The patient's unmet needs (PUNs)
A 62-year-old woman presents convinced that she is suffering – as her mother did – from osteoarthritis of the hip. She has been experiencing persistent pain over her right lateral thigh for a few months, worse when she lies on that side at night. On examination, she has a good range of hip movement, causing only mild discomfort, but the area over her greater trochanter is very tender. She's relieved to hear that she doesn't seem to have osteoarthritis, but is keen to have your diagnosis of trochanteric bursitis confirmed – and promptly treated.
The doctor's educational needs (DENs)
How common is trochanteric bursitis and what causes it?
Greater trochanteric pain syndrome (GTPS) has become the preferred term for trochanteric bursitis because imaging and histology studies have shown that inflammation of the bursa is not always present in patients with pain over the greater trochanter.1 Other possible causes of GTPS are tendinopathy or a tear in the gluteus medius.
GTPS is a common cause of hip pain – typically chronic intermittent pain over the greater trochanter on the lateral side of the thigh. It can occasionally be bilateral. Trochanteric bursitis is the symptom produced by inflammation of the bursa around the greater trochanter, most commonly between the greater trochanter and gluteus medius muscle. It is estimated that GTPS affects from 10-25% of the population in industrialised societies, with a female to male ratio of 3:1, and the incidence is reported to be 1.8 patients per 1,000 per year.2
It is generally a disease affecting older patients – most commonly between the fourth and sixth decades of life – but can be a cause of lateral hip pain in some young people, such as runners.3 Prevalence is higher in people with low back pain, osteoarthritis, obesity and iliotibial band tenderness.4 Based on a Dutch primary care study, a GP with a list of about 2,000 people can expect to see three to four cases of GTPS every year.2 Other conditions associated with GTPS include:
• lumbar spine degenerative conditions like osteoarthritis or disc disease
• osteoarthritis of the hip joint
• rheumatoid arthritis
• leg length discrepancy
• pes planus.
What are the classical presenting features and what should we cover in an examination?
Patients complain of lateral hip pain, which may radiate down the lateral side of the thigh to the knee. Some may have difficulty walking. Pain is generally worse at night – some patients are unable to lie on the affected side – and may be exacerbated by prolonged standing, climbing stairs or physical activity like running.
Look for diffuse tenderness around the greater trochanter – the most prominent bony point on the lateral side of the femur – but you may also find point tenderness postero-lateral to the trochanter.1 Hip rotation and gait should also be assessed.
The following tests are also useful:
• Resisted active abduction. With the patient lying supine, abduct the affected hip joint by 45 degrees against resistance. The test is positive if pain is produced.
• Resisted internal rotation test. With the patient lying supine, flex the hip to 45 degrees and ask the patient to externally rotate as far as possible. Then get the patient to internally rotate the hip against resistance. The test is positive if the patient gets pain on internal rotation.
• Trendelenburg test. This will help exclude an intra-articular cause of the pain. The patient stands unassisted on each leg in turn, with the examiner's fingers placed on the anterior superior iliac spines. The foot on the contralateral side is lifted by bending at the knee. Normally the hip will be held stable by the gluteus medius acting as an abductor in the supporting leg. But if the pelvis drops on the unsupported side this is a positive Trendelenburg sign – the hip on which the patient is standing has a weak or mechanically disadvantaged gluteus medius.
Other conditions – beyond GTPS – which may present with lateral hip pain include iliotibial band syndrome and meralgia paraesthetica.
Sacroiliac joint dysfunction and lumbar radiculopathy generally cause posterior hip pain and these patients usually have a history of low back pain. It is important to rule out infection in patients who have had recent hip surgery.
Should any investigations be performed in this scenario? If so, what and why?
The diagnosis of GTPS is clinical and radiological investigations are not usually necessary, but can be used to exclude other conditions if symptoms persist beyond six to eight weeks despite conservative measures. An MRI can exclude other causes, but can also confirm inflammation around the greater trochanter. An MRI or bone scan to evaluate low back pain may be considered – an X-ray of the hip to look for osteoarthritis may also be appropriate. Ultrasound can help to identify tears in the gluteus medius and minimus and inflamed trochanteric bursa.
