Chronic Hip Pain
Pain can irradiate up to the groin. In sportsmen the iliopsoas muscle and tendon are commonly responsible for many cases of groin pain. The ileopsoas is an internal muscle of the hip that flexes, abducts and externally rotates the head of femur. It originates from the lateral facets of the first four lumbar vertebrae and from the iliac joint, and inserts on the lesser trochanter of the femur. This is a bilater postural muscle which is typically under greater tension amongst individuals with accentuated lumbar lordosis.The diagnosis is usually clinical, and is based on muscular tests to determine resistance and palpation. Sometimes, additional examinations are required to exclude a possible muscular injury (MRI scan) or the involvement of the coxo-femural articulation (X-ray). Treatment is universally conservative and it is based on specific myofascial massage in addition to relaxing muscle massage on the other muscular districts that are usually involved, postural and stretching exercises, selective tonification of the psoas and synergistic muscles.
It is also very important to integrate therapies in the gym with a vertebral manipulation that can address possible failures in the articulation of the pelvis.
One or more of the following symptoms may be experienced:
Pain and swelling occurring over the side of the hip
Referred pain that travels down the outside thigh and may continue down to the knee
Pain when sleeping on your side; especially the affected hip
Pain upon getting up from a deep chair or after prolonged sitting (eg. in a car)
Pain when climbing stairs
Pain in sitting with the legs crossed
Increased pain when walking, cycling or standing for long periods of timeWhat Causes Trochanteric Bursitis?
The trochanteric bursa may be inflamed by a group of muscles or tendons rubbing over the bursa and causing friction against the thigh bone. This injury can occur traumatically from a fall or a sport-related impact contusion.
It can also be a case of gradual onset via a repetitive trauma to the bursa from such activities as running (with poor muscles control or technique), walking into fatigue, or cycling, especially when the bicycle seat is too high.
It is also a secondary injury associated with chronic conditions such as:
Scoliosis – curvature of the spine
Unequal leg length
Weak hip muscles
Osteoarthritis (degenerative joint disease) of the hips or lower back
Calcium deposition in the gluteal tendons that run over the bursa
Rheumatoid arthritis.How is Trochanteric Bursitis Diagnosed?
Your physiotherapist will provide you with an assessment of your medical history and a physical examination of your hip, pelvis and back. A hallmark sign is if you feel tenderness over the bursa or greater trochanter (hip bone) when pressure is applied.
Diagnosis can also be confirmed by medical imaging techniques that include ultrasound scan & MRI.What is Trochanteric Bursitis Treatment?
•Bursitis is an inflammed bursa. Daily application of ice packs is highly recommended to reduce your pain and swelling.
•NSAIDs or anti-inflammatory drugs (i.e. ibuprofen). Use of these medications should be discussed with your doctor.
•Single injection of a corticosteroid with a local anaesthetic into the bursa may be required to stimulate your healing response. It is preferable to have this injection using ultrasound guidance.
Trochanteric Bursitis Treatment
PHASE I – Pain Relief