HIP BURSITIS

Hip bursitis is a painful condition caused by inflammation of a bursa in the hip. Bursae are small, jelly-like fluid-filled sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They are positioned between bones and soft tissues, acting as gliding cushions to help reduce friction.

There are two major bursae in the hip that typically become irritated and inflamed. One bursa covers the outer bony prominence of the hip (femur) called the greater trochanter. Inflammation of this bursa is called trochanteric bursitis. Another bursa - the iliopsoas bursa - is located on the inside/anterior (groin side) of the hip. When this bursa becomes inflamed, the condition is also sometimes referred to as hip bursitis, but is more accurately titled as iliopsoas bursitis.

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Causes

Hip bursitis can affect anyone, but is more common in women and middle-aged or elderly people. It is less common in younger people and in men.

There are multiple risk factors that have been associated with the development of hip bursitis:

• Repetitive stress (overuse) injury - This can occur when running, stair climbing, bicycling, or standing for long periods of time.
• Hip injury - An injury to the point of your hip can occur when you fall onto your hip, bump your hip, or lie on one side of your body for an extended period of time.
• Spine disease - This includes scoliosis, arthritis of the lumbar (lower) spine, and other spine problems.
• Leg-length inequality - When one leg is significantly shorter than the other, it affects the way you walk, and can lead to irritation of a hip bursa.
• Rheumatoid arthritis - This makes the bursa more likely to become inflamed.
• Previous surgery - Surgery around the hip or prosthetic implants in the hip can irritate the bursa and cause bursitis.
• Bone spurs or calcium deposits - These can develop within the tendons that attach muscles to the trochanter. They can irritate the bursa and cause inflammation.
• Abductor tendon tears

Symptoms

The main symptom of trochanteric bursitis is pain at the outer side of the hip. The pain usually extends to the outside of the thigh area. In the early stages, the pain is usually described as sharp and intense. Later, the pain may become more of an ache and spread across a larger area of the hip. Typically, the pain is worse at night, when lying on the affected hip, and when getting up from a chair after being seated for a while. It also may get worse with prolonged walking, stair climbing, or squatting.  Pain can also radiate down the outer side of the thigh towards the knee.

Diagnosis

A physical examination will demonstrate looking tenderness in the area of the outer prominence of the hip, occasionally associated with swelling. Additional tests to assist in confirmation of the diagnosis, and to rule out other possible injuries or conditions, can include imaging studies, such as x-rays, bone scans, and magnetic resonance imaging (MRI), the later being more accurate than ultrasound and also better at delineating if abductor tendon tears are the initiating cause.

Conservative (Nonsurgical) Treatment

The initial treatment for hip bursitis does not involve surgery, with the goals focussed on resolving the inflammation and pain.  Many people with hip bursitis can experience relief with simple lifestyle changes, including:

• Activity modification - Avoid the activities that worsen symptoms.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) - Ibuprofen, Naproxen, Piroxicam, Celecoxib, and others, may relieve pain and control inflammation. 
• Assistive devices - Use of a walking cane or crutches for a week or more when needed.
• Physical therapy - Exercises may be advised to increase hip strength and flexibility. You may do these exercises on your own, or a physical therapist may teach you how to stretch your hip muscles and use other treatments such as rolling therapy (massage), ice, heat, or ultrasound.
• Steroid injection - Injection of a corticosteroid along with a local anesthetic may also be helpful in relieving symptoms of hip bursitis. This is a simple and effective treatment that can be done in the doctor's office. It involves a single injection into the bursa. The injection may provide temporary (months) or permanent relief. If pain and inflammation return, another injection or two, given a few months apart, may be needed. It is important to limit the number of injections, as prolonged corticosteroid injections may damage the surrounding tissues.

Steroid injection should be avoided in the presence of an abductor tendon tear as it may interfere with subsequent surgery for repair.

Surgical Treatment

Surgery is rarely needed for hip bursitis. If the bursa remains inflamed and painful after all nonsurgical treatments have been tried, surgical removal of the bursa may be considered. Removal of the bursa does not hurt the hip, and the hip can function normally without it. This can be done as an open procedure or as an arthroscopic procedure, and A/Prof Woodgate will discuss the best option in each individual case.