Trochanteric Bursitis - What is it?

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Do you find your hip hurting after running or after running a long race? This article provides diagnosis and treatment for greater trochanteric pain syndrome.

Member question

Do I have trochanteric bursitis? I am six weeks out of running a marathon. I haven’t really been able to run the past few days: it’s not unbearable but it’s not comfortable either.  What are my treatment and recovery options?

Answer from Andrew Getzin, MD
Member AMSSM

Congratulations on completing the marathon. I am sorry to hear that your hip is not behaving. Historically, your current hip problem has been called trochanteric bursitis. However, the term trochanteric bursitis is somewhat a misnomer because this entity is neither inflammatory (as the suffix -itis suggests) nor usually a problem with the bursa. A more accurate term to describe your problem is greater trochanteric pain syndrome (GTPS). GTPS, similar to rotator cuff syndrome, is a collection of problems with similar presentation that typically occur from increasing the training load too rapidly.

Understanding anatomy and function helps explain why this problem develops. The greater trochanter is the part of the upper portion of the femur (thigh bone) that sticks out laterally and is the site of attachment of the gluteus medius and gluteus minimus- both deep butt muscles that act as hip abductors and stabilizers during running. There are several small fluid filled sacs called bursa in the region that can become swollen when irritated with excessive pressure. The Iliotibial band (ITB) is a fibrous structure that runs over top of the bursa and the muscles. It originates from the hip and inserts into the lateral aspect of the proximal tibia (shin bone) just distal to the knee. The classic understanding of the GTPS was that due to an increased load from running, the core and gluteal muscles become overloaded. The ITB then tries to compensate which results in it becoming tighter. The end result was thought to be ITB compression of the bursa and hence the term trochanteric bursitis. However, MRI and ultrasound studies looking at this problem have shown very little bursa swelling but instead reveal breakdown of the gluteal muscle from too much load over time. 

In order to obtain an accurate diagnosis, it is important to be evaluated by a clinician who understands GTPS and ideally somebody who treats triathletes and runners. Other problems that masquerade as GTPS need to be eliminated including back problems, stress fractures, and intra-articular hip problems. Usually an accurate diagnosis can be made via the history and physical exam. Patients with GTPS have pain with sleeping on the affected side and with standing on the affected side due to recruitment of the gluteal muscles for stability.

Unfortunately the best treatment, like most overuse problems, is time. The good news is that the overwhelming majority of runners with GTPS will get better if they allow themselves to heal which usually occurs in 4- 8 weeks if the problem developed relatively rapidly. Physical therapy working on proximal stability is an excellent adjunct to patience. In addition, soft tissue work by a physical therapist, massage therapist, or use of active tissue release (ART) can help break down potential adhesions that may contribute to the problem.

I am glad that you are not pushing into pain by running now. It is essential to listen to your body and not exacerbate the existing problem. While you are healing you can cross train with biking and swimming. If it does not calm down in a reasonable period of time, sometimes having it imaged either by plain x-ray, MRI, or ideally ultrasound may be helpful. Radiographic visualization can provide a more precise diagnosis and help target additional treatment. Many people benefit from either blind or ultrasound-guided injection. There are a variety of different substances that can be injected including corticosteroids and newer biologic agents.

It is important to figure out how you developed GTPS so you can avoid it recurring. Remember that injury occurs from an imbalance of cumulative load applied and how your body handles the load. You may benefit from a running gait analysis once you are able to run symptom free. You can prevent future recurrence by being judicious with increasing your training load as you progress back to full activity while simultaneously continuing to work on how your body handles those loads via stability work. 

Good luck! 

Andrew Getzin, MD
Team Physician USA Triathlon
All-American USA Triathlon
USA Level 1 Triathlon Coach
www.cayugamed.org/sportsmedicine 

References:

1. Bird, Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arth Rheum 2001,44,2138-2145
2. Mallow, Greater trochanteric pain syndrome diagnosis and treatment. Phys Med Rehab Clin N Am 2014,25,279-289

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date: October 21, 2014