What conservative measures can be tried? Are there specific exercises that help this condition, and does physiotherapy have a role?
Generally GTPS is a self-limiting condition and symptoms settle with conservative treatment, but patients should be advised that symptoms may persist.
Conservative measures include:
• ice pack and heat treatment
• weight loss if appropriate
• physiotherapy to improve flexibility and muscle strengthening.
Restricting repetitive bending and avoiding direct pressure on the bursa can also help.
Physiotherapy options include passive stretching exercises such as cross leg pulls. The affected leg is crossed over the other leg with the spine in a neutral position. The knee on the symptomatic side is grasped and the leg pulled towards the opposite side until a gentle pulling sensation is felt in the outer buttock or hip area.
The buttock should be kept flat and it is important that the patient does not roll the pelvis. The exercise can be repeated after a brief rest. Another option is to sit with the leg abducted and externally rotated to reduce the pressure on the bursa.5 A physiotherapist will also offer patients advice on hip and back stretching advice to prevent recurrence.
Many doctors inject trochanteric bursitis with local steroids, yet it must be very difficult to accurately inject the bursa. Is simply injecting into the tender area effective?
If conservative measures fail, injection of the trochanteric bursa with local anaesthetic or steroids is appropriate. There are no placebo-controlled studies, but one of the most useful prospective studies found that local steroid injection was associated with a response rate of 77%, 69% and 61% at one, six and 26 weeks respectively.6
Injecting into the site of maximal tenderness is appropriate, using methylprednisolone 40-80mg or triamcinolone 40mg with 5-10ml of lidocaine 1%.
This can be repeated up to three times at three-monthly intervals. One study compared fluoroscopy-guided injection into the bursa with ‘blind' injection using bony landmarks. Three months after the injection, 47% of patients in the blind group had a positive outcome compared with 41% in the fluoroscopy group. So guidance dramatically increases treatment cost without necessarily improving outcomes.7
Which patients require referral and what further treatment can the specialist offer?
Signs of infection in the lateral hip region, such as a tender palpable mass, redness, oedema or warmth warrant urgent referral to an orthopaedic surgeon. Otherwise, refer to a specialist if the diagnosis is in doubt, if there is a poor response to steroid injection and physiotherapy or if symptoms might be due to previous hip surgery or a fracture of the femur. Surgical options include release of the iliotibial band over the greater trochanter, excision of the inflamed bursa (bursectomy), proximal or distal Z-plasty and repair of the damaged tendons.
This patient was particularly keen to know how likely she was to recover. What can we confidently tell patients?
It is important to reassure patients that two-thirds will have recovered within a year. This comes from a follow-up study of patients managed in primary care that also looked at the factors influencing outcome.2
The risk of symptoms persisting for more than a year was almost five-fold higher in those with osteoarthritis of the lower limbs compared with people without osteoarthritis. Other risk factors for a poorer outcome include higher initial pain intensity, longer duration of pain, greater movement restriction, higher disability and older age.
Dr Savita Shanbhag is a GP in Swansea and a clinical assistant in rheumatology
1 Williams BS and Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg 2009;108:1662-70
2 Lievense A, Bierma-Zeinstra S, Schouten B et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract 2005;55:199-204
3 Strauss EJ, Nho SJ and Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc 2005;18:113-19
4 Segal NA, Felson DT, Torner JC et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil 2007;88:988-92
5 Anderson BC. Trochanteric bursitis; version 19.3. September 2011; www.uptodate.com
6 Shbeeb MI and Matteson EL. Trochanteric bursitis (greater trochanteric pain syndrome). Mayo Clin Proc 1996;71:565-9
7 Cohen SP, Strassels SA, Foster L et al. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial. BMJ 2009;338:b1088