Trochanteric Bursitis – Is Your Low Back the Real Issue?

By: Dr. Marc Robinson, PT, DPT, Cert. MDT
Do you really have trochanteric bursitis or is there another source of your pain?

In the last four years, I have seen approximately two true cases of trochanteric bursitis out of nearly 100 patients who received a diagnosis of trochanteric bursitis by their physicians.

Two.

This means that only 2% of my patients really had trochanteric bursitis.

Healthcare professionals are incorrectly diagnosing this injury.

Whoops.

Yes, that’s right. You may be receiving the wrong treatment for an injury that does not exist.

This issue needs to be brought to your attention and I want you to think differently about trochanteric bursitis because conventional medical wisdom needs an update just like the iOS on your Iphone.

Is trochanteric bursitis a real diagnosis?

Yes, it exists. People get trochanteric bursitis but it’s less common than most think.

In this article, I’ll show you why trochanteric bursitis is often incorrectly diagnosed and how you can avoid chasing the wrong treatment.

First, I’ll discuss several facts about trochanteric bursitis then I’ll share a few stories of real
patients who were misdiagnosed with trochanteric bursitis.

What is Trochanteric Bursitis?

Trochanteric bursitis refers to inflammation of the bursa sac by the greater trochanter.  The bursa is a fluid-filled sac that reduced friction between muscle and bone. 1

The greater trochanter is located on the side of your hips.  If you put your hands on the side of your hips below your waist, you will feel the greater trochanter.

But, there is a new name for this diagnosis.

Trochanteric bursitis is now recognized as greater trochanteric pain syndrome (GTPS) which covers a broad range of symptoms felt on the side of the hip.2-6

Research studies show that the criteria for diagnosing GTPS is not well defined.

Here is what the website UpToDate has to say about greater trochanteric pain syndrome: 2

“Historically, the term “trochanteric bursitis” was used to describe any pain around the lateral hip. However, advanced imaging and histopathological studies have shown that involvement of the trochanteric bursae in patients with lateral hip pain is uncommon and, when present, exists as a secondary or associated finding. Thus, trochanteric bursitis is a misnomer when it used to describe all causes of lateral hip pain. In fact, primary trochanteric bursitis is rare and is typically of microbial etiology.”

The change in the definition of trochanteric bursitis is a good example how conventional medical wisdom changes as science improves our understanding of pain.

Typically, when people feel pain on the side of the hip, they are given a diagnosis of trochanteric bursitis mostly because their pain is located right over the greater trochanter and pressing on this area may hurt.

Since the diagnostic criteria is not well defined, this conclusion can lead to someone being misdiagnosed.

I have rarely seen true cases of people having irritation of their bursa sac.

So, where is their pain coming from?

The location of your pain is not always the source of your pain.

For example, if you have pain on the side of the hip, the source of the pain can be from the lower back.

Identifying the source of the pain requires an accurate and thorough assessment to rule out pain referred from the lower back.

In many cases, people diagnosed with “trochanteric bursitis” have nothing wrong with the  bursa sac in the hip instead they have pain referred from the lower back.

This phenomenon is called somatic pain referral.

Somatic referred pain involves nerve endings that are stimulated in the spine which can be felt in other areas of the body such as the side of the hip.7

I’ll share a couple stories to help clarify how this is possible.

Real Patient Story #1

 Julie was referred to me by her doctor with a diagnosis of trochanteric bursitis.  She reported pain on the side of her hip.

Her pain would get worse with sitting and better with walking or running.  She didn’t have any pain with squatting or lunging.

If she had true trochanteric bursitis, she would likely get pain with walking, running, squatting, or lunging.  Sitting would not aggravate the bursa.

In her case, she had reduced pain with these activities which indicated that irritation of her bursa sac was very unlikely.

Based on these clinical clues, I wanted to rule out the lower back as the source of her pain.  I assessed her lower back using the McKenzie Method.

Guess what happened?!

We treated her lower back which alleviated her hip pain!

The lower back was the source of her symptoms and the only way to identify this was to perform an accurate assessment.

At this point, I sent her home with exercises she could perform for her lower back which helped to alleviate her hip pain.

You may be thinking there is no way for the lower back to be causing your hip pain. You may not have lower back pain at all!

However, I have found that people often have issues in the lower back they are not aware of. Then, we start examining the lower back and these problems are quickly uncovered.

Real Patient Story #2

The next story is my own experience with hip pain.

Okay, I didn’t have pain in the side of my hip. It was more in the front.

I was squatting at the gym and I tried narrowing my stance while squatting.  The next day I felt pain in my hip joint.

I thought the pain would go away but it got worse.

Health care professionals can be stubborn when managing their own issues and I was no difference.

I shrugged off this pain for 2 months before I started taking it seriously.  After 2 months, I became emotionally affected by the pain because it was limiting my exercise routines at the gym and I was started to get pain while walking.

For a minute, I wondered if the pain was referring from my lower back.

But there was one catch:.  I had no pain in my lower back.

I remember thinking to myself there is no way the pain in my hip was related to my lower back.  I felt the pain right in my hip joint so obviously, there was a problem in my hip joint.

I was hanging out with my friend in LA and he was also a physical therapist.  After hanging out, he completed an impromptu evaluation of my hip.

Guess what happened?!

He treated my lower back and my hip pain was eliminated!

I tried to provoke the pain with the movements that previously hurt it but I could not reproduce the pain.

It was confirmed.  My lower back was referring to my hip!

I could not believe it.

This example goes to show that the source of pain is not always coming from the area where you feel the pain.

Trochanteric Bursitis

How Can You Get Rid of Trochanteric Bursitis?

