Greater Trochanteric Bursitis: Clinical Presentation and Physical Examination
Greater trochanteric bursitis presents with chronic, intermittent aching pain over the lateral hip that is elicited by direct palpation over the greater trochanter, though this condition frequently coexists with gluteus medius/minimus tendinopathy and may be difficult to distinguish clinically. 1, 2
Typical Symptoms
- Lateral hip pain that is chronic and intermittent in nature, peaking in incidence between the fourth and sixth decades of life 3
- Pain is aggravated by activities involving repetitive loading of lateral hip structures 2
- Morning stiffness lasting more than 30 minutes in patients younger than 45 years is a red flag suggesting underlying axial spondyloarthropathy rather than isolated bursitis 1
- Symptoms can be debilitating and result in significant functional limitation 3
Physical Examination Findings
- Point tenderness to palpation directly over the greater trochanter is the hallmark examination finding 3, 4
- Pain does not involve the hip joint itself 5
- The examination should assess for abductor weakness, which suggests associated gluteus medius or minimus tendon pathology rather than isolated bursitis 6
- Evaluate for external coxa saltans (snapping hip), which can occur in the peritrochanteric space 4
Critical Diagnostic Considerations
Differentiation between true trochanteric bursitis and gluteus medius/minimus tendinopathy is difficult on clinical examination alone, as these conditions frequently coexist. 6, 1, 2, 7
Imaging Algorithm
- Obtain radiographs first to rule out other causes of hip pain, including osteoarthritis, fractures, or bone lesions 6, 1, 7
- Ultrasound can effectively detect trochanteric bursitis and evaluate gluteal tendons, though distinguishing bursitis from tendinosis remains challenging 6, 1, 7
- MRI provides comprehensive assessment of peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 6, 1, 7
Initial Management Approach
First-Line Conservative Treatment
- NSAIDs for pain relief and anti-inflammatory effects 1, 7
- Acetaminophen as first-line for mild-to-moderate pain, not exceeding 4 grams daily, particularly in patients with cardiovascular disease 1, 7
- Physical therapy focusing on eccentric strengthening of hip abductor muscles and stretching of the iliotibial band 1, 7
- Activity modification to reduce repetitive loading of the affected area 1, 7
- Land-based physical therapy is preferred over aquatic therapy 1, 7
Second-Line Treatment
- Ultrasound-guided corticosteroid injection into the trochanteric bursa provides both diagnostic information and therapeutic benefit 6, 1, 7
- Ultrasound guidance improves injection accuracy compared to landmark-based techniques 1, 7
Important Clinical Pitfalls
- In patients with hip prostheses, extracapsular disease from adverse reactions to metal debris can be misinterpreted as trochanteric bursitis 6, 7
- Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 7
- In patients younger than 45 years with morning stiffness exceeding 30 minutes, obtain MRI of the sacroiliac joints and refer to rheumatology to evaluate for axial spondyloarthropathy 1