Greater trochanteric pain syndrome

Alternate names

• Great trochanteric pain syndrome
• Great trochanteric bursitis

Definition

• The trochanteric bursa is located on the lateral aspect of the hip, lying superficial to the hip abductor musculature and deep to the Iliotibial band (ITB). The inflammation of this bursa is called trochanteric bursitis.

Etiology

• The underlying cause of trochanteric bursitis can be repetitive microtrauma, blunt trauma, or idiopathic. Overuse of the surrounding musculature leading to tendinopathies of the gluteus medius and/or minimus is common. Repetitive hip abduction seen in stair climbing or cycling can contribute to an inflammatory cascade of the bursa. Older patients who sustain falls directly over the bursa can initiate an inflammatory cascade within the tissue. Sedentary or bed bound patients are also prone to trochanteric bursitis as constant pressure over the greater trochanterof the proximal femur can also initiate the inflammatory response of the bursa.

Epidemiology

• Trochanteric bursitis is common and thought to affect roughly 15% of women and 8% of men. Middle-aged women are most commonly affected, although young female athletes are also prone to developing it. Females have increased Q angles which leads to tighter ITB which cause strain over the bursa when exposed to repetitive motion including running and jumping.

Signs and symptoms

• Patients will often present complaining of unilateral lateral hip pain. Suspicion for trochanteric bursitis should be high in the differential if the pain onset was gradual, the patient maintains the ability to ambulate, and pain improves with over-the-counter anti-inflammatory medication.
• The patient will often be able to localize the pain focally to the area directly over the greater trochanter of the proximal femur.
• Pain often worsens with prolonged activity, or maneuvers involving stabilization of pelvis such as standing on one leg.
• Pain is often elicited with adduction of the femur and relieved with abduction as this tensions and relieves tension on the overlying ITB, respectively.

Diagnosis

• Physical examination is the gold standard for the diagnosis of trochanteric bursitis.
• Patients should maintain their ability to straight leg raise without pain, and log roll (internal and external rotation of the leg at the hip joint with the hip flexed to 90 degrees) will also not elicit pain in the hip joint.
• Radiographs - two view and AP pelvis should be obtained to rule out associated fracture of other osseous abnormalities.
• If the patient has associated fevers, chills, or other signs of systemic infections, CBC with differential can be obtained to look for the presence of leukocytosis.

Management

• Initial management for trochanteric bursitis is always nonoperative. Antibiotics are not indicated in the management of trochanteric bursitis.
• Pharmamaceutical - Oral non-steroidal anti-inflammatories (NSAIDs) assist in blocking the inflammatory cascade and aid in symptomatic pain relief and propagation of bursitis.
• Physical therapy - directed toward quadricep strengthening and ischial tibial band stretching is important in addressing the underlying pathology. Hip abduction exercises directed at stretching and strengthening gluteus medius and minimus should also be initiated. Teaching proper running and jumping form and technique to the adolescent athlete is also important. It is important to maintain hip mobility and flexibility while treating trochanteric bursitis.
• Corticosteroid injections - Trochanteric bursitis is also amenable to steroid injection. Injections deliver a localized dose of cortisone often coupled with local anesthetic lidocaine or marcaine to provide relief and directly target local inflammation.
• Surgical management for trochanteric bursitis is rarely employed. Surgery is reserved for refractory cases or for those that do not respond to usual conservative therapy. Surgical management includes sharp excision and debridement of the bursa.

Differential diagnosis

• Snapping hip syndrome (iliopsoas tendinitis)
• fracture of the great trochanter
• femoral neck fracture
• hamstring avulsion injury/sprain

Prognosis

• Prognosis is promising with trochanteric bursitis, as patients can expect complete resolution of symptoms with conservative management without any long term sequelae. Resolution with NSAIDs and/or corticosteroid injection can be expected within just several days of initiation of treatment.

Complications

• Complications of trochanteric bursitis are rare. Complications are more closely associated with NSAID use and infrequently corticosteroid injection.
• NSAIDs can cause gastric ulceration and subsequent bleeding in those that are high risk or are taking anticoagulants.
• Complications associated with corticosteroid injections include elevated for blood glucose levels (especially in those with poorly controlled diabetes), injection site irritation, or injected site bleeding.

References

• Aaron J. Seidman; Matthew Varacallo. Trochanteric bursitis [Updated June 29, 2020]. In StatPearls[Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538503/

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