Summary of Condition
Trochanteric bursitis can arise from a variety of contributing factors. Some of these factors include: gluteus muscle pathologies, IT band pathology, lower limb postural abnormalities, repetitive activity patterns or obesity. Each patient case of this syndrome will be slightly different based on their presenting weaknesses, areas of tightness, altered activity patterns and behavior of pain. What is most important to keep in mind when treating a patient with trochanteric bursitis is to understand what is causing their pain syndrome. Then each patient's specific contributing factors can be appropriately addressed to reduce the associate signs, symptoms and disability of trochanteric bursitis. What a patient will experience when presenting with trochanteric bursitis is pain; usually pain with specific movements. There can also be associated muscle weakness in the hip or lower limb, loss of hip range of motion, possible swelling and a reduction in normal activity patterns.
Guide to PT Practice7
Preferred Practice Patterns:
4D: Impaired joint mobility, motor function, muscle performance and range of motion associated with connective tissue dysfunction.
4E: Impaired joint mobility, motor function, muscle performance and range of motion associated with localized inflammation.
Goals of Physical Therapy:
Patients should experience improvements in their presenting deficits in joint mobility, motor function, muscle performance and range of motion. These improvements should lead to more complete involvement in recreational, community, occupational and home activities.
Expected Number of Visits:
Patients should expect for treatment sessions in these practice patterns to last between 6 and 24 visits. Frequency of visits will vary, this clinical decision will be based on such factors as: clinical presentation, PT evaluation and patient goals.
Appropriate interventions will vary based on each patient's individual presentation of trochanteric bursitis. Not all of the suggested interventions may be utilized in each patient's care.
Some of the interventions chosen to treat trochanteric bursitis include: muscle performance training (strength/endurance/power), postural/body mechanics training, balance/agility training, flexibility exercises, gait training, massage, joint mobilizations, ADL training, prevention.
PT Treatment may also include the use of such modalities as: cryotherapy, hydrotherapy, ultrasound, electrical stimulation or thermotherapy.
Relieving Pain & Decreasing Swelling
There are several modality treatment options that can be utilized to reduce pain and swelling in a patient with trochanteric bursitis. Often times, when pain is the primary complaint, pain reduction can allow for other underlying contributors to be more effectively treated. Eliminating swelling from the affected hip can also allow further treatments to be more effective.
Ice and NSAIDs1
Two common treatments to initially reduce pain include the use of ice and non-steroidal anti-inflammatory drugs (NSAIDs). These both work to interrupt the inflammatory process that is active in the painful hip to begin reducing the patient’s amounts of pain and swelling.
Transcutaneous Electrical Nerve Stimulation (TENS)8
The following settings of TENS can help reduce pain and can be used as a patient controlled device to control chronic pain.
- Frequency: 60-120 Hz
- Pulse width/duration: 200 microsec
- Amplitude: patient controlled: should be strong and comfortable without causing muscle contraction or causing any pain
Many patients acquire trochanteric bursitis due to repetitive activities, such as hill running, walking/running on uneven surfaces or living with a leg length discrepancy. If this is a causative factor in a particular patient’s pain syndrome, then altering that activity pattern can take away the repetitive insult and begin to reduce ongoing pain and swelling. Shoe lifts, or other appropriate orthotics can help to address a leg length discrepancy. Training schedule modifications or rest periods can help athletes who train on uneven surfaces to break their cycle of pain and swelling.
Because trochanteric bursitis can be caused by altered biomechanics from a variety of sources, it is important to consider if muscular weakness is a factor contributing to a patient’s specific pain syndrome2. Not only should muscular strength be addressed, but also muscular endurance and power should be addressed as appropriate3.
Weakness or tendinopathy of the gluteus medius muscle has been shown to be associated with trochanteric bursitis4. This would be very important to address, especially if the patient’s activity patterns are also a contributing factor. This can be achieved be performing lateral straight leg raises from the standing or sidelying positions. Another useful strengthening exercise for weak hip musculature is the “clam-shell” exercise (seen to the right). This involves the patient in sidelying, with their knees bent and raising the top knee as if the legs are a clam shell. This would be particularly beneficial if external rotators are also weak.
Other muscles about the hip joint that may be weak and should be addressed in patient specific cases include: quadriceps, hip adductors, hip extensors, hamstrings and hip flexors. Each patient will have a unique syndrome surrounding their trochanteric bursitis and should be evaluated based on their signs, symptoms, lifestyle and activity patterns.
Improving Range of Motion
Similarly to muscular strength considerations, range of motion impairments may or may not present with each patient’s case of trochanteric bursitis. But it is important to address deficits in hip range of motion as they are applicable to each patient’s individual case of trochanteric bursitis2.
