Anatomy & Background
The hip is built for weight bearing and the ability to move in several different planes. A bursa is a fluid filled sack that reduces friction between tendons as well as friction between tendons and bone. There are four bursae surrounding the hip joint with the most commonly injured bursa being the trochanteric bursa. The four major bursae of the hip are:
- Trochanteric Bursa: located on the outside of the hip between the greater trochanter of the femur (leg bone) and the gluteal muscles.
- Ischial Bursa: located between the hamstring muscle and the ischial tuberosity of the pelvis in the buttock area.
- Iliopsoas Bursa: located in the groin area between the large psoas muscle and femur bone.
- Gluteal Medius Bursa: located between the gluteus medius muscle and the greater trochanter. It is near the trochanteric bursa.
Causes of Hip Bursitis
- A direct blow to the bursa from falling on the outside of the hip or on the buttocks, can produce inflammation and irritation.
- A fall onto the hip or bursa.
- Constant pressure from lying on the side of the bursa.
- Repeated stress or friction injury as the tendon rubs over the bursa during activity.
- Weakness of the muscles over the bursa.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the bursa.
- Tightness in the hip, specifically the psoas hip flexor, iliotibial band and hamstrings.
- The bursa may become swollen as a response to other hip conditions.
- Pain and tenderness over the location of the bursa (especially on the outside of the greater trochanter bursae which may radiate down the outside of the thigh. The psoas bursae will produce groin pain while the ischial bursa may produce pain in the buttock area).
- Pain during activities that stress the bursa or causes stress to the tendons that are lubricated by the bursa, like kneeling, jumping, and running.
- Swelling, accompanied by loss of motion of the hip.
Physical Therapy Intervenes
Physical therapy for hip bursitis must remain conservative at first to avoid further agitation. There should be a focus on rest, inflammation reduction and attempting to increase blood circulation to promote healing. Once inflammation is under control, a program of stretching and functional strengthening will begin, aiming to restore full motion, reduce imbalances by increasing strength and lowering the amount of stress on the tendons and bursae of the hip joint. Common physical therapy interventions in the treatment of Hip Bursitis include:
- Manual Therapeutic Technique (MTT) soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the knee as well as to modulate pain.
- Therapeutic Exercises (TE) stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee to support, stabilize and decrease the stresses placed on the burse and tendons of the hip joint.
- Neuromuscular Reeducation (NMR) aids by restoring stability and improving movement techniques and mechanics, such as kneeling, of the involved lower extremity to reduce stress on burase and tendons in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved bursae.
- A home program that includes strengthening, stretching and stabilization exercises to help the person perform daily tasks and advance to the next functional level.
The first line of treatment involves limiting the activities that produce pain or stress to the involved bursa. Further treatment methods include:
- RICE: (Rest, Ice, Compression, Elevation) to reduce the stress on the bursa.
- NSAIDS (non-steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Antibiotics may be necessary if bursitis is due to infection.
- Aspiration of the bursa fluid involving the fluid’s removal with a needle and syringe – often there is inadequate fluid accumulation for aspiration.
- Injection of steroids to reduce inflammation in bursa.
- Physical Therapy to reduce pain and inflammation, improve flexibility and strengthen the surrounding muscles of the hip.
- Patients often benefit by weight reduction, stretching exercises and wearing proper footwear for exercise activities.
- In the most extreme cases, surgery may be advised to remove the bursa.
A round of conservative treatment usually produces encouraging results for most patients suffering from hip bursitis. It is important to start curtailing pain and inflammation immediately so that motion and strength to the area may be restored. This will help the patient gradually return to performing daily activities and further instruction should be given to help the patient reduce the chance of a re-occurrence of the bursitis. Generally, most patients can return to full activity within 2 to 6 weeks depending on the severity of the condition. Some preventative measures patients can undertake to reduce re-occurrence are:
- Modifications to work or daily activities so as to avoid prolonged pressure or unexpected blows on the bursa.
- Maintaining a routine of strength and flexibility exercises to reduce stress on the bursa and tendons of the hip.
- Avoiding highly repetitive activities if possible.