Trochanteric Bursitis – Is Your Lower 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 hip pain?

Guess how many clients I have seen with Trochanteric Bursitis in the last four years?

Answer: 2 out of 100

I have seen two true cases of trochanteric bursitis out of 100 clients referred to me by their physician with a diagnosis of Trochanteric Bursitis.

Only 2% of my clients really had Trochanteric Bursitis. A very low percentage.

Trochanteric Bursitis is frequently misdiagnosed by health care professionals and it may be one reason why your hip pain is not getting better.

If you feel frustrated with persistent hip pain, I want to help you identify the true source of your pain.

Does Trochanteric Bursitis exist?

Yes, it exists but trochanteric bursitis is uncommon. Some people can have Trochanteric bursitis, but I want to show you that many times hip pain is coming from the lower back.

In this article, I’ll explain how the lower back can be a source of hip pain, a real story of my client who was misdiagnosed, and what you can do to recover faster.

First, let's discuss important information 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 reduces friction between muscles and bone. 1

The greater trochanter is the bony bump located on the side of your hips. If you stand and place your hands on the side of your hips below your belt line and shift your weight from side to side, you will feel the greater trochanter.

Like the pending software update on your iPhone, there is an update to the diagnosis of Trochanteric Bursitis that only a portion of the medical community has adopted. The rest are still operating with outdated software.

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 the criteria for diagnosing GTPS is not clearly defined.

The website UpToDate provides a good summary of 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 typical of microbial etiology.”

The change in the definition of Trochanteric Bursitis is a good example of why we should educate ourselves to stay up-to-date on the newer science of pain and injury.

Why is Trochanteric Bursitis Misdiagnosed? 

Many healthcare providers make the diagnosis because the area over the greater trochanter is painful with touch.

Pain with touch is not enough information to make an accurate diagnosis of trochanteric bursitis.

Identifying the source of pain requires an accurate and thorough assessment.

Your doctor or rehab professional should rule out the lower back as the source of hip pain because the lower back is a common source of pain on the side of the hip.

Are you surprised the lower back plays a role in hip pain?

I was surprised too!

When I first started my career as a physical therapist, I used to give my clients exercises for Trochanteric Bursitis, but they did not get better.

Then, I learned a new approach called Mechanical Diagnosis and Therapy (MDT). MDT is a system for accurately assessing and treating pain.

It is important to follow a logical system to recover faster from injuries instead of guessing what exercises you should do.

How Can Hip Pain Come From the Lower Back?

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

For example, if you have pain on the side of the hip, the structures on the side of the hip may be healthy. You may feel pain in that specific location; however, the pain may radiating from a different area in the body.

In many cases, people diagnosed with “Trochanteric Bursitis” do not have inflammation of their bursa sac. Instead, they have pain referred from their lower back.

The phenomenon of pain radiating to another area of the body 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

Now, I will share a real story of my client who had somatic referred pain and a misdiagnosis of Trochanteric Bursitis.

Real Client Story

 

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

Her hip pain would get worse with sitting. Sitting should not make Trochanteric Bursitis feel worse.

She had reduced hip pain with walking or running. It is unlikely that walking or running would reduce hip pain with Trochanteric Bursitis.

She did not have hip pain with squatting or lunging. Again, unlikely with Trochanteric Bursitis.

Based on these findings, 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?!

Movements of her lower back provoked her hip pain! Like a thermostat, we were able to increase or decrease her hip pain in the clinic using specific movements of the lower back.

After the assessment, I sent her home with one exercise and I instructed her to use a lower back support while sitting.

Because of the assessment, I felt confident this exercise would reduce her hip pain. When she returned for her second visit, she noticed major improvements.

Her right hip pain had reduced mostly from a combination of the exercise I gave her and using a lower back support to maintain her spine in a better position while sitting.

Trochanteric Bursitis

How Can You Get Rid of Trochanteric Bursitis?

The treatment will depend on the source of the pain and the findings of an assessment which vary between individuals.

The right treatment option should be determined by a skilled healthcare provider; however, I will provide a few scenarios for educational purposes.

 

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

 

Hip Strengthening – Strengthening the muscles around the hip joint will improve the function of the hip. Tears of the gluteus medius or gluteus minimus can occur with pain on the side of the hip which can mimic 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 (nonsteroidal anti-inflammatory 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) It is much better to take a natural anti-inflammatory like turmeric.

● 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 the highest potency turmeric available:  Click Here

 

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.

How Can You Get Better Now?

 You go to your doctor and get diagnosed with trochanteric bursitis. You try some exercises and nothing helps you.

Now what? What do you actually do?

To get better, you have to empower yourself with the right knowledge and mindset.

If you have tried physical therapy or other techniques and you still experience hip pain, then you should take our 2-week low back pain program.

This course will teach you how to identify if your pain is coming from the hip or lower back using the principle of centralization. Centralization is one of the most important concepts to recover from hip and lower back pain.

I am confident you will gain valuable insights from this course that you can't get anywhere else. The information in this program is equivalent to 4-5 visits with a physical therapist.

I'm providing you incredible value for a fraction of the cost to see a physical therapist in-person. Instead of driving to a clinic, you will get lifetime access to this course on your smartphone, tablet or computer allowing you to complete the exercise anytime, anywhere.

Anyone with a busy schedule and or someone who doesn't like to take time off work will love the convenience of this course. In addition, it is very helpful to watch the tutorial videos in the course because people often forget what their doctor or physical therapist told them in-person.

Buy the course now because the price is low for a limited time only. I am confident you will benefit from the course, but if you are not satisfied, I will give you a full refund. You have no risk in trying these exercises and empowering yourself with the techniques you will learn.

Click here to learn more about the 2-week low back pain program.

 

 

References
1. Greater Trochanteric Bursitis. (2018, March 07). Retrieved from https://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=23f6269e-988c-48e2-b2b2-3a3e67e4233d
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
3. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil 2007; 88
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Fearon AM, Scarvell JM, Neeman T, et al. Greater trochanteric pain syndrome: defining the clinical syndrome. Br J Sports Med 2013; 47:649.
5. Tan, L. A., Benkli, B., Tuchman, A., Li, X. J., Desai, N. N., Bottiglieri, T. S., . . . Lehman, J. R. (n.d.). High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for evaluation of degenerative lumbar pathologies. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29685405
6. Trinh, K. H. (2017). Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis). Musculoskeletal Sports and Spine Disorders,217-219. doi:10.1007/978-3-319-50512-1_47
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
9. Griffin MR. Epidemiology of nonsteroidal anti-inflammatory drug-associated gastrointestinal injury. Am J Med. 1998;104(3A):23S–29S. 41S–42S.
10. Prednisone and other corticosteroids: Balance the risks and benefits. (2015, November 26). Retrieved from https://www.mayoclinic.org/steroids/art-20045692
11. Lustenberger, D. P., Ng, V. Y., Best, T. M., & Ellis, T. J. (2011, September). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3689218/
12. Grumet RC, Frank RM, Slabaugh MA, et al. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):191-196.
13. Bunker T, Esler C, Leach W. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79:618–620.[PubMed]