Pain in the bum?

Invigorate Health and Performance, Hip Bursitis

Pain on the outside of your leg, hip pain lying on your side or trouble walking upstairs? You might have something called bursitis

Trochanteric bursitis is irritation of the bursa on the outside of the hip (called the greater trochanter). Bursae, are small, jelly-like sacs that are throughout the body, including; the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and which help cushion and reduce friction between these structures. Bursitis is irritation of the bursa. There are two major bursae in the hip that typically become irritated with one covering the bony point of the hip bone called the greater trochanter (see image below) which can lead to trochanteric bursitis.

Why don’t they just call it greater trochanter pain then?

Well, more recently they have been and have adopted a new term called Greater Trochanteric Pain Syndrome” (GTPS). Bursae are tough structures that take a lot of pressure to become irritated and only become painful after unnecessary friction and compression. Current research suggests that bursitis is almost always associated with gluteal tendinopathy and often associated with weakness of the gluteal muscles (muscles at your bottom). Gluteal tendinopathy occurs when there is degeneration of the gluteal tendons (tendons connect muscles to bones) which occur after constant overload to the muscle where it can no longer cope. Given bursitis and gluteal tendinopathy often includes pain and irritation at the bone, tendon (tendinopathy) and the bursa (bursitis), it has more recently been referred to under the umbrella term “Greater Trochanteric Pain Syndrome” (GTPS).

Typically, signs and of GTPS include:

  • Pain on the outside (lateral) of hip over at the greater trochanter
  • Pain may also refer to the thigh and knee
  • Pain when lying on the “bad side”
  • Pain that gets worse during activities such as getting up from a deep chair or getting out of a car
  • Pain with walking up stairs
  • Increased pain when walking, running or standing for long periods
  • Pain when sitting cross legged
  • Weakness of gluteal/bottom muscles

So how can you fix it?

Often people believe GTPS will “get better by itself” without treatment or commonly mistake exercise as “causing more pain” and that “more damage will be done”. I can assure you both statements are incorrect. From my experience, physiotherapy can make a huge difference by reducing symptoms and improving function through both exercise and hands on treatment.

Physiotherapy treatment should be considered when treating GTPS with particular focus on strengthening exercises, reducing load on the affected tissues and reducing compression to the area. Isomeric contractions are commonly used in early stages as it helps to provide immediate pain reduction. Essentially isometric contractions are achieved by when the muscle turns on but with a static hold (usually 5 sets of 5 reps with 45 seconds holds). Treatment of gluteal tendinopathy obtains best results when the muscle is loaded gradually through an isometric contraction followed by isotonic contractions (which I will explain below). Similarly, since trochanteric bursitis often goes hand in hand with gluteal tendinopathy, the treatment is similar to a tendinopathy and gradual loading of the muscle is also completed (i.e. isometric contractions followed by isotonic contractions).

Gradual loading of the tendon begins with isometric exercises (static muscle contraction – as I explained above), then progressively moves towards isotonic contractions where the muscle turns on and moves through range. A bit confused? Let me explain it with an example – think about when you do a bicep curl you move the weight from starting position to the end position – this is an isotonic contraction as you are moving through range). Specifically, the muscle of the hip that help move your leg away from your body (the gluteus medius and minimus) should be targeted due to weakness often occurring in these muscles with GTPS. Strengthening should not only include these muscles but also core muscles of the low back that help stabilise your back and pelvis, however each individual is unique and therefore a specific program should be designed for each individual by your physiotherapist.

Physiotherapy techniques such as dry needling, soft tissue massage and mobilisation can be applied to areas where there is stiffness and tightness (which many include the lower spine region, hip, knee and ankle, thereby improving mobility and correcting biomechanics to reduce pain at the lateral hip.

Education regarding limiting certain activities that aggravate your pain and postures should be advised by your physiotherapist such a sitting for long periods, particularly in a low chair, or propping on one hip while standing and crossing of legs, as these all-place additional stress and tension on the tendon and bursa, further irritating it.

What else can you do besides physiotherapy?

Anti-inflammatory medications are not as advantageous as once thought, however a trial of anti-inflammatories or simple pain relief like paracetamol may however be worthwhile initially or if the symptoms are bad. A corticosteroid injection, which is an anti-inflammatory steroid medication is effective in the short-term only (3 to 4 months) to relieve pain and can be offered by your doctor. Relief from a cortisone injection is usually highly effective but only temporary and multiple injections can cause more harm than good. There is some contention regarding how many times an injection can be repeated but generally it will be considered 2-3 times. Injections are not required in all cases but frequently patients will need and injection in addition to their physiotherapy program if their pain is not improving quickly.

Written by William Lewis (Physiotherapist)