The trochanteric bursa is a synovial tissue located superficially to the greater trochanter, the part of the proximal femur that protrudes laterally from the hip. In fact, every individual has 4 or more trochanteric bursas in each hip. These bursas act as an “empty sac” over the bony prominences, facilitating the sliding of tendons and fasciae over the bone. Trochanteric bursitis is a common cause of hip pain and patients often experience limited physical activity and sleep with difficulty.
Inflammation of any of the trochanteric bursas is known as trochanteric bursitis and is one of the most common causes of hip pain. Some research suggests that it is not just inflammation of the bursa that would cause pain. Trochanteric bursas have small nerves inside which irritated or compressed can cause pain. Other diseases may develop with pain in the trochanteric region, such as rupture of the abductor tendons. For these reasons, some authors have suggested the name lateral trochanteric pain syndrome in place of trochanteric bursitis.
There are also other bursas that can cause hip symptoms, such as the sciatic bursa and iliopsoas muscle, but are much less frequent than trochanteric bursitis.
Trochanteric bursitis is caused by excessive movement of the tendons and fascia over the greater trochanter. Direct pressure can cause or aggravate symptoms. As the inflammation progresses, the bursa progressively loses its sliding function (“like an empty sac”) and thickens its walls.
Patients with trochanteric bursitis often have one or more of the following conditions: lumbar spine disease; length difference between the lower limbs; sacroiliac joint disease; knee arthrosis and ankle sprain. These abnormalities are believed to alter gait and consequently irritate the trochanteric bursa.
Although there are more than four trochanteric bursas that can be affected, the symptoms are usually the same regardless of the affected bursa. Trochanteric bursitis causes pain in the side of the hip and thigh and may cause difficulty walking. Direct pressure on the bursa increases pain and it is difficult to lie on the affected side. Because of all these manifestations, trochanteric bursitis can impair sleep, prevent physical activity and significantly reduce quality of life.
Trochanteric bursitis is the most common cause of lateral hip pain. However, the following causes should also be considered: intra-articular problems, ruptures of the gluteus tendons; occult fracture; hip outer shoulder; tumor metastases and other unusual causes.
Generally, further examinations are not required for diagnosis. Nevertheless, x-rays are required to exclude some diseases. Ultrasonography, computed tomography and magnetic resonance imaging are useful in some cases to aid diagnosis, rule out other diseases and guide treatment.
Trochanteric bursa infiltration is also useful in the diagnosis of some patients.
Treatment of trochanteric bursitis
Non-surgical treatment of trochanteric bursitis achieves satisfactory results in most patients, including the use of medications, physical therapy, and infiltrations. Definitive resolution (“cure”) of trochanteric bursitis may be difficult to achieve in some cases, which does not mean that symptoms will not improve with treatment.
The medications are analgesic and anti-inflammatory. Physical therapy associates local temperature measurements with tissue stretching exercises that put pressure on the bursa. Changes in gait and muscle function may also be corrected by physical therapy in some cases. The use of therapeutic ultrasound, percutaneous electrical stimulation (TENS) or shockwave therapies may eventually be indicated. Bursa infiltration with anesthetic and steroid may be indicated when previous measures did not control symptoms.
Surgical treatment is indicated in the minority of patients, where symptoms cause important limitations and treatment without surgery did not produce good results. Surgery involves the removal of the inflamed bursa and usually the release of tissues (fasciae) causing pressure on the trochanteric bursa. Abductor tendons are evaluated and tears can be repaired, as with shoulder tendon repairs. The surgery can be performed in a traditional way, called open or by video arthroscopy (endoscopy). Evolution in materials and techniques has allowed increasingly complex procedures to be performed through hip video arthroscopy.