an alternative for chronic and persistent cases, patients should be thoroughly informed about the varying success rates associated with these procedures. 

Enhancing Healthcare Team Outcomes

Collaboration among healthcare professionals is critical in the comprehensive diagnosis and treatment of tuberculosis. This interprofessional healthcare team includes clinicians (MDs, DOs, NPs, and PAs), orthopedic specialists, chiropractors, physical therapists, and nurses. All members of a healthcare team should maintain open communication with one another regarding the patient's care. Maintaining accurate and up-to-date records of all patient interactions, interventions, and status changes is crucial. This level of communication is pivotal for ensuring a successful diagnosis and effectively managing these patients. Adopting an interprofessional case model is instrumental in achieving optimal outcomes for patients.

Primary care clinicians should be educated on diagnosing and treating trochanteric bursitis, as they serve as patients' initial point of contact. Their expertise and intervention can aid in preventing the increased healthcare expenses associated with specialist consultations. Although most patients achieve excellent outcomes, it is essential to recognize that the recovery process of the condition may extend over several weeks.[35]