How is hip bursitis diagnosed in a middle‑aged or older female with lateral hip pain worsened by walking, stair climbing, lying on the affected side, hip abduction, and a positive Ober’s test, without joint line tenderness or limited range of motion?

Diagnosis of Hip Bursitis (Greater Trochanteric Pain Syndrome)

Primary Diagnostic Approach

Hip bursitis—now more accurately termed Greater Trochanteric Pain Syndrome (GTPS)—is diagnosed clinically based on lateral hip pain with tenderness over the greater trochanter, worsened by lying on the affected side, walking, and stair climbing, in the absence of groin pain. 1

Key Clinical Features That Confirm the Diagnosis

• Lateral hip pain is the hallmark symptom that distinguishes GTPS from intra-articular hip pathology (which presents with anterior groin pain). 1
• Pain is aggravated by:
  • Lying on the affected side 2
  • Walking and stair climbing 2
  • Hip abduction against resistance 3
• Point tenderness directly over the greater trochanter on palpation is the most reliable clinical finding. 2, 3
• A positive Ober's test (indicating iliotibial band tightness) supports the diagnosis. 3

Critical Exclusions Required Before Confirming GTPS

You must exclude intra-articular hip pathology and lumbar spine disease before diagnosing GTPS. 4, 1

• Absence of groin pain helps rule out FAI syndrome and labral tears. 1
• A negative FADIR test (flexion-adduction-internal rotation) helps exclude intra-articular hip pathology, though its specificity is limited. 4, 1
• Normal hip range of motion (particularly internal rotation and flexion) argues against FAI syndrome. 5
• No joint line tenderness helps exclude osteoarthritis. 3
• Screen the lumbar spine to rule out L1-L3 radiculopathy, which can mimic lateral hip pain. 5

Imaging Strategy

Initial Imaging

Start with AP pelvis and lateral hip radiographs to exclude alternative diagnoses such as osteoarthritis, fractures, hip dysplasia, or stress fractures. 1

• Radiographs showing greater trochanter surface irregularities have poor diagnostic accuracy for GTPS (only 24.7% positive predictive value), so do not rely on plain films to confirm the diagnosis. 1
• Imaging findings must always be combined with clinical symptoms and signs; never diagnose based on imaging alone. 4

Advanced Imaging Indications

Order MRI of the hip without contrast if:

1. Trendelenburg gait is present (suggesting abductor tendon tear). 1
2. Symptoms are refractory to initial conservative treatment after 6-12 weeks. 1, 3

• MRI evaluates for gluteus medius and minimus tendon tears, which are present in the majority of patients with refractory lateral hip pain. 6
• Isolated trochanteric bursitis without tendon pathology is rare (only 2% of cases), so focus on identifying abductor tendon pathology as the primary pain generator. 6

Understanding the Pathophysiology: Why "Bursitis" Is a Misnomer

The term "trochanteric bursitis" is misleading because histological studies show no inflammatory changes in bursal tissue. 7

• Bursal samples from patients with clinical "trochanteric bursitis" demonstrate no acute or chronic inflammation on histology. 7
• The true pathology is usually gluteus medius/minimus tendinopathy or partial tears, not bursal inflammation. 6, 7
• Up to 25% of patients have secondary bursal fluid accumulation alongside tendon pathology, but the tendon damage is the primary problem. 6

Common Diagnostic Pitfalls to Avoid

• Do not dismiss lateral hip pain as "just bursitis" without excluding lumbar radiculopathy, which can present identically. 5
• Do not diagnose GTPS if groin pain is present—this suggests intra-articular pathology requiring different management. 1
• Do not order MRI initially—it is not required for diagnosis and should be reserved for refractory cases or when Trendelenburg gait suggests tendon rupture. 1, 3
• Incidental imaging findings (bursal fluid, tendon signal changes) are common in asymptomatic individuals, so clinical correlation is mandatory. 4, 1
• Multiple hip conditions can coexist (e.g., GTPS with mild FAI morphology), so evaluate the entire clinical picture. 4

Demographic Context

• GTPS peaks in the fourth to sixth decades of life and is more common in women (94% in some series). 2, 6
• Risk factors include leg-length discrepancy, obesity, and repetitive hip abduction activities. 3