HIP BURSITIS

Hip bursitis is an inflammation of the large bursa that covers the bony protrusion at the top of the thighbone, sometimes referred to as the greater trochanter of the femur.

TYPES OF HIP BURSITIS 

TROCHANTERIC BURSITIS

The bony protrusion at the top of the thighbone (femur), where the upper thigh curves outward, is known as the greater trochanter. Above this bony knob is the trochanteric bursa. It acts as a cushion and lessens friction between the iliotibial band, a soft tissue band that travels over the bone during hip and knee motion.

Hip bursitis, also known as trochanteric bursitis, is an inflammation of the trochanteric bursa. 

Common causes of trochanteric bursa inflammation include:

• An injury that results in the bursa filling with blood, such as one caused by a fall or other direct impact (called a hematoma). The bursa may become irritated and swollen due to the blood.
• Hip joint rubbing repeatedly. A too-tight iliotibial band (IT band), for instance, may rub against the trochanteric bursa of the hip when the knee and hip are moved.
• Trochanteric bursitis can also be brought on by prolonged pressure over the outside of the hip, such as from sleeping on a hard surface when camping. The next morning, you could detect a large amount of pain on the outside of the thigh.
• The gluteus medius tendon may be torn or inflamed.

ILIOPSOAS BURSITIS

There are more bursa found close to the hip joint in addition to the trochanteric bursa. One of them, known as the iliopsoas bursa, is situated underneath the iliopsoas muscle, close to the groin. Iliopsoas bursitis or iliopectineal bursitis is the medical term for irritation of this bursa. Hip bursitis is another term commonly used to describe this condition.

GREATER TROCHANTER PAIN SYNDROME 

Greater trochanter pain syndrome is a term used to describe hip discomfort on the outside. Greater trochanter pain syndrome and hip bursitis can be used interchangeably. However, a recent study  indicates that only 20% of persons with greater trochanter pain syndrome may have hip bursitis.

The IT band's tightness and a gluteal tendon injury are two other common causes of this syndrome. There are various potential causes of greater trochanter pain syndrome.

SEPTIC HIP BURSITIS

A hip bursa can become infected and cause septic hip bursitis, which is extremely uncommon. It could be a dangerous condition that has to be treated with antibiotics and medical attention.

Similar to aseptic (non-infectious) hip bursitis, septic hip bursitis can result in symptoms such as fatigue, fever, warmth and redness at the hip, and/or a general feeling of being unwell. Understanding the signs of septic bursitis can help with prompt and effective treatment.

SIGN AND SYMPTOMS 

• Hip discomfort is the most typical sign of hip bursitis. 
• The discomfort could be a mild aching or a severe shooting pain. 
• Pain at the outside of the hip, where the upper thigh curves out, is experienced when bursitis affects the trochanteric bursa of the hip. 
• Groin discomfort will be experienced if the iliopsoas bursa in the hip is injured.

The location and degree of the hip bursitis will impact the person's pain, including its location, intensity, and frequency.

In the absence of a fall or other trauma, hip bursitis discomfort typically develops over time. The discomfort will usually get worse if it isn't treated. Individuals may also report:

Hip Tenderness : Pain is frequently felt when the skin on the outer hip is pressed. Similar to this, applying weight on the hip when lying down on the affected side may trigger a rapid, acute rise in discomfort.

Radiating Pain : At first, the discomfort could mostly be felt on the outside of the lower hip. The discomfort could eventually move down the outside of the thigh and towards the knee, as well as to other parts of the body such the lower back, buttocks, or groin .

Pain that gets worse with repetition of motion : After doing continuous, repetitive hip movements like walking, jogging, or climbing stairs, the pain may become more intense.

Pain that gets worse after being inactive for a while : The majority of patients report that the discomfort gets worse after sleeping or after spending some time seated.

Extreme ranges of motion cause pain: Extreme rotation, hip adduction (moving the leg past the midline of the body with the hip), or hip abduction may cause pain in some patients (using the hip to move the leg away from the body). Adduction can aggravate hip bursitis brought on by a tight IT band, whereas abduction can alleviate it. This is especially true when the patient is having their leg moved by the physician during a medical examination (passive motion).

Hip bursitis, especially aseptic bursitis, is less common than elbow and knee bursitis in terms of swelling and skin redness. This is so because the hip bursa is situated below layers of fat, muscle, and other soft tissues, whereas the knee and elbow bursae are situated just below the skin.

Signs of Septic Hip Bursitis

In addition to the symptoms mentioned above, those who have septic hip bursitis may also observe:

• Fatigue that does not appear to be caused by insufficient sleep
• Fever
• feeling ill or flu-like (feeling "off")
• Hip skin feels warm to the touch and is red (less common)

CAUSES 

The most typical causes and risk factors are as follows:

Hip Injury or Trauma :The bursa may swell with blood and/or experience inflammation if you fall on the outside of your hip or hit it against any rough surface. The bursa membrane may continue to be inflamed even though the blood may be reabsorbed by the body, leading to bursitis symptoms. Traumatic hip bursitis is the name given to this disease.

