Trochanteritis is a painful condition in which the athlete (but not exclusively) feels pain on the outer surface of his hip. It usually affects runners and athletes involved in sports such as football. It is more common in women (due to the construction of their pelvis. The pelvis in women is wider than in men) and in middle-aged or elderly people (and especially those who have undergone a hip surgery). It is essentially an inflammatory condition of the bursa (a sac with gelatinous content) over the major trochanter. First of all, the term “trochanteritis” is not correct. The term trochanteritis has prevailed over time and the correct term is “inflammation of the major trochanter or trochanteric bursitis”, although it accurately describes the pathological anatomical background of this disease. However, for convenience reasons, we use the term trochanteritis.
“Trochanteritis” means inflammation of the trochanter (i.e. the upper end of the femur). In fact, it is not a bone inflammation, but an inflammation of the bursa that normally surrounds it, which is why inflammation of the major trochanter is internationally called “trochanteric bursitis“.
Anatomy
Inflammation of the trochanteric bursa is one of the most common causes of pain in the hip area. However, in order to understand how this excruciatingly painful, chronic condition is created, we need to know some anatomical elements.
The major trochanter is a bone protrusion of the femur on the outer surface of the hip. On the surface of the trochanter there is a bursa (a small sac), filled with fluid that acts as a pillow and allows smooth movement, reducing friction between the muscles and the bone. The major trochanter is the area that the muscles attach to and are responsible for the outward flexion and abduction of the lower limb at the hip joint. The minor trochanter is the point at which the major hip flexor, the iliopsoas, is attached.
There are about 18 bursas in the hip area. One of these sacs (deep trochanteric or gluteus medius bursa) lies between the gluteus medius tendon and the postero-lateral surface of the major trochanter. This bursa is a frequent source of pain and inflammation in the hip area.
Causes
In trochanteritis, the clinical picture is due to the mobility of the gluteal tendon and the tensor fascia lata over the outer part of the femur. As a protective reaction, the bursa is filled with more fluid to prevent tendon friction on the bony protrusion of the major trochanter. This results in the appearance of pain on the outer hip surface. Repeated hip flexion and direct pressure exacerbate symptoms. But what will lead to increased hip mobility and therefore to the development of trochanteritis?
Because, admittedly, increased mobility in the hip area is not common!!! The secret is in the alignment of the pelvis and lower limb. In people whose alignment is lost, it is them who will eventually develop trochanteritis.
The most common pathological conditions that can lead to loss of alignment of the pelvis with the lower extremity, and therefore potentially to trochanteritis, are primarily muscle weaknesses of the torso-stabilizing muscles, weak muscles of the lower limb as well as stiffness of the same muscles. Other causes that disrupt the pelvic – limb alignment are lumbar spine disorders, leg length discrepancy, sacroiliac joint diseases, knee arthritis, disorders of the ankle joint and generally any condition that changes the patient’s gait.
Conditions that predispose to the onset of trochanteritis are:
- Repeated strain or injury to the hip joint that can be caused by running (running and trochanteritis), stair climbing, cycling (bicycle and trochanteritis) and standing for long periods.
- Injury to the hip by falling on it, direct blow on the hip area or lying down for a long time on the same side of the body.
- Poor posture that can be due to scoliosis, lumbar spine arthritis and other spinal disorders (poor posture and trochanteritis).
- Any lower limb irregularities (leg length discrepancy and trochanteritis).
- Pathological conditions such as rheumatoid arthritis, gout and psoriasis.
- Surgery in the hip area (osteosynthesis of hip fractures or hip arthroplasty).
- The presence of osteophytes or calcium deposits in tendons that adhere to the major trochanter.
The patients typically complain of pain on the lateral surface of the hip, over the outer side of the thigh or difficulty in walking. This pain usually worsens with the direct pressure on the affected area and may be reflected more peripherally (as in the knee). Patients often rub their thighs when describing the painful symptoms.
Depending on the degree of inflammation and edema, pressure sensitivity in the early stages is limited around the trochanter, but in advanced cases it spreads to the entire thigh area. Initially, there is mild morning pain and stiffness, but as time goes on the pain becomes intense and excruciating. It is usually more pronounced in the evening when the patient is lying down on the affected side, when he / she gets up from the chair after sitting for a while, after walking and climbing stairs.
For athletes, and especially runners, trochanteritis is a condition that hinders the athlete’s progress and greatly affects both their training and performance. Rarely do runners report direct injury on the affected area. This is for sports that involve contacts and falls (football, basketball). A runner who abruptly increases volume (km/week) or training intensity can injure the trochanter area. Runners who follow the same trails for training purposes (e.g. mountain training) or keep running on the same side of the street also burden their hip joints. The outer lower extremity is always burdened. Initially the pain occurs at an advanced stage during the run (after covering the half of a long-distance race) or near the end of the race. After some hours the pain is gone. As trochanteritis is not treated, its symptoms become more and more frequent. The athlete ultimately feels constant pain and is unable to start running, aching daily even during rest periods.
Diagnosis
The diagnosis will be based on medical history and clinical examination. Imaging examinations, such as X-rays, bone scintigraphy, and magnetic resonance imaging may be requested by the orthopedist to rule out the possibility of an injury or other medical condition with the same clinical picture.
