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Trochanteric Bursitis
Chapter 142
Trochanteric Bursitis
DEFINITION • Inflammation of the trochanteric bursa, which lies between the greater trochanter and the tendon of the gluteus medius muscle and the iliotibial tract. • Part of trochanteric pain syndrome, which includes bursitis, gluteal tendinopathy, and tendon tears.
SIGNS AND SYMPTOMS • Pain localized in the outer thigh that is made worse with any hip movement. • Pain may radiate to proximal femur. • Tenderness to palpation of the trochanteric bursa. • Warmth may be present. • Area over the trochanteric bursa may feel boggy or edematous. • Crepitus or catching sensation may be present. • Exacerbation of pain with resisted extension, abduction, and rotation of the hip. • Pain often worse at night. • Patient unable to sleep on the affected hip. • Gradual decrease in range of motion.
• Bursitis is identified as low-echo fluid on US or high–signal intensity (SI) fluid on T2-weighted with fat suppression (FST2W) MR images in the locations of known bursae. • Small amounts of fluid may be a normal finding in some individuals. • Peritendinous inflammatory change or tendon degeneration and tendon tears may be present when bursitis is associated with gluteal tendinopathy: • Tendon thickening. • Low-echo change on US. • Increased SI on FST2W MR images.
OTHER RECOMMENDED TESTING • Laboratory testing to rule out inflammatory arthritis. • Bursa aspiration with Gram staining and culture and sensitivity testing if infection in question. • Joint aspiration to rule out crystal arthropathies. • Joint aspiration to rule out infection if diagnosis in question.
DIFFERENTIAL DIAGNOSIS
• Incidence: Male = Female. • Young athletes often affected. • More common after trauma, including repetitive stress injuries. • Increased incidence with jogging on uneven or soft surfaces.
• Calcific tendinitis. • Avulsion fractures. • Osteoarthritis of the hip. • Inflammatory arthritis of the hip. • Neoplasm. • Labral tears of the hip. • Piriformis syndrome. • Sacral insufficiency fractures. • Septic arthritis of the hip.
IMAGING RECOMMENDATIONS
TREATMENT
• Radiography to detect underlying bone or joint disease. • US or MRI to assess the soft tissue structures. • US to guide injection therapy.
• Conservative treatment consisting of local heat, cold, simple analgesics, and nonsteroidal anti-inflammatory agents will improve symptoms in mild cases. • Physical therapy, including gentle stretching, rangeof-motion exercises, and deep heat modalities, may be beneficial in selected patients. • Injection with local anesthetic and steroid will provide symptomatic relief if conservative therapy fails or the pain is limiting activities of daily living. • Surgery may be required for persistent pain or progressive functional disability. 361
DEMOGRAPHICS
IMAGING FINDINGS • Radiographic findings are often normal: • Insertional bone formation may occur around the greater trochanter as a result of chronic insertional tendinopathy.
362
Part 3 • the extremities
in Gm
G me
d
ITB
*
*
* Greater trochanter
Figure 142.1 Diagrammatic representation of the various bursae (blue) around the greater trochanter. The trochanteric bursa lies deep to the iliotibial band (ITB) and superficial to the gluteus medius (G med) and gluteus minimus (G min) tendons. There is also a sub–gluteus medius bursa and a sub–gluteus minimus bursa. The minimus tendon inserts anteriorly, and the medius tendon more posteriorly, on the trochanter.
Figure 142.2 Coronal FST2W MR image of a patient with lateral hip pain and trochanteric bursitis with high-SI fluid lying between the iliotibial tract (broken white arrows) and the gluteus minimus tendon (white arrows).
Figure 142.3 Axial US image of the hip in a patient with lateral hip pain. There is low-echo fluid within the sub–gluteus medius bursa (broken white arrow), which lies between the gluteus medius muscle and tendon (asterisks) and the posterolateral facet of the greater trochanter. The iliotibial band is superficial to the gluteus medius (white arrows).
Figure 142.4 Radiograph of the hip of a patient with calcific tendinitis due to hydroxyapatite crystal deposition; it can be identified as a focal area of calcification in the gluteal tendon superior to the greater trochanter. Radiographs obtained 6 months later showed that the calcification had spontaneously resolved.
Trochanteric Bursitis
A
363
B
Figure 142.5 (A), Coronal T1W MR image of an elderly woman with osteoporosis and lateral hip pain but no history of trauma. Previous radiographic findings had been normal. There is an insufficiency fracture through the base of the greater trochanter (white arrow). (B), The coronal FST2W MR image shows the extensive high-SI hematoma within the adjacent trochanteric bursa, with more generalized soft tissue edema. The fracture line is not well shown, but there is marrow edema in the proximal femur.
