ESTES PARK, COLO. – Trochanteric bursitis is an often overlooked cause of hip pain that’s sometimes so severe it can mimic a septic hip.
This overuse syndrome, common among weekend warriors, is also often mistaken for lumbar radiculopathy. The distinction is this: The pseudoradiculopathy of trochanteric bursitis doesn’t extend below the knee, while lumbar radiculopathy with sciatica typically goes past the knee laterally and runs down the leg, often as far as the foot, Dr. Robert W. Janson said at a conference on internal medicine sponsored by the University of Colorado.
Patients with trochanteric bursitis report pain over the trochanteric area and lateral thigh. This lateral hip pain is accentuated by walking, climbing stairs, or sitting in a deep chair. Patients report discomfort sleeping on the affected side. The range of motion in the hip joint is normal, but there is local point tenderness over the greater tuberosity that is exacerbated with external rotation of the hip and hip abduction against resistance.
"It just takes a second. Feel the greater tuberosity. You push in there, and they respond with the positive chandelier sign," the rheumatologist said, using a term for a pain response so sudden and electrifying that the patient figuratively rises up off the examination table and grabs for the ceiling lights.
The etiology of trochanteric bursitis is often a gait abnormality from a leg-length discrepancy. A difference of 2 cm or more is deemed clinically significant. The two static anatomic landmarks used in measuring leg-length discrepancy are the anterior superior iliac spine located right under the belt line and the medial malleolus.
"We’re concerned if the difference between the two legs is more than 2 cm. We typically work with a podiatrist to give the patient an insert or shoe lift. Remember, if you have a 2-cm leg-length discrepancy, you don’t replace all 2 cm. The podiatrist will start at one-eighth or one-quarter of an inch and work up as tolerated," according to Dr. Janson, chief of the rheumatology section at the Denver Veterans Affairs Medical Center.
Other common causes of trochanteric bursitis include osteoarthritis of the hip or lumbosacral spine, scoliosis, or a pathologically tight tensor fascia latae caused by running. This common running overuse injury entails tightness of the iliotibial band, with resultant inflammation of the bursa from repeated snapping of the shortened band over the greater tuberosity.
Treatment, beyond correction of any biomechanical causes, involves the usual general measures employed in overuse injuries: rest, with possible partial weight bearing; ice; full-anti-inflammatory-dose NSAIDs for at least several weeks; and physical therapy directed at stretching the gluteus medius and a possibly tight iliotibial band.
A local injection of 10-20 mg of long-acting methylprednisolone mixed with a few milliliters of lidocaine will bring much-appreciated symptomatic relief.
"The greater tuberosity is about the size of a silver dollar. When you inject the bursa, mark the greater tuberosity and go straight down the center as the patient lies laterally. A few seconds spent palpating that area and outlining the greater tuberosity can really be beneficial for your steroid injection," Dr. Janson commented.
Use a long needle, and bear in mind a time-honored rheumatologic pearl: "All injections in rheumatology should flow easily. If you find you’re against resistance, you’re in the wrong place," according to Dr. Janson.
He reported having no financial conflicts.