Hip Bursitis? Trochanteric Bursitis? Or something else? – A discussion around common hip pain and how to treat it.

Today, Nate and the Longevity Exercise Physiology teams at the Drummoyne, EdgecliffMarrickvilleBella VistaRandwick, PymbleBalmain and Neutral Bay  locations discuss a common chronic pain condition of the hip, outlining the anatomy of the condition, and leading into a treatment framework based around behavioural modifications to avoid movements that may aggravate symptoms, as well as exercises to help build strength in the appropriate musculature.

Hip bursitis, also known as trochanteric bursitis, and greater trochanteric pain syndrome is an extremely common chronic pain condition that can cause a serious limitation of function and quality of life.

While the “itis” tag, or inflammation, is thought to be the most common indicator of this condition, current evidence is beginning to refute that terminology.

ANATOMY OF THE HIP JOINT

The lateral aspect of the hip is predominantly characterised by the bony prominence of the greater trochanter. Sitting over the greater trochanter is the bursa, a fluid-filled sac that helps to reduce friction between the bone and soft tissues. Deep to the bursa is the iliotibial band, and the tendons for the gluteus medius and minimus muscles, which work to stabilise your pelvis in weight-bearing postures, predominantly standing, walking, and running.

HISTORY AND THEORY OF DIAGNOSIS

Although this condition has long been defined by the bursa, recent evidence has shown that symptoms may draw from multiple factors that interplay around the hip joint. The understanding of the anatomy in this sense, underpins the total rehabilitation strategy, revolving around education on what areas need to be strengthened, and why? As well as an anatomical understanding of movements that may aggravate symptoms.

Long et al. 2013 examined 877 patients (602 women, 275 men) over a 6-year period, all of whom had been diagnosed with greater trochanteric pain syndrome. They found that almost 80% of subjects did not show any sign of bursitis on an ultrasound. Instead, the data suggested a more likely causative factor of pain to be a pathology of the tendons in the gluteus maximus and minimus, as well as the iliotibial band.

This paper was built on a growing body of evidence, beginning in a 2001 paper by Bird et al. that only found enlargement, or inflammation of the bursa in the MRI of 8% of patients, compared to a gluteal tendinopathy in 83%.

MOVEMENTS THAT AGGRAVATE SYMPTOMS AND HOW TO CHANGE THEM

Self-management based off proper education around the condition, and the behaviours, movements, and activities that may aggravate symptoms is a crucial component of rehabilitation.

Modifications to behaviours based around reducing compression of the gluteal tendons and bursa at the affected side underpin all the suggestions below:

  • Sleeping: minimise sleeping on the affected side as much as possible and keep a pillow between legs when sleeping on the unaffected side.
  • Standing: avoid constantly leaning on one side
  • Sitting: avoid crossing your legs or sitting in deep hip flexion for prolonged periods.
  • Walking: try to reduce any “hip kick” where the hips swing to the side during gait. Step-back volume to what is manageable for you, and work it back up over time.
  • Running: increasing stride cadence can reduce the angle of hip adduction (Hafer et al., 2015)
  • Stretching: avoid stretches that bring the leg on the affected side towards the midline of the body. Classic Piriformis stretches may aggravate symptoms.

HOW EXERCISE CAN HELP

Given the evidence, the goal seems to be to strengthen the hip musculature, particularly the gluteals in hip abduction, and external rotation. Some great places to start are with a side-plank, lying straight leg raises, or clam shells. Additionally, isometric and eccentric work has shown to be particularly effective in treating tendinopathies, so work in some isometric holds where possible. On top of this, learning how to squat, deadlift, and walk effectively to reduce or remove aggravating factors is an important factor in self-managing symptoms moving forward. Build strength with basic, bilateral movements before progressing to their single leg variants.

 

To speak with an Exercise Physiologist today to help treat your hip pain, call Longevity Exercise Physiology Edgecliff, Pymble, Marrickville, Randwick, Drummoyne, Balmain, Bella Vista and Neutral Bay on 1300 964 002!

 

 

 

 

 

Written by Nate Sutton

REFERENCES

  • Bird, P. A., Oakley, S. P., Shnier, R., & Kirkham, B. W. (2001). Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology44(9), 2138-2145.
  • Hafer, J. F., Brown, A. M., DeMille, P., Hillstrom, H. J., & Garber, C. E. (2015). The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of sports sciences33(7), 724-731.
  • 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 Roentgenology201(5), 1083-1086.