Trochanteric Bursitis
DEFINITION • Inflammation of the trochanteric bursa, which lies between the greater trochanter and the tendon of the gluteus medius muscle and the iliotibial tract. • Part of trochanteric pain syndrome, which includes bursitis, gluteal tendinopathy, and tendon tears.
SIGNS AND SYMPTOMS • Pain localized in the outer thigh that is made worse with any hip movement. • Pain may radiate to proximal femur. • Tenderness to palpation of the trochanteric bursa. • Warmth may be present. • Area over the trochanteric bursa may feel boggy or edematous. • Crepitus or catching sensation may be present. • Exacerbation of pain with resisted extension, abduction, and rotation of the hip. • Pain often worse at night. • Patient unable to sleep on the affected hip. • Gradual decrease in range of motion.
• Bursitis is identified as low-echo fluid on US or high–signal intensity (SI) fluid on T2-weighted with fat suppression (FST2W) MR images in the locations of known bursae. • Small amounts of fluid may be a normal finding in some individuals. • Peritendinous inflammatory change or tendon degeneration and tendon tears may be present when bursitis is associated with gluteal tendinopathy: • Tendon thickening. • Low-echo change on US. • Increased SI on FST2W MR images.
OTHER RECOMMENDED TESTING • Laboratory testing to rule out inflammatory arthritis. • Bursa aspiration with Gram staining and culture and sensitivity testing if infection in question. • Joint aspiration to rule out crystal arthropathies. • Joint aspiration to rule out infection if diagnosis in question.
DIFFERENTIAL DIAGNOSIS
• Incidence: Male = Female. • Young athletes often affected. • More common after trauma, including repetitive stress injuries. • Increased incidence with jogging on uneven or soft surfaces.
• Calcific tendinitis. • Avulsion fractures. • Osteoarthritis of the hip. • Inflammatory arthritis of the hip. • Neoplasm. • Labral tears of the hip. • Piriformis syndrome. • Sacral insufficiency fractures. • Septic arthritis of the hip.
IMAGING RECOMMENDATIONS
TREATMENT
• Radiography to detect underlying bone or joint disease. • US or MRI to assess the soft tissue structures. • US to guide injection therapy.
• Conservative treatment consisting of local heat, cold, simple analgesics, and nonsteroidal anti-inflammatory agents will improve symptoms in mild cases. • Physical therapy, including gentle stretching, rangeof-motion exercises, and deep heat modalities, may be beneficial in selected patients. • Injection with local anesthetic and steroid will provide symptomatic relief if conservative therapy fails or the pain is limiting activities of daily living. • Surgery may be required for persistent pain or progressive functional disability. 361
DEMOGRAPHICS
IMAGING FINDINGS • Radiographic findings are often normal: • Insertional bone formation may occur around the greater trochanter as a result of chronic insertional tendinopathy.
362
Part 3 • the extremities
in Gm
G me
d
ITB
*
*
* Greater trochanter
Figure 142.1 Diagrammatic representation of the various bursae (blue) around the greater trochanter. The trochanteric bursa lies deep to the iliotibial band (ITB) and superficial to the gluteus medius (G med) and gluteus minimus (G min) tendons. There is also a sub–gluteus medius bursa and a sub–gluteus minimus bursa. The minimus tendon inserts anteriorly, and the medius tendon more posteriorly, on the trochanter.
Figure 142.2 Coronal FST2W MR image of a patient with lateral hip pain and trochanteric bursitis with high-SI fluid lying between the iliotibial tract (broken white arrows) and the gluteus minimus tendon (white arrows).
Figure 142.3 Axial US image of the hip in a patient with lateral hip pain. There is low-echo fluid within the sub–gluteus medius bursa (broken white arrow), which lies between the gluteus medius muscle and tendon (asterisks) and the posterolateral facet of the greater trochanter. The iliotibial band is superficial to the gluteus medius (white arrows).
Figure 142.4 Radiograph of the hip of a patient with calcific tendinitis due to hydroxyapatite crystal deposition; it can be identified as a focal area of calcification in the gluteal tendon superior to the greater trochanter. Radiographs obtained 6 months later showed that the calcification had spontaneously resolved.
Trochanteric Bursitis
A
363
B
Figure 142.5 (A), Coronal T1W MR image of an elderly woman with osteoporosis and lateral hip pain but no history of trauma. Previous radiographic findings had been normal. There is an insufficiency fracture through the base of the greater trochanter (white arrow). (B), The coronal FST2W MR image shows the extensive high-SI hematoma within the adjacent trochanteric bursa, with more generalized soft tissue edema. The fracture line is not well shown, but there is marrow edema in the proximal femur.