Can lumbar spine disease cause greater trochanteric bursitis?

Can Greater Trochanteric Bursitis Be Caused by Lumbar Spine Disease?

Yes, lumbar spine disease can cause or contribute to greater trochanteric pain syndrome, and this association is clinically significant—patients with moderate to severe lumbar degenerative disease are the most likely to experience relapse after local injection therapy.

The Evidence for Lumbar Spine Association

The relationship between lumbar spine pathology and lateral hip pain is well-established in the literature:

• A direct correlation exists between lumbar degenerative disease, gluteus medius tendinopathy, and trochanteric bursitis 1
• Moderate to severe lumbar degenerative disease is the major predictor of treatment failure after trochanteric injection with local anesthetic and glucocorticoids—only 63% of patients responded to injection, with relapse strongly associated with spinal pathology 1
• Lumbar radiculopathy (particularly L2-L3 levels) and lumbar facet syndrome with referred pain to the lateral thigh are among the most common causes of "pseudotrochanteric bursitis"—pain that mimics true trochanteric pathology 2

Clinical Presentation Overlap

The diagnostic challenge stems from significant symptom overlap:

• Patients with greater trochanteric pain syndrome frequently present with chronic low back pain and sciatica, making differentiation difficult 3
• Pain radiates to the posterolateral thigh with paresthesias in the legs, mimicking nerve root compression 3
• Lateral hip pain is a common complaint in patients with a history of lower back pain from spinal disease 1

Diagnostic Approach

Initial Evaluation

• Obtain radiographs first to exclude arthritis, bone tumors, and other structural pathology 4, 5, 6
• Radiographs showing >2 mm surface irregularities of the greater trochanter suggest abductor tendon abnormalities (sensitivity 64%, specificity 26%, but PPV only 24.7%) 4, 5, 6

Advanced Imaging When Indicated

• MRI can assess peritrochanteric structures including gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 4, 6
• Ultrasound can detect trochanteric bursitis, though differentiation from gluteus medius tendinosis may be difficult as the two frequently coexist 4, 6
• Scintigraphy provides sensitive and specific diagnosis of gluteus medius tendinitis and trochanteric bursitis, and can identify lumbar degenerative disease 1

Diagnostic Injection

• Diagnostic injection with lidocaine alone or combined with corticosteroid can confirm the trochanteric bursa as the pain source 4, 6
• Ultrasound guidance improves injection accuracy 5
• Failure to respond to injection or early relapse strongly suggests lumbar spine pathology as the primary driver 1

Critical Clinical Pitfalls

The "True Bursitis" Myth

• Recent histopathologic studies show no acute or chronic inflammation in bursal specimens from patients with clinical trochanteric bursitis, challenging the traditional inflammatory model 7
• The pathology is more commonly gluteus medius or minimus tendinopathy rather than true bursal inflammation 8, 7

Misdiagnosis Risks

• In post-arthroplasty patients, extracapsular disease from adverse reactions to metal debris can be misinterpreted as trochanteric bursitis 4, 9
• Lumbar radiculopathy, facet syndrome, and entrapment neuropathies (subcostal, lateral cutaneous branches of iliohypogastric nerves) must be excluded 2

Treatment Implications

When Lumbar Pathology Is Present

• Patients with associated lumbar degenerative disease have significantly worse outcomes with isolated trochanteric injection 1
• Address the lumbar spine pathology concurrently—treating only the trochanteric region will likely result in treatment failure 1, 3

Conservative Management

• NSAIDs provide pain relief and anti-inflammatory effects 8
• Physical therapy with eccentric strengthening exercises, iliotibial band stretching, and hip abductor strengthening 6
• Activity modification to reduce pressure on the affected area 5

Injection Therapy

• Corticosteroid injection into the trochanteric bursa provides diagnostic information and therapeutic benefit, though pain relief may not persist long-term, especially with coexisting lumbar pathology 5, 6, 8
• Peritendinous injections are preferred over intratendinous injections to avoid tendon damage 6

Surgical Consideration

• Surgery should only be considered after 3-6 months of comprehensive conservative treatment failure 5, 6

Mechanistic Understanding

The proposed mechanism involves altered gait mechanics and compensatory muscle overload secondary to lumbar spine disease, leading to gluteus medius tendinopathy and secondary bursal irritation 1. This explains why isolated treatment of the trochanteric region fails when significant lumbar pathology persists.