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Greater
Trochanteric
Bursitis
Kathy Mulford
ABSTRACT
Greater trochanteric bursitis is a
common regional pain syndrome
which frequently simulates major
hip diseases and low back pain.
Symptoms include pain over the
lateral hip area with occasional
radiation of pain into the lateral
thigh. It is commonly seen between
the fourth and sixth decades of life
but can be seen in all age groups.
Treatment includes local glucocorticoid injections combined with
physical therapy and anti-inflammatory medication. Patient education is important in the success of
treatment. This article reviews the
anatomy, causes, symptoms, diagnosis, and treatment of greater
trochanteric bursitis.
Keywords: bursitis, glucocorticoid injections, hip, low back pain
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The Journal for Nurse Practitioners - JNP
G
reater trochanteric bursitis is a frequent but
overlooked clinical condition, mimicking major
hip diseases, low back pain, and nerve root pain associated with low back pain. The condition is characterized
by pain in the region of the greater trochanter, lateral
thigh, and buttocks. Because greater trochanteric bursitis is frequently misdiagnosed as other diseases, it is
important for practitioners to understand the causes,
symptoms, and treatment of this condition.
ANATOMY
Studies have shown that up to 21 bursae can be found in
the hip region.1 Four bursae surround the greater
trochanter; three are constant (two major and one minor).
The minor bursa is the gluteus minimus bursa, which lies
above and slightly anterior to the proximal superior surface of the greater trochanter.The two major bursae
include the subgluteus medius and the subgluteus maximus bursa.The gluteus medius is situated posterior and
superior to the proximal edge of the greater trochanter.
The subgluteus maximus is lateral to the greater
trochanter. It is almond shaped, 4 to 6 cm in length, and 2
to 4 cm in width (Figure 1).This bursa functions as a
gliding mechanism for the anterior portion of the gluteus
maximus as it passes over the greater trochanter to insert
into the iliotibial band. Any irritation to these bursae can
result in symptoms of greater trochanteric bursitis. It is
important to note that, in addition to constant bursae or
ones that a person is born with, bursae develop to cushion
areas of friction.These are called adventitious bursae.
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CAUSE
Greater trochanteric bursitis can be caused by trauma
(23%-44%),2 but more often it is associated with repetitive
microtrauma caused by active use of the muscles inserting
on the greater trochanter.This microtrauma results in
degenerative changes of tendons, muscles, or fibrous tissues.3 Predisposing factors associated with greater
trochanteric bursitis include alterations in the biomechanics of the lower extremities resulting from osteoarthritis of
the hip joint, degenerative disc disease of the lower spine,
and leg-length discrepancy. Other conditions are listed in
Table 1. Because no known definitive studies link cause
and effect in greater trochanteric bursitis and these conditions, one can only casually relate these conditions to
greater trochanteric bursitis.The incidence of greater
trochanteric bursitis is well documented with peaks
between the fourth and sixth decades of life, although it
has been reported in all age groups. Studies have also
shown a greater incidence in women than in men.4
SYMPTOMS
Greater trochanteric bursitis is characterized by intermittent pain over the lateral aspect of the hip. It is
usually aching in nature but can be intense. This pain
is usually chronic but may on occasion be acute or
subacute. The pain can radiate into the lower buttocks
and the lateral aspect of the thigh, but it rarely
extends into the posterior aspect of the thigh or
below the knee. Occasionally, patients experience
numbness in the upper thigh with no specific dermatomal pattern. Patients report pain from greater
trochanteric bursitis with a variety of activities or
movements. The most common trigger reported is
prolonged standing or lying on the affected side.5
Climbing stairs and running are also triggers. Any
movement of the affected hip can reproduce the pain
of greater trochanteric bursitis, but external rotation
and abduction of the hip are most common. Getting
in or out of a car and placing a foot on the opposite
knee (as if to tie one’s shoe) are examples of these
movements. Greater trochanteric bursitis can cause
varying degrees of disabilities. The most common disability is exercise limitations to include walking. It is
also associated with broken sleep patterns secondary
to the inability to lie on the affected side because of
pain. In addition, a large number of patients have
bilateral bursitis, further interrupting sleep patterns.
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Figure 1. Anatomy of the greater trochanteric bursa.
Photo credit: Michael Marion, MD.
Hip Bursitis
Hip Joint
Inflamed
Trochanteric
Bursa
Femur
Muscle
PHYSICAL EXAMINATION
Pinpoint tenderness over the greater trochanter area is
the hallmark physical finding in all symptomatic
patients. Tenderness may extend into the lower buttock and lateral thigh but not to a significant degree.
