A 67-year-old, slightly obese female was referred for poorly controlled hypertension and complaints of bilateral hip pain. Her pain worsens at night: It wakes her up when she rolls over on her hips. She also feels more pain when she is going up stairs.
Recently, she had difficulty bearing weight on her left hip. She has used a cane purchased at a yard sale for the past two and a half years. Daily ibuprofen provides her with little relief.
Physical Exam
On exam, we found that the patient had lateral thigh tenderness over the greater trochanter bilaterally and slight groin pain on internal/external rotation bilaterally. (See photos 1 and 2.)
We ordered an MRI because of concern that there might be a hip fracture. The results of the MRI indicate that both trochanteric bursae were inflamed and filled with fluid. The left bursa had much more fluid than the right. (See photo 3.)
Photo 1
Photo 2
Trochanteric Bursitis
We see trochanteric bursitis in runners and also after local trauma. This condition is most commonly found, however, in individuals with gait disturbances, such as those caused by a post-stroke condition, a discrepancy in leg length, pregnancy, medically complicated obesity, or improperly adjusted canes and walkers.
The pain caused by trochanteric bursitis may be severe and may radiate into the buttock or anterior thigh, mimicking fracture or radiculopathy.
The Trochanteric Bursae
There are three trochanteric bursae around the greater trochanter: two major and one minor. The minor bursa is the subgluteus minimus bursa, which is located above and slightly anterior to the proximal superior surface of the greater trochanter.
There are two major bursae. The subgluteus medius bursa can be found beneath the gluteus medius muscle, posterior and superior to the proximal edge of the greater trochanter. The subgluteus maximus bursa is lateral to the greater trochanter but separated from the trochanter by the gluteus medius muscle beneath the converging fibers of the tensor fascia lata and the gluteus maximus muscle and fascia as they join to form the iliotibial tract. Almond-shaped, 4 to 6 cm in length, and 2 to 4 cm in width, this bursa functions as a gliding mechanism for the anterior portion of the gluteus maximus tendon as it passes over the greater trochanter to insert into the iliotibial band. (See photo 4.)
Photo 3
Treatment
Although non-steroidal anti-inflammatory drugs (NSAIDs) provide relief to some patients, the elderly, who are most affected by trochanteric bursitis, frequently have contraindications to NSAID use. Local steroid injections provide durable relief for most patients. To limit recurrences, correct gait abnormalities and strengthen postural and hip muscles.
Trochanteric Bursitis Injection
To administer a trochanteric bursitis injection, first locate the subgluteus maximus bursa by palpating the greater trochanter. The bursa is located directly above the periosteum.
Next, identify an area of point tenderness. Instill a mixture of steroid and local anesthetic. The correct location will be confirmed by immediate pain relief; the steroid effect, however, may take up to week to provide pain relief. (See photo 5.)
Three-Month Follow-Up
The patient returned three months after her trochanateric bursae were injected with a depo-steroid preparation Today she no longer requires a cane. She is sleeping well and climbing stairs easily. Her blood pressure is well controlled, and she is on minimal medications after withdrawal of NSAIDs. She enjoys a renewed interest in German folk dancing.
Prevention
Prevention hinges on normalizing the gait abnormality that caused the bursal inflammation. That usually means strengthening the quadriceps—with or without a properly adjusted gait assist device such as a cane or an orthotic. (See photo 6.) TH