Repetitive pressure or friction : Repetitive mini-traumas to the bursa can lead to hip bursitis. These minor injuries have the same potential to result in issues as a single, more severe trauma. For instance, individuals who frequently ride a bike, run, or ascend stairs may be more susceptible to hip bursitis.

Specific health issues: People who are already prone to joint pain from other inflammatory diseases, such as rheumatoid arthritis and gout, are more likely to acquire hip bursitis.

Excessive weight: Obesity may alter gait and/or place undue pressure on the hip joint, which raises the possibility of hip bursitis.

Problems that affect biomechanics : The biomechanics of the hips can be altered by a number of physical disorders, including scoliosis, low back issues, and differences in leg length. The biomechanics of jogging or walking on uneven ground can also be impacted. The alteration in biomechanics may set off a chain reaction that causes hip side discomfort.

Calcium crystals or bone spurs: Bone spurs, also known as osteophytes, and calcium deposits, which are small collections of calcium that are typically small and soft but can develop and harden over time, can irritate hip bursae and other soft tissue.

Previous hip surgery: A hip operation, even a minor one, can make hip bursa more likely to occur.

Gender and Age: Compared to men, women are more prone to experience hip side pain. Hip bursitis can affect individuals of any age, but it is more common in people in their 40s, 50s, and 60s.

History of inflammation of the bursa: Patients who have previously experienced bursitis are more prone than others to experience it once more. Bursitis that lasts for a long time or recurs is referred to as persistent bursitis.

Bacterial infection of a bursa: Septic hip bursitis is the medical term for an inflammation of the trochanteric bursa. People may be more prone to developing septic bursitis if they have specific medical conditions or take drugs that suppress their immune systems. For instance, septic bursitis may be more common in individuals with diabetes, alcoholism, chronic obstructive pulmonary disease (COPD), gout, and rheumatoid arthritis.

DIAGNOSIS

Diagnosis is based on the patient's symptom and physical examination

PHYSICAL EXAMINATION 

PALPATION

Asking the patient to lie on their side with their painful side facing up and palpating over the greater trochanteric bursa are the two main ways to identify greater trochanteric bursitis. It is important to value tenderness.

• A number of physical examinations, such as having the patient extend their leg outward (abduction) and bring it in into their midline (adduction) are performed .

EXTERNAL SNAPPING HIP

With the patient on their side (painful side up), you will grab the entire leg and flex and extend the limb while palpating the iliotibial tendon (near the greater trochanter) and feeling for a popping or snapping that may be accompanied by pain. This is done to test for an externally snapping hip. This test is considered positive in greater trochanteric pain syndrome .

IMAGING AND LAB TEST

X ray: X-rays are the most commonly asked type of medical imaging. X-rays can be used to identify whether hip discomfort is being caused by osteoarthritis or a stress fracture.

Magnetic Resonance Imaging (MRI): Hip bursitis can be identified without an MRI, however one may be requested to confirm or rule out other diagnosis. A thorough image of the soft tissue can be obtained with an MRI, which can also reveal anomalies like a bursa that is enlarged or tendons that are injured.

Ultrasound : Like an MRI, an ultrasound is not required to identify hip bursitis. The extra synovial fluid detected in a bulging bursa is one example of the excess fluid that an ultrasound can find.

Aspiration and Lab test : A needle and syringe are used to aspirate fluid from the bursa of the hip during the procedure.

Medical imaging is frequently used during an aspiration treatment to make sure the needle is inserted precisely into the problematic hip bursa.

The patient can feel more comfortable and pressure in the hip can be relieved by draining fluid from the irritated bursa.

Provide a sample of fluid that can be examined and tested for infections.

TREATMENT 

CONSERVATIVE MANAGEMENT

Rest and activity modification :Rest and other methods to reduce inflammation are typically effective when hip bursitis results from an injury or overuse. Sports and/or prolonged standing are activities that people with hip bursitis should avoid because they will exacerbate and inflame the bursa. A doctor may also suggest using a cane, crutches, or shoe inserts to relieve strain on the hip.

Ice: Localized pain and swelling can be lessened by applying ice or a cold compress to the aching hip. After any exercise or activity that can inflame the hip bursa, this therapy is advised.

NSAIDs, sometimes known as non-steroidal anti-inflammatory medicines. Anti-inflammatory drugs help lessen hip bursitis-related discomfort by reducing swelling and inflammation.

Aspiration to drain the hip bursa

Corticosteroid injection

Physical therapy: Physical therapy may be recommended by a doctor to aid with the existing bursitis and stop further flare-ups. Stretching the iliotibial band and strengthening the quadriceps and glutes are two possible objectives of physical therapy (IT band). Athletes can learn the right form for running and jumping.