One aspect of range of motion that can be compromised in patients with trochanteric bursitis is tissue length. Commonly, patients will present with tightness in the hip flexor and quadriceps muscles as well as the IT band. Stretching these tissues is very beneficial for patients with trochanteric bursitis to improve biomechanics and movement patterns.
Stretching the hip flexors and quadriceps muscles can be done through a “runner’s lunge” stretch (seen to the left) or in the position of the Thomas test.
Stretching of the IT band can be done on a foam roller or with the crossed leg stretch (seen to the right).
Improving quality of functional activities is important in addressing all aspects of trochanteric bursitis. As mentioned before, activity modifications and relative rest may be important in the initial stages of treatment before those activities are properly trained and introduced again.
Gait training could be an important component of treatment of trochanteric bursitis. This may especially be applicable when patients have gluteus medius pathologies resulting in a Trendelenburg gait pattern, hip drop or altered lower limb posture.
An important component within gait and stair training is improving eccentric control and muscle endurance of the gluteus medius muscle. This can be functionally trained by doing lunges or step-downs/ups while in front of a full-length mirror. This way the patient is able to perform these functional strengthening activities while receiving visual feedback from the mirror. This feedback will encourage the patient to keep their hips level and learn to not let the hip drop while in single leg stance.
For patients who do have tendinopathy of the gluteus medius, it will be important to treat the damaged tissue within the principles of soft tissue healing4. For these patients, stretching, strengthening and functional activity retraining should be introduced gradually to avoid further tissue damage.
Patients who spend long periods of time on hills or embankments as part of their athletic training or occupation should take relative rest from these activities. They can be reintroduced at a gradual rate so that no pain or other symptoms are returning as a result of the newly introduced activity. This will help the patient return to their lifestyle activities safely while reducing the chances of recurrence of the trochanteric bursitis.
Home Exercise Program
As a home exercise program (HEP), patients should be instructed in four different activities to do on their own to enhance the treatment from their physical therapist. These should consist of two relevant strengthening and two relevant stretching exercises.
A sample HEP could look like this:
|Exercise||Description||Reps & Sets|
|Lateral Leg Raise||In sidelying: to strengthen hip abductors||3 sets of 15 reps|
|Clam Shells||In sidelying: to strengthen hip abductors and external rotators||3 sets of 15 reps|
|Runner's Lunge Strentch||In standing: to stretch hip flexors||2 holds of 30 sec (on each leg)|
|IT Band stretch||In standing (legs crossed): to stretch IT band||2 holds of 20 sec (on each leg)|
The use of modalities is widespread in the treatment of trochanteric bursitis5. Some of the more common methods include: ultrasound, electric stimulation and low-energy shock-wave therapy (SWT).
- Ultrasound (particularly pulsed ultrasound) is commonly used to decrease pain and reduce any associated muscle stiffness/spasm associated with trochanteric bursitis6. This would not be the best modality to choose in the acute phase, when a strong inflammatory response is already present in the patient’s limb. While the evidence supporting the use of ultrasound is extremely limited, it is still a treatment option and some of the pain relief experienced is from a placebo effect, but pain relief in general is psychologically beneficial for any patient.
- Electric stimulation is also a commonly used PT modality treatment for patients who have trochanteric bursitis. It is used to relieve pain and facilitate the treatment process when used in conjunction with other PT treatments. However, there is little evidence supporting the effective use of electric stimulation and the specific improvements it may provide for patients. TENS has been shown to help alleviate chronic pain in patients8, but this research makes a tenuous link to acute management of trochanteric bursitis.
- SWT has been shown to reduce measures of pain and disability in patients with trochanteric bursitis. Patients who received SWT also experienced successful return to sport and occupational activities. Long-term follow-ups comparing SWT to traditional conservative treatment show few differences, with most the of benefit of SWT in the first few months of treatment.
1. Butcher J, Salzman K, Lillegard W. Lower extremity bursitis. Am Fam Physician. 1996;53(7):2317-2324.
2. Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: A systematic review. Clin J Sport Med. 2011;21(5):447-453.
3. Bewyer D. Rationale for treatment of hip abductor pain syndrome. Iowa Orthop J. 2003;23:57-60.
4. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism. 2001;44(9):2138-2145.
5. Williams BS, Cohen SP. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-1670.
6. Gerber J, Herrin S. Conservative treatment of calcific trochanteric bursitis. J Manipulative Physiol. 1994;17(4):250-252.
7. Benz L, Biggs K, Bohmert J, Boyce D, Brody L, Fillyaw M et al. The Interactive Guide to Physical Therapy Practice. American Physical Therapy Association Website. 2003. Accessed March 10, 2012.
8. Bates JAV, Nathan PW. Transcutaneous electrical nerve stimulation for chronic pain. Anaesthesia. 1980;35(8):817-822.