Hip bursitis not improving

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Bursitis refers to inflammation of the small fluid-filled sacs that surround and cushion joints.

The hip, a relatively large joint, has a number of bursae that surround and cushion it.

Hip pain has a number of possible causes including bursitis, tendonitis, and arthritis. Referred pain from the low back can also be mistaken for hip pain.

The two most common forms of hip bursitis are trochanteric bursitis and iliopsoas bursitis. Trochanteric bursitis is felt laterally (on the outside of the hip) and is aggravated by weight-bearing as well as by pressure. Lying on the side of the painful bursa aggravates the pain.

Iliopsoas bursitis is felt over the groin and is aggravated by flexion (bending) of the hip.

Tendonitis affecting the tendons that insert along the inner and outer parts of the hip can also cause severe pain. These forms of tendonitis may be confused with bursitis.

Finally, arthritis affecting the hip joint generally causes severe groin pain. Pain in the buttock may also occur. This can be confusing because ischialgluteal bursitis may also cause buttock pain. Arthritis may masquerade as bursitis and tendonitis pain.

Treatment for hip bursitis will involve the use of anti-inflammatory medications, physical therapy, exercises, and injections of glucocorticoid. Therefore, in a situation where the bursitis pain is not improving after appropriate therapy, a search for other possible causes of the pain should be started. Make certain that a stress fracture, arthritis, or a labral tear is not present. Diagnostic testing including magnetic resonance imaging (MRI) should be considered.

Trochanteric bursitis of the hip is frequently the result of a tight iliotibial band (one of the major tendon groups on the outside of the hip)rubbing repeatedly over the greater trochanter and adjacent bursa of the hip.

Frequently, exercises aimed at improving flexibility, coupled with proper warmup and stretching before exercising, can alleviate the problem.

If the problem is resistant bursitis, then other treatment modalities that might work include yoga, prolotherapy, transcutaneous nerve stimulation, massage, and acupuncture.

Ultrasound-guided needle tenotomy with platelet-rich plasma is a minimally invasive procedure that often works remarkably well for resistant bursitis.

Bursectomy, a surgical procedure where the bursa is removed should be reserved as a last resort and only if the diagnosis is absolutely certain.

Another issue is misdiagnosis. Often, enthesopathy (tendonitis) involving the pyriformis insertion or obturator internus insertion can be mistaken for trochanteric bursitis. It's important to confirm the diagnosis using ultrasound.

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