REHABILITATION 

Phase 1 (Acute Phase)

 Goals 

• Control pain and inflammation 
• Begin pain free flexibility exercises
•  Establish pain free hip ROM Recommended Exercises Range of motion and flexibility
•  Lower extremity stretching (based on individual assessment) Gluteus maximus ,  IT Band/ Tensor Fascia Latia (TFL) ,  Hamstring , Hip Rotators ,  Iliopsoas , Piriformis

GLUTEUS MAXIMUS STRETCHING

IT BAND / TFL STRETCHING

 

HEMSTRING STRECHING

HIP ROTATOR STRETCH 

PIRIFORMIS STRETCHING 

ILIOPSOAS STRETCHING

Guidelines 

Perform range of motion exercises daily. Do 2-3 sets of 15-20 Reps. Perform stretching program daily. Hold stretches for 30 seconds and perform 2-3 repetitions of each.

Phase 2 (Sub-acute Phase A)

 Goals 

• Continued protection of injured joint
• Continue to improve flexibility Begin to strengthen areas of weakness/instability

Recommended Exercises Cycle (slow progression of resistance)

• Range of Motion and Flexibility Continue flexibility from Phase 1 
• Begin open chain strengthening (based on strength assessment) (Bridging, Clamshells ,Quadruped positional exercises, Straight leg raise (SLR) ,Hip abduction ,Hip extension, Hip external rotation ,SLS (single leg stance) drills)

BRIDGING

CLAMSHELL

QUADRUPED 

STRAIGHT LEG RAISING 

HIP ABDUCTION 

HIP EXTENSION 

HIP EXTERNAL ROTATION 

SINGLE LEG STANCE DRILL

Guidelines 

Perform stretching program daily. Hold stretches for 30 seconds and perform 2-3 repetitions of each. Cardio program should be performed no more that 3-5 times a week for 20-35 minutes. Perform strengthening exercises daily. Do 2-3 sets of 15-20 Reps.)

Phase 3 (Sub-acute Phase B) 

Goals 

• Continue to avoid exacerbation of symptoms 
• Continue to maximize return of strength and flexibility 
• Establish closed chain strength and stability 

Recommended Exercises 

• Range of Motion and Flexibility 
• Continue cycle, add walking
• Continue lower extremity stretching from Phase 1 and 2 

Strengthening

• Continue progression of open chain program with ankle weights 

Hamstring curl 

Leg Extension

Terminal Knee Extension 

• Can add gym equipment (Leg Press, Multi-Hip) 
• Pain free closed chain hip strengthening 

TERMINAL KNEE EXTENSION

STEP UP LATERAL 

WALL SQUATS

STANDING HEEL RAISES - SINGLE LEG

SIDESTEPPING

LATERAL LUNGE - ALTERNATE

POSTERIOR (BACKWARD) LUNGE

AIR SQUAT

SINGLE LEG DEADLIFT

SINGLE LEG STANCE IR/ER

• Step Ups (frontal and Lateral)

• Continued progression with SLS activities

Guidelines

Perform stretching program daily. Hold stretches for 30 seconds and perform 2-3 repetitions of each. Cardio program should be performed no more that 3-5 times a week for 20-45 minutes. Perform strengthening exercises 3 times a week. Do 2-3 sets of 15-20 Reps. 

Phase 4 (Return to sport/Activity Phase) 

Goals

• Continue to avoid hip bursae overload 
• Progress with single leg strengthening
•  Achieve adequate strength and flexibility to return to activity

 Recommended Exercises 

• Flexibility Continue daily stretching 
• Cardio Continue cycle, walking , Return to running progression (outlined by physician or physical therapist) 
• Strengthening Continue SLR program and gym equipment progression , Static lunge/Split-Squat ,  Lateral lunge, Progressive single leg strengthening (single leg squat, single leg dead lift, single leg ER) 
• Return to Sport Work with physician or physical therapist to outline progressive return to sport 

Guidelines

Perform stretching program daily. Hold stretches for 30 seconds and perform 2-3 repetitions of each. Cardio program should be progressed in preparation for return to sport. Perform strengthening exercises 3 times a week. Do 2-3 sets of 15-20 Reps

 

Loss of weight: Losing weight can be an important aspect of an effective treatment plan if being overweight is a potential underlying cause of hip bursitis.

Extracorporeal shock wave therapy (ESWT): Extracorporeal shock wave therapy, which promotes healing by using sound waves, may be suggested by some medical professionals. Although not common, this course of treatment might be suggested for someone with greater trochanter pain syndrome.

Antibiotics 

NON-CONSERVATIVE MANAGEMENT

Bursectomy

Tendon repair and iliotibial (IT) band release

Osteotomy of the greater trochanter