A simple X-ray is necessary in patients with recurrent episodes of trochanteritis (calcium deposits into bursa- as shown in the figure) or in patients with orthopedic implants to rule out other pathological conditions.
An ultrasound is an easy and dynamic imaging test to detect the presence of excess fluid in the synovial sac of the trochanter. In Patra’s Orthopedic Clinic, ultrasound is used both in the diagnosis and in any therapeutic infusion of preparations to treat trochanteritis.
Treatment
Treatment of trochanteritis is generally conservative. The first step, of course, is to diagnose it.
The next is the implementation of a series of measures aimed at mitigating discomfort and reducing inflammation.
As already mentioned, bursitis of the major trochanter is the result of overloading of the area; therefore, it is classified as an overuse syndrome (overuse syndrome – trochanteritis). The goals of treatment are firstly to relieve the patient’s pain and then a physiotherapy program to prevent relapse.
Limitation of activity: The patient’s activities that irritate the area should be slightly limited (walking, exercising or lying down on the painful area). Sometimes, in severe symptomatology, the use of a walking cane or crutches is necessary. Swimming exercises are useful when athletes develop trochanteritis and do not want to ruin their fitness program.
Ice therapy: it is necessary in the acute phase and should be repeated every 2 to 3 hours a day for approximately 20 minutes. In chronic situations, alternating hot to cold pads works best.
Oral Anti-Inflammatory Treatment: During the acute phase, anti-inflammatory drugs should be administered for a period of 5-7 days in order to reduce pain and improve the patient’s mobility.
Topical Corticosteroid Infusion in Trochanteritis: Topical cortisone injections with anesthetic (lidocaine) are effective in trochanteritis (cortisone in trochanteritis). The injections are usually performed without radioscopic guidance, but with the assistance of the ultrasound for greater accuracy and less injury to other structures.
Conditions where ultrasound guidance is necessary for injections are:
- Obesity
- Repeated injections
- Chronic inflammation
- Medical history of previous surgery
- Chronic pain with peripheral sensitivity; in these cases, the injection can be performed in the area of sensitivity and not in the area of pain.
If the pain subsides for more than 50%, a second injection of cortisone is repeated after 2 weeks.
Physiotherapy in trochanteritis: In cases where trochanteritis has developed into a chronic condition, physiotherapy sessions (TENS, iontophoresis and ultrasound) have been proven to be particularly useful in treating it.
Physiotherapeutic Massage. This can be achieved with physiotherapy sessions. An alternative method to achieve a similar result at home is to use a foam roll or a bottle of soft drink in our refrigerator. We use it cool and roll it by applying pressure on the area of pain. In this way we can simulate a physiotherapeutic massage. This massage should be performed 3 times a day for 10-15 minutes each time.
Extracorporeal Shock Wave Therapy (ESWT): It is effective in trochanteric bursitis, especially in patients who have developed calcifications due to multiple relapses in the area.
Orthotic footwear application: This corrects the over-pronation of the foot and relieves the trochanters during running. The use of shoe inserts in trochanteritis is meant to help athletes who repeatedly use over-pronation of the foot. Therefore, an athlete should be carefully examined in order to identify the cause of the problem and to find an appropriate solution. Not all remedies are equally effective for all patients!!!!
Modification of footwear: In cases of leg length discrepancy, modifications of footwear may help in reducing the intensity of the discomfort.
Recommended exercise program in trochanteritis. After the symptoms have subsided to the point that the patient (athlete or not) can walk without pain, it is the ideal time to start an exercise program. The exercises aim to improve the flexibility of muscles and soft tissue and to strengthen the muscles of the affected hip area. This results in the muscular balance of the hip and gluteal muscles, which is necessary for normal joint movement.
Many patients suffering from major trochanteric bursitis present stiff hip joints and limited range of motion. This exercise attempts to increase flexibility and range of motion.
The purpose of the exercise is to release the iliotibial band and to stretch the tensor fascia lata.
Also the extension of any contracted muscles, such as gluteal muscles, the posterior femoral muscles, the quadriceps and the opiates, is also desirable. Finally, emphasis is placed on strengthening the hip abductors (especially the gluteus medius), the external rotors, the extensors, and the torso (abdominal and dorsal) muscles, in order to improve pelvic control and thereby improve gait, disorders that seem to play a decisive role in the onset of the disease. Such an exercise program will be provided to you by the Patra’s Orthopedic Clinic, which will be personalized based on the muscle imbalances resulting from a thorough physical examination, in which the muscle groups that exhibit increased stiffness will be defined. Implementing this exercise will provide healing, as well as prevention, so that the patient will not experience a similar episode.
Surgical treatment of trochanteritis is a solution in very few cases that do not respond to conservative treatment or in cases of frequent relapses (although personal experience has proven that the cause of trochanteritis has not been treated in these cases…). The procedure consists of linear release of the iliotibial band in combination with sub-gluteal bursectomy. Rarely, bursectomy and partial resection of the major trochanter may be performed. There is also arthroscopic treatment in which, through two small holes, the area is excised, the trochanter is removed, and, depending on the symptomatology, partial detachment of the abductor muscles or the vastus lateralis from the major trochanter is performed.