I will discuss typically treatment options for a few different scenarios. The treatment will depend on the source of the pain and the findings of your examination which vary between individuals.

The right treatment option should be determined by your healthcare provider.

 

Scenario #1: You truly have inflammation of the bursa sac.

● Hip strengthening – Strengthening the muscles around the hip joint will improve function of the hip. Tears of the gluteus medius or gluteus minimus can occur with pain on the side of the hip which can mimick the symptoms of trochanteric bursitis. Tears of the hip muscles can exacerbate the problem and lead to more hip weakness. An examination by a physical therapist will help you determine which exercises will provide the most benefit. An MRI can help identify a tear along with the findings from a physical therapy examination.

● Stretching/Mobility – Restrictions in muscles around the hip can influence trochanteric bursitis. A physical therapist can guide you in exercises to improve mobility in your hip.

● NSAIDS (nonsteriodal anti-inflammartory drugs) – Ibuprofen and Advil are examples of NSAIDS which can reduce inflammation. Many people get irritation to their stomach after taking NSAIDS and long term use of NSAIDS can lead to negative health effects. NSAIDS cause approximately 41,000 hospitalizations and 3300 deaths in older adults each year. 8

● Steroid Injections- Corticosteroids can be injected into the hip. Corticosteroids can have negative side effects and doctors usually limit injections to three to four times per year. I prefer to rely on injections as a last resort treatment option. An sports medicine doctor or musculoskeletal specialist can administer the injection for you. It is not within the scope of practice for physical therapists to provide steroid injections. 9

● Surgery – The IT band can be lengthened to alleviate tension and irritation to the bursa. The bursa can be removed and tears in hip muscles can be repaired. Sports medicine doctors and musculoskeletal specialists can perform the surgery. Physical therapists do not perform surgery. 10-11

 

Scenario #2: You have a tear in your hip muscles. 

● Hip strengthening – The type of exercises depend on the grade of the muscle tear which can be detected by an MRI or ultrasound. Minor tears usually recover without surgery and it would be beneficial to see a physical therapist who can guide you with the right exercises.

● Surgery –The gluteus medius or gluteus minimus can tear and cause pain on the side of the hip. If rehab is not effective, the muscle can be repaired by surgery.  A study found that up to 22% of elderly patients with hip injuries had gluteus medius tear. 10 You will need physical therapy after surgery for a muscle tear.

● Stretching/Mobility – Muscle tears usually cause compensatory changes in the hip such as limited mobility. You can address any limitations in muscle length and improve mobility in the hip joint with exercises taught by a physical therapist.

● NSAIDS – Ibuprofen can be used conservatively to manage inflammation right after the initial injury. Try to avoid the chronic use of NSAIDS when possible. A great alternative to the chronic use of NSAIDS is to use a powerful natural anti-inflammatory like turmeric.  Here is one of the highest potency turmeric supplements on the market:  Active Atoms Turmeric.

 

Scenario #3: Your hip pain is coming from the lower back. 

● The McKenzie Method – An evaluation by a physical therapist certified in the McKenzie Method will identify if your hip pain is coming from your lower back. Specific exercises for the lower back can quickly improve your hip pain.

● Hip strengthening – If your hip pain is coming from the lower back, you will still benefit from exercises to strengthen your hip muscles. Pain causes inhibition and disuse of muscle which leads to weakness so you’ll want to strengthen your hips.

● Stretching/Mobility – Pain can also lead to restricted hip mobility. Identifying restrictions usually requires an assessment from a physical therapist who can guide you with recognizing these limitations. It is important to identify whether a restriction truly exists otherwise you may be trying to improve restrictions that don’t exist.

● Motor Control/Coordination – Motor control involves the ability to control movement. Poor control of movement can lead to stress at the lower back and hip. The body functions a chain reaction of movement and one part of the body affects the other; therefore, it will be important to improve the way you move your body.  Coordination involves the ability to perform movements in a smooth, controlled manner which includes having the appropriate speed, directions, timing, and distance of movement. A basketball player is coordinated when shooting a free throw.  You may not be a basketball player but you can still improve your coordination with daily activities to recover faster and stay out of injury.

Closing Statements

Trochanteric bursitis is a diagnosis that relates to inflammation of the bursa sac; however, the diagnosis has been widely used by healthcare professionals to refer to pain on the side of the hip.

Greater trochanteric pain syndrome (GTPS) is a more accurate description since this diagnosis covers a broad range of symptoms felt at the hip; however, this diagnosis is vague.

In addition, receiving a diagnosis of GTPS does not tell you how to fix the problem.

For example, you go to your doctor and get diagnosed with GTPS.

Now what? What do you actually do?

Accurately identifying the cause of the pain usually requires an assessment from a physical therapist or other health care profession who knows how to properly manage greater trochanter pain syndrome.

Once the root cause of the problem is identified, you can perform specific exercises and techniques to fix the problem.

If you have been to a physical therapist for trochanteric bursitis related to the lower back, you can continue your recovery process in our low back recovery program.

Our low back recovery program was designed to teach you the most important factors to avoid lower back pain and pain referring into the hip.

The tutorial videos will explain common causes of lower back issues and what you can do to avoid pain and injury.

To learn more information Click Here.

References
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2. (n.d.). Retrieved from https://www.uptodate.com/contents/greater-trochanteric-pain-syndrome-formerly-trochanteric-bursitis?search=Trochanteric bursitis&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1
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7. Heiling, D. (2016, October 19). REFERRED PAIN AND RADICULAR PAIN. Retrieved from https://www.heilingdwyer.com/referred-pain-radicular-pain/
8. Marcum, Z. A., & Hanlon, J. T. (2010). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3158445/#R2
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