While the patient is standing, palpate the lateral hip
area in a cephalic direction beginning below the
greater trochanter eminence until the area of maximal
tenderness is identified. This technique may also be
done with the patient lying down on the unaffected
side. Pain can also be reproduced by resisted abduction and external rotation. To perform resisted abduction, place the patient in a sitting position with knees
flexed. The examiner places his or her hand on the
lateral aspect of the upper thigh and instructs the
patient to move the thigh laterally against the resistance. External rotation of the hip is obtained by placing the patient in a sitting position with the knees
flexed and adducting the lower leg (shin). Pain on
flexion and extension of the hip is indicative of intraarticular hip disease and not usually greater
trochanteric bursitis. Objective swelling is rare because
of the bulky muscles overlying the deep structures of
the trochanter bursa. Other physical findings such as
limited lumbar range of motion and muscle atrophy
may reveal other associated conditions such as lumbar
spondylosis and nerve root compression. In severe
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329
Table 1. Conditions Associated With
Trochanteric Bursitis1
Ipsilateral or contralateral hip arthritis
Degenerative arthritis of the lower lumbar spine
Degenerative disc disease of the lower lumbar spine
Degenerative joint disease of the knees
Chronic mechanical low back pain
Leg-length discrepancy
Residual weakness of hip or thigh muscles after a hip or
disc operation
Inflammatory arthritis of the hip
Obesity
Fibromyalgia
Iliotibial band syndrome
Total hip arthroplasty
Pes planus
Tendonitis of the external rotators of the hip
cases of bursitis the presence of soft tissue crepitus can
be found.
DIAGNOSTIC STUDIES
X-rays of the hip, pelvis, and lower spine may show
evidence of one or more of the associated musculoskeletal conditions; however, there are no definitive
x-ray findings of greater trochanteric bursitis. On occasion, calcifications around the greater trochanter may
be seen (approximately 40% of patients with greater
trochanteric bursitis).6 These calcifications vary in size
and shape from a few millimeters to 3 to 4 cm in
diameter. They appear as linear or small, rounded masses that are separated or grouped together. Irregularities
can also be seen on the surface of the greater
trochanter. Bone scans may show increased uptake in
the area of the greater trochanter, and magnetic resonance imaging scans or sonography may show a highintensity signal in the greater trochanter area, but all of
these findings may not always have actual clinical significance and vice versa.7
DIAGNOSIS
Diagnosing greater trochanteric bursitis is based mainly
on clinical findings. A typical history of pain on ambulation and disruptive sleep because of the pain of lying on
the affected side associated with physical findings of ten330
The Journal for Nurse Practitioners - JNP
derness to palpation solidify the diagnosis. Associated
conditions such as lumbar spondylosis and degenerative
disc disease or degenerative joint disease of the hip must
be differentiated and treated accordingly.
CLINICAL SCENARIO
A 65-year-old woman comes to the office complaining
of right-sided buttock and hip pain. She reports that
her symptoms began a little over 3 weeks ago and have
gradually worsened. The symptoms are aggravated by
walking, going up stairs, and lying on the affected side.
She also reports extreme tenderness to touch over the
outside of her hip area and pain with movement of her
hip joint. She denies any trauma, fever, or chills. She
denies groin pain; however, she does report occasional
lateral thigh pain.
She has used heat to the area and Aleve occasionally
with no relief. She is worried about arthritis of the hip
and fears needing a hip replacement.
Past medical history is positive for lumbar degenerative disc disease, acid reflux, and high cholesterol.
Past surgical history and family history are noncontributory.
Social history: Patient is a widow, lives alone in a
two-story house, and works as a legal secretary. She is a
nonsmoker and is very active in her community doing
volunteer work.
Physical examination finds a well-developed, wellnourished, woman in moderate distress. She has buttocks or hip pain when standing from a sitting position but walks with a normal gait. She has moderate
limited range of motion of the lumbar spine with
mild pain and limited hip abduction secondary to hip
pain. No erythema or edema is seen over the right
buttocks or hip area. Marked tenderness to palpation
is found over the right greater trochanteric area. She is
neurologically intact in the lower extremities.
Plain x-rays of the lumbar spine (three views:
anteroposterior [AP], lateral, and lateral standing) and
an AP of the pelvis were obtained. Findings include
moderate lumbar spondylosis with disc space narrowing at the L4 to S1 levels. No lumbar fractures or
spondylolisthesis is seen. AP of the pelvis shows no
fractures or dislocations. There is minimal degenerative
joint disease (DJD) of the hips bilaterally.
Diagnosis includes the following: (1) right-sided
greater trochanteric bursitis, (2) lumbar spondylosis L4 to
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S1, (3) degenerative disc disease L4 to S1, and (4) minimal bilateral DJD of the hips.
Even though this
patient obtained
excellent results with
her treatment for
greater trochanteric
bursitis, many
patients require
several months of
physical therapy and
anti-inflammatory
medications to obtain
such results.
