Hip Bursitis?

The purpose of this blog is to discuss a condition that goes by many names: hip bursitis, trochanteric bursitis, greater trochanteric pain syndrome, gluteal tendinopathy, and the list goes on. I’m going to outline which of these diagnoses is most accurate based on the research, and then use that information to show you activity modifications and exercise progressions that you can do to help manage your symptoms.

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Anatomy

Let’s start by describing the anatomy of this region. On the outside aspect of your hip, you have a bony prominence known as the greater trochanter. It is part of the femur, or thigh bone, and serves as an attachment site for various muscles including the gluteus medius and minimus. These two muscles primarily act to abduct your hip in a non-weight bearing position, or, more importantly, stabilize the pelvis in a weight bearing position. Superficial to these tissues, or closer to the skin, lies the Iliotibial Band that runs from the pelvis all the way down to the knee. The tensor fascia latae attaches to it from the front, and part of the gluteus maximus attaches to it from the back. Finally, you have several bursae here which are small fluid filled sacs that help to cushion and reduce friction in the area.

Hip Bursitis Diagnosis

Understanding the anatomy is an integral component of defining the diagnosis and outlining the appropriate framework for rehabilitation because many individuals associate symptoms here with the word “bursitis” based on what they’ve heard or read. The suffix “itis” implies inflammation of a bursa, the subgluteus maximus bursa to be exact, which then often dictates treatment – rest, ice, and anti inflammatories.

However, hip bursitis or trochanteric bursitis, are not the most appropriate terms to describe this lateral hip pain.

• In 2001, Bird et al. performed MRI examination of 24 symptomatic patients and only found bursal distention, or enlargement, in 8% of cases. Additionally, it wasn’t an independent finding, meaning that it was always associated with gluteus medius pathology. Gluteus medius pathology was discovered in 83% of cases.
• In 2003, Connell and colleagues found that 53 of the 75 patients in their study showed sonographic evidence of gluteus medius tendinopathy.
• In 2008, Woodley et al. found that gluteus medius tendon pathology was more common in symptomatic hips, while bursitis was actually equally prevalent in symptomatic and asymptomatic hips within the same group of participants!
• In another study in 2008 titled “Trochanteric Bursitis – Refuting the Myth of Inflammation” by Silva and colleagues, the researchers removed the subgluteus maximus bursa in 5 patients undergoing total hip athroplasty and reported that histologic analysis showed no evidence of inflammation in the individuals diagnosed with trochanteric bursitis.
• In 2010, Fearon et al. retrospectively compared preoperative ultrasound imaging with surgical and histopathological findings in 24 patients who had combined gluteal tendon reconstruction and bursectomy and concluded that “there was no evidence of ongoing acute bursitis.” Therefore, they believed treatment should address the gluteal tendinopathy as a primary goal.
• Finally, Long et al. in 2013 retrospectively reviewed musculoskeletal sonographic examinations performed at their institution over a 6 year period for greater trochanteric pain syndrome and found that 80% of patients did not have bursitis on ultrasound. They concluded that “the cause of greater trochanteric pain syndrome is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band.”

So what do we do with all of this information? Well, it’s not to say that inflammation is never present or never a possible contributing factor, but it definitely doesn’t seem to be the primary driver of symptoms. Therefore, we probably shouldn’t be using the term hip bursitis. The reason that this is so important is that it can help shift your mindset and guide treatment.

For example, as I alluded to earlier, if you assume that your symptoms are due to inflammation, you might take a very passive approach – rest, ice, and medication. It almost puts you in the backseat.

But, if you treat it more like a tendinopathy, managing load to the area as needed, then you’re in control. You’re in the driver’s seat and you can start taking the appropriate steps to helping yourself.

The last thing to note before moving on to the next two sections is that there are many other reasons that individuals might have symptoms in this region that are beyond the scope of this blog. However, Grimaldi et al. 2016 and Ganderton et al. 2017 found that pain with standing on one leg for 30 seconds or resisted hip abduction can help rule in this condition, and no pain with palpation of the greater trochanter can help rule out the condition.

Activity Modifications

Activity modifications are a key component of rehabilitation for this lateral hip pain as outlined by Grimaldi and Fearon in 2015, and Grimaldi et al. in 2015. These recommendations are based on trying to reduce compression of the gluteal tendons at their attachment site on the greater trochanter – either directly such as by lying on that side or via the overlying IT Band when the hip is in adduction as demonstrated by Birnbaum and colleagues in 2004.

Let’s rattle off some possible activities to modify, but also understand that if they don’t cause you any issues, don’t worry about them.

• Sleeping – minimize sleeping on the affected side and keep a pillow or two between your legs when sleeping on the unaffected side.
• Sitting – limit sitting cross legged or in deep hip flexion for extended periods of time.
• Stretching – temporarily avoid the so called piriformis and IT Band stretches as they might contribute to symptoms.
• Standing – reduce time spent “hanging” on one leg (passively resting on one leg).
• Walking – track your steps to determine your tolerable baseline and then build up over time.
• Stairs – use the handrail on the opposite side of your affected hip to offload those tendons as needed.
• Running – increasing cadence by 5-10% may help reduce hip adduction.

Those are all considerations for ways to potentially reduce the amount of load experienced by the gluteal tendons, but we also want to build up their capacity so that they can handle more load. That’s where the exercise progressions come into play.

Hip Bursitis Exercise Progressions

With regards to changes in function, Allison and colleagues dominate the research here. Individuals with gluteal tendinopathy demonstrate weakness of their hip abductors bilaterally and alterations in muscle activity and mechanics during gait so the focus of rehabilitation will be two-fold: strengthen the hip abductors and eventually progress to single leg, weight bearing exercises.

Honestly, it doesn’t actually matter how you accomplish these tasks as long as the exercises are appropriately challenging and tolerable, you’re objectively making progress on a week-to-week or month-to-month basis, and you’re giving yourself at least 3 months of a dedicated regimen. Otherwise, don’t get too caught up in the minutia.

Isometrics are one possible starting point (not a rite of passage). I’m going to show you three different tiers of exercises (easy, medium, and hard) and you really only need to pick 1 or 2 exercises based on your symptoms and strength, and then you can regress or progress as needed. 3 to 5 sets of 10-60 seconds at the highest comfortable intensity, daily or every other day is a good starting point.

Two options for easy:

1. Standing with your feet a little more than hip width apart while thinking about spreading the floor beneath you without actually moving your legs.
2. Lying on your back with a pillow under your knees and a belt or band just above your knees. Try to spread that belt or band outward and hold.

Two options for medium:

1. Short side plank on your forearm and knees
2. Sidelying hip abduction (isometric not shown)

Two options for hard:

1. Side plank on your forearm and feet
2. Banded sidelying hip abduction (isometric not shown)

Isotonics are another possible starting point and I’m a big fan of sidesteps:

1. Easiest: no band
2. Medium: band around knees
3. Hardest: band around ankles

You can vary the width of your step and resistance of the band to accommodate your needs. You can also see how this could be progressed from the standing isometric. And as I mentioned, you want to eventually perform some type of single leg exercises. You can start with squats, deadlifts, and bridges and then progress to their single leg variants. Or, you can start with single leg balance and work your way to step ups, step downs, reaches, standing fire hydrants, etc.

Summary

1. Gluteal tendinopathy, greater trochanteric pain syndrome, and lateral hip pain are more appropriate terms to describe these symptoms since inflammation of the bursa doesn’t seem to be the driving factor here.
2. Monitor and modify aggravating activities such as sleeping, sitting, and stretching (if needed).
3. Strengthen your hip musculature, particularly your hip abductors, and eventually include challenging, single leg exercises.

Thank you so much for reading! Please leave your questions in the comments below!

Other research:

• Exercise trials: Rompe 2009, Mellor 2018, Ganderton 2018
• Psychological factors
• Physio knowledge and practice