Mrs Q, a 47 year old English teacher, presented to the clinic with a 12 week history of intermittent right sided hip pain. She sought treatment as the episodes had become more frequent and her symptoms had increased in the two weeks prior to attending the clinic.
Both Mrs Q’s work and social lifestyle had been impacted by sleepless nights and reduced mobility. Constant pain and tiredness served to distract her from her job and her morale suffered a further blow as she had to stop all sporting activity. Normally Mrs Q jogged three times a week and also attended the gym twice a week, doing a mix of cardio and strengthening work.
Mrs Q complained of a deep aching or burning pain over the outer surface of her right hip radiating down the outer surface of the thigh above the knee. This was made worse by direct contact or increased activity.
The pain was often more intense lying on the affected side (her preferred sleeping position). Her job required her to walk up and down several flights of stairs between classrooms and also stand for long periods at the front of the classroom.
When Mrs Q was examined the symptoms were reproduced by palpating the right sided greater trochanter (the outer surface of the upper thigh). This is regarded as a classic physical finding.
No swelling was evident in Mrs Q’s case but the muscles immediate to the area had increased in tone. A number of orthopaedic tests were conducted to exclude other possible causes of hip pain. She was diagnosed with hip bursitis (specifically the trochanteric bursa).
The overall management of the condition included:
- Rest – avoid running and long periods of standing.
- Osteopathic treatment – involving soft tissue techniques.
- Hydrotherapy – icing 10-20 minutes, several times a day.
- Stretching exercises
- Non-steroidal anti-inflammatory drugs (NSAIDs) – to reduce pain and swelling.
- Pain killers.
Mrs Q’s symptoms started to improve after one week and by week three her were symptoms were nearly completely resolved.
Long term management
When talking to Mrs Q about the possible elements that may have contributed to her condition she reported a change in running route. She had moved home approximately 6 months before and so longer had access to her favoured local all-weather running track.
Since the move she had started road running on the small single track country roads in her area. Further questioning revealed that the most likely suspect responsible for her symptoms was the natural camber of the road (the dropping curve as the road tapers at the edge). This effectively made the leg nearest to the middle of the road appear ‘longer’, altering her foot, knee and hip mechanics.
Mrs Q began some short gentle runs on the treadmill at her local gym and planned to avoid running on roads with pronounced cambers.
There are hundreds of bursa found throughout the body. They serve to decrease friction between two surfaces that move in different directions. They are thin slippery, fluid-containing sacs.
Commonly bursitis is a non-infectious condition (aseptic bursitis) caused by inflammation that may come from soft-tissue trauma or strain. On rare occasions, the hip bursa can become infected with bacteria (septic bursitis). Gout may very occasionally cause bursitis the hip bursa can become inflamed by crystals that deposit there from gout.
Bursitis of the Hip & Pelvis
Bursitis of the hip is the most common cause of hip pain.
This is commonly caused by friction of the tensor fascia late (TFL) / gluteal muscles irritating the underlying bursae. This frequently causes pain over the outer hip, making it difficult for those affected to lie on the involved side. It may also cause a dull, burning pain on the lateral hip, made worse with walking, stair climbing and exercise.
This bursa is located in the upper buttock area. Ischial bursitis may cause dull pain in this area that is most noticeable when climbing uphill. The pain sometimes occurs after prolonged sitting, particularly on hard surfaces, hence the names “tailor’s bottom” and “weaver’s bottom”.
Who does it affect?
Hip bursitis can affect anyone, but is more common in elderly people, women and middle-aged. It’s not as common in younger people.
- Leg-length inequality – This can alter gait and weight-bearing which can lead to irritation of a hip bursa.
- Repetitive stress (overuse) – Stair climbing or standing for long periods.
- Physical trauma.
- Prolonged pressure on the bursa.
- Twisting or fast joint movement, like cycling or jogging.
- Previous hip surgery – prosthetic implants can irritate the bursa.
- Poor posture.
- Hip bone spurs or calcium deposits. They can develop within the tendons that attach muscles to the trochanter of the hip. They can irritate the bursa and cause inflammation.
- Spinal disease – This includes scoliosis and arthritis of the lumbar spine.
- Rheumatoid arthritis – This makes the bursa more likely to become inflamed.
It’s usually diagnosed based on clinical evaluation and using exclusion criteria. An experienced practitioner can isolate tender areas over the greater trochanter of the hip that corresponds to underlying bursa. Very occasionally clinicians may use diagnostic injections of local anaesthetic into the bursa to aid diagnosis. X-Rays or scans may be used to exclude other conditions such as osteoarthritis.
The treatment of any bursitis depends on whether or not it involves infection.
Non-infectious hip bursitis can be treated with cold packs, rest, and non-steroidal anti-inflammatory drugs, pain killers, osteopathy (or physiotherapy) and/or Medical Acupuncture / Dry Needling. It can also be treated with an injection of cortisone or local anaesthetic.
Long term management
This may include:
- weight reduction
- stretching exercises
- proper footwear / orthotics
- Osteopathic treatment
Infectious (septic) bursitis
This is quite unusual. The bursa fluid is sent to the lab for examination to identify the precise bacteria causing the infection. Septic bursitis generally requires intravenous antibiotic therapy.
Trochanteric bursitis is often seen alongside other conditions including:
- Osteoarthritis of the hip or knee
- Iliotibial band syndrome
- Disc disease of the lower back
- Thyroid disease