Treatment includes the following: (1) greater
trochanteric bursa injection with lidocaine, Marcaine,
and triamcinolon (Kenalog); (2) ice to area (20 minutes
on and 20 minutes off) for 48 to 72 hours while
awake; (3) avoid strenuous activity and frequent stair
climbing; (4) Celebrex 200 mg every day with food;
(5) begin physical therapy 2 to 3 times a week for 4 to
6 weeks; (6) reevaluate at follow-up in 5 weeks; and
(7) provide education on diagnosis and prevention.
At the follow-up visit 5 weeks later, the patient
reports marked reduction in right-sided hip pain. She
continues physical therapy twice a week and has begun a
home exercise program. She recognizes the importance
of daily stretching and the avoidance of repetitive bending and twisting.
Even though this patient obtained excellent results with
her treatment for greater trochanteric bursitis, many patients
require several months of physical therapy and anti-inflammatory medications to obtain such results. It is important to
educate the patient about the chronicity of this malady.
TREATMENT
Historically, greater trochanteric bursitis has been treated
both surgically (excising the bursal sac and the accompanywww.npjournal.org
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The Journal for Nurse Practitioners - JNP
331
ing calcifications) and nonsurgically (rest, physical therapy,
nonsteroidal anti-inflammatory medication, and cortisone
injections) with varying results. Studies looking at the success of glucocorticoid injections showed response rates
ranging from 60% to 100% after one or more injections.1
Current treatment consists of activity modifications; physical therapy modalities, including ice, heat, and diathermy;
nonsteroidal anti-inflammatory medications; and glucocorticoid injections. Most patients are initially treated with
physical therapy, activity modifications, and anti-inflammatory medication. Because greater trochanteric bursitis can
take 2 to 3 months if not longer to resolve, it is important
to educate the patient about this time line. If these treatments are ineffective in resolving symptoms, the use of glucocorticoid injections is considered.
In my current practice when an injection is indicated, the point of maximum tenderness is identified and
5 mL 1% lidocaine and 5 mL 0.25% Marcaine are infiltrated widely around the area and as deep as the surface
of the bursa. This injection is followed by a combination of 40 mg triamcinolone, 7 mL 0.25% Marcaine,
and 2 mL 1% lidocaine. Half of this injection is placed
at the point of maximal tenderness, and the rest is peppered in the area surrounding the bursa. A 22-gauge
3.5-inch spinal needle is used. Complications are rare
but can include sterile abscess, granulomatous reaction,
soft tissue and nerve injury, and skin atrophy especially
in repeated injections. My practice does not advise
more that two or three injections in one bursa in a 12month period. It is also our practice to continue physical therapy, anti-inflammatory medication, and activity
modifications after injections.
Educating the patient about length of time for recovery
and the importance of continued treatment after injections
is imperative for success in relieving the symptoms. It is also
important to educate the patient about the triggers that can
cause future flares and how to prevent them.
to treatment, it is important for health care providers to
include this diagnosis in their differential when evaluating hip pain.
References
1. Shbeeb MI, Matteson EL. Greater trochanteric bursitis (greater trochanter
pain syndrome). Mayo Clin Proc. 1996;71(6):565-569.
2. Gordon EJ. Trochanteric bursitis and tendonitis. Clin Orthop. 1961; 20:193-202.
3. Raman D, Haslock I. Trochanteric bursitis—a frequent cause of “hip” pain in
rheumatoid arthritis. Ann Rheum Dis. 1982;41(6):602-603.
4. Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical
problem. Arch Phys Med Rehabil. 1986;67(11):815-817.
5. Caruso FA, Toney MA. Trochanteric bursitis. A case report of plain film,
scintigraphic, and MRI correlation. Clin Nucl Med. 1994;19(5):393-395.
6. Sayegh F, Potoupnis M, Kapetanos G. Greater trochanter bursitis pain
syndrome in females with chronic low back pain and sciatica. Acta Orthop
Belg. 2004;70(5):423-428.
7. Finlay K, Friedman L. Ultrasonography of the lower extremity. Orthop Clin
North Am. 2006;37(3):245-275.
8. Alvarez-Nemegyei J, Canoso JJ. Evidence based soft tissue rheumatology,
III: trochanteric bursitis. J Clin Rheumatol. 2004;10(3):123-124.
Kathy Mulford, MS, CRNP, is an adult nurse practitioner
in orthopedics and spine disorders with Orthopeadic
Associates, Inc, in Towson, Maryland. She has no relationships with business or industry and can be reached at
[email protected].
1555-4155/07/$ see front matter
© 2007 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2007.03.001
CONCLUSION
Hip pain is a common complaint that brings patients to
health care providers, including both primary care and
specialty providers. Causes of hip pain often are attributed to disorders in the lower back or hip joint. Greater
trochanteric bursitis is often underdiagnosed as a cause of
hip pain despite its characteristic symptoms of diffuse
pain in the buttocks and lateral thigh. Because greater
trochanteric bursitis is so common and fairly responsive
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The Journal for Nurse Practitioners - JNP
May 2007