The greater trochanter is the prominent piece of bone situated at the upper outer aspect of the femur, as is palpable in most people just to the outer side of where a trouser pocket starts. It is the area of bone where a large mass of muscles (the hip abductors) attach to the femur.
A bursa is a sack of fluid, which acts a lubricator. Bursae are found in many sites around the body; typically between areas of bone or tendon and the skin. The function of a bursa is to minimise potential rubbing and friction between two tissues.
The trochanteric bursa is found just lateral (outside) of the hip joint, beneath the skin, the fat and the facia lata, just superficial to the muscle layers of the gluteus medius and the vastus lateralis, where they attach to the bone.
When a bursa becomes inflamed, the area becomes tender and painful. The region may become hot, red and swollen. However, with certain deep bursae (such as the trochanteric bursa), these signs may not be apparent. When a bursa becomes inflamed, the condition is referred to as ‘bursitis’.
Sometimes inflammation of the muscle tendons can mimic symptoms. Some people may have multiple problems, and this is called ‘trochanteric syndrome’.
Trochanteric bursitis may come on after trauma, repetitive micro-trauma (overuse), in the presence of osteoarthritis, or even after a hip replacement. Tendon problems may also occur due to problems with how you walk or run (gait). Many times, no specific cause can ever be clearly identified.
Trochanteric bursitis normally causes a sharp or burning pain over the lateral (outside) side of the hip. The pain may radiate down the lateral side of the thigh towards the knee. The pain is usually made worse by walking or trying to run. The most pathognomic (typical) symptoms and signs are tenderness over the lateral side of the hip, plus pain when trying to lie on that side in bed. This pain often interferes with patients’ sleep
Diagnosis is often clear from simple history taking plus clinical examination. However, in cases where the diagnosis may not be entirely clear, or where more definite confirmation is desired, then the investigation of choice is an ultrasound or high-resolution 3T MRI scan of the hip. An MRI scan will also be able to check for other hip pathology, such as a labral tear or early hip arthritis. X-rays should also be performed to exclude the potential presence of osteoarthritis of the hip.
Sometimes, no actual treatment may be needed. The first step in the treatment of trochanteric bursitis is to try rest and to use anti-inflammatories. Some patients’ symptoms may be helped by physiotherapy. In cases where the symptoms are severe enough to justify intervention, then the first line of treatment is to have a local anaesthetic plus cortisone injection into the bursa. The cortisone is a very powerful anti-inflammatory and normally works very well, although it may sometimes be necessary to repeat the injection more than once. The injection can sometimes be given directly in the outpatient clinic; however ultrasound-guided injection in the X-ray department is the gold-standard. Ultrasound has the advantage of being able to target other areas, such as inflammation of the tendons.
Other treatment options may include shockwave therapy.
In that very small proportion of patients where all other treatment options fail and where the symptoms remain severe, surgical excision of the bursa is very occasionally necessary. This is an open operation, performed normally under a general anaesthetic. The operation lasts only 20 or 30 minutes, but the dissection does go quite deep. Therefore, there can be significant post-operative discomfort, and patients normally need to stay in hospital overnight post-operatively. The wound normally takes only a week or so to heal, but the deeper tissues may take up to 6 weeks to settle, during which time some patients may require a walking stick initially to help them walk, followed by a course of physiotherapy treatments to help them regain their strength and motion.
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