Category Archives: Bursitis

What can be done about trochanteric bursitis

Bursae are small sacs that contain minute amounts of fluid. They are located around most joints and are responsible for cushioning. When they become inflamed, the condition is referred to as “bursitis.”

One of the most common causes of hip pain is trochanteric bursitis. It is an affliction of middle-aged to elderly people and tends to affect women more often than men. Patients are often overweight.

hip-painThe primary symptom is aching pain located on the side of the hip at an area called the “greater trochanter”. The pain sometimes radiates down the side of the thigh.

The pain is aggravated by walking, climbing stairs, and lying on the affected side. The pain tends to come on gradually and can become so severe the patient has difficulty walking. In some cases, trauma plays a role and can cause a more acute onset of pain.

On examination, there is tenderness located over the lateral hip. The pain elicited by examination can be excruciating. Having the patient lift their leg laterally (to the side) can also bring out the pain. There may be a noticeable limp.

The condition is almost always accompanied by tendinopathy, meaning the tendons overlying the bursa are diseased or damaged. The two tendons that are most often affected are the gluteus minimus and gluteus medius.

Some conditions can predispose to trochanteric bursitis. These include scoliosis as well as leg length differences.

The diagnosis is suspected clinically and can be confirmed by magnetic resonance imaging (MRI). Another condition that can mimic this problem is sciatica.

The treatment initially can be conservative with stretching of the gluteus medius and gluteus minimus tendons as well as the iliotibial band, a long ligament that stretches from the greater trochanter of the hip down to the knee. Non-steroidal-anti-inflammatory drugs (NSAIDS) can provide symptomatic relief as can ice packs or moist heat.

Patients who are overweight should be counseled regarding weight loss.

In stubborn cases, ultrasound guided injections of glucocorticoid (“cortisone”) may be useful. These injections should be used sparingly because they may cause more tendon degeneration.

Patients who continue to have symptoms will require a procedure called ultrasound-guided percutaneous needle tenotomy accompanied by platelet-rich plasma (PRP).

The theory here is that using a small gauge needle to poke holes in the area of degeneration will induce an acute inflammatory response. This causes the release of active growth and healing factors from the platelets in the platelet-rich plasma. This procedure will lead to healing of the diseased bursa and adjacent tendons.

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Iliopsoas bursitis… an underdiagnosed cause of hip pain

Bursitis is a term that describes inflammation of a bursa- the small sacks that surround joints.

One of the more common conditions that causes pain in the front of the hip is iliopsoas bursitis. This is particularly common in active people who exercise regularly.

The iliopsoas muscle originates from the inside of the pelvis as well as the lumbar spine. This muscle inserts onto a small bony ridge on the upper femur (upper leg bone).

The iliopsoas bursa is a small fluid filled sac that lies just behind the iliopsoas muscle and in front of the hip joint. Its purpose is to provide cushioning for the hip joint as well as to ensure proper gliding of the tendons adjacent to it.

As with many types of bursae, inflammation can affect the iliopsoas bursa. When this occurs, the patient will experience pain in the groin as well as the front of the thigh. The pain is aggravated by flexing (bending)  the hip. Activities such as walking, running, and climbing stairs can be painful.hip-flexor

Sometimes patients may hold their leg with the hip slightly bent and the foot turned out in order to minimize discomfort. Patients may also have a limp.

On examination, there is tenderness when pressure is placed directly over the front of the hip. In severe cases, the bursa may be swollen.

While overactivity or trauma may be the most common cause of this type of bursitis, arthritis can also lead to iliopsoas bursitis.

Between 15 to 20% of the time, the bursa communicates with the hip joint. In situations like this, it is sometimes difficult to differentiate whether the discomfort is coming from the bursa versus the joint.

The diagnosis is suspected by taking a careful history and doing a careful physical examination. The clinical impression can be confirmed by either magnetic resonance imaging or diagnostic ultrasound.

The treatment for this condition is usually conservative to start with. Non-steroidal anti-inflammatory drugs and physical therapy may be helpful.

Ice may also be palliative.

Aspiration of fluid from the bursa and simultaneous injection of  glucocorticoid using ultrasound guidance can be curative. On rare occasion, the bursitis may return. If the bursitis does recur, aspiration followed by needle fenestration and injection with platelet rich plasma (PRP) may be effective.

If the bursitis recurs repeatedly, surgery may be required.

For more information on bursitis and related disorders go to:

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Is it arthritis, tendonitis, or bursitis?

When a patient complains of pain in a joint, the arthritis specialist needs to figure out the exact location of the pain source.  Is it due to something happening within the joint itself or is it due to adjacent structures such as the bone, ligaments, tendon, or bursa. Another possibility is that the pain could be referred meaning that the site that is causing the pain is not where the pain is.

hip-painAn example of this latter situation is osteoarthritis of the hip that often causes pain in the knee.  Also, a pinched nerve in the low back can also cause pain in the leg.

Arthritis pain is often accompanied by stiffness in the joint, pain with use, reduced range of motion, and occasionally swelling due to inflammation or fluid accumulation. The joint can be stiff after inactivity.  For example, patients with osteoarthritis or rheumatoid arthritis will often get stiff if they sit for a long time.  They can then loosen up by moving around.

Patients with an arthritic condition involving a joint have the “quartet” of arthritis: swelling, heat, redness, and pain.knee-arthritis

The presence of fluid inside the joint (called an “effusion”) can help establish the diagnosis.

Bone pain is most often due to fracture but may also occur due to infection (this is called “osteomyelitis”), or irritation of the bone surface, the periosteum.  Periosteal problems can occur as a result of malignancy or conditions such as Paget’s disease of bone, an unusual metabolic disease that causes bone deformity as well as bone pain.

Patients with tendonitis or bursitis usually have localized pain. Pain is aggravated by activity and relieved by rest. Getting a detailed history can provide clues to recent overuse that could be the trigger for the problem. Knowledge of anatomy can often pinpoint the source.  Physical examination is critical because certain maneuvers can provoke or reproduce the pain thereby narrowing the diagnostic focus.rub-hands

With bursitis, if there is significant inflammation, there will be swelling as well as pain and redness localized to the affected bursa.

Sometimes, though, it is difficult to separate a tendon issue from a bursal issue because the structures lie in such close proximity.  Examples would be tendonitis/bursitis involving the shoulder or hip where this problem can be a difficult one to differentiate.  Occasionally both the tendons and bursae can be affected.

Ligament problems are almost always due to trauma and the history as well as physical examination can establish the diagnosis.  Confirmatory imaging studies such as magnetic resonance imaging and diagnostic ultrasound can be helpful here.

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