Background and Etiology
The hip joint is one of the largest joints in the body. It is composed of one osseous (contains bone) joint. The hip is built for weight bearing and movement in several different planes. The stability of the hip joint comes from the capsule, ligaments, muscle and a cartilaginous tissue called the labrum. There are four bursae surrounding the hip joint. A bursa is a fluid filled sack that reduces friction between tendons, and between tendons and bone. The most commonly injured bursa is 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. This area bares the weight of the body when sitting.
- 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.
- 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 on the bursa from lying on that side.
- 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 of the structures of the hip like the psoas hip flexor, iliotibial band and hamstrings.
- Bursa can 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 bursa that may radiate down the outside of the thigh. The psoas bursa will produce groin pain while the ischial bursa may produce pain in the buttock area because this is where the body bares weight while in a sitting position.
- Loss of motion of the hip
- Pain with activities that stress the bursa like kneeling, jumping, running or activities that cause stress on the tendons that are lubricated by the bursa.
- Initial treatment of bursitis includes avoiding activities that produce pain or stress of the bursa and associated tendons (jumping, running, kneeling, etc.)
- The use of ice to reduce inflammation and pain.
- NSAIDS (non-steroidal anti-inflammatory drugs)
- Physical Therapy to reduce pain and inflammation, improve flexibility and strengthen the surrounding muscles of the hip.
- In severe cases the fluid in the bursa may need to be drained. Fluid can be checked for possible infection.
- Antibiotics if there is an infection of the bursa
- Surgery may be indicated in extreme cases if the problem becomes chronic.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals. Physical therapy for hip bursitis must remain conservative at the onset in order to not aggravate the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced a program of stretching and functional strengthening will be initiated to restore full motion, and improve strength to reduce imbalances and stress on the tendons and bursa of the hip joint.
Common Physical Therapy interventions in the treatment of Hip Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the knee. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including 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 bursa and tendons of the hip joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on bursa 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 bursa.
- A home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
- Avoiding the activities that produce the pain or stress the involved bursa is the first line of treatment.
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on the bursa.
- NSAIDS (non-steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Needle drainage to remove excessive fluid from the bursa
- Injection of steroids to reduce inflammation in bursa
- In the case of infection, antibiotics may be prescribed,
- In severe recurrent conditions surgery to remove the bursa may be indicated.
In general, patients respond well to conservative treatment of hip bursitis. It is important that once the pain and inflammation is reduced, and motion and strength are restored, that the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful to reduce the chance of a reoccurrence of the bursitis. In most cases full return to activity will take from 2-6 weeks depending on the severity of the condition. As a preventive measure individuals should:
- Make modifications in work or daily activities to avoid prolonged pressure or unexpected blows on the bursa.
- Maintain strength and flexibility to reduce stress on the bursa and tendons of the hip.
- Avoid highly repetitive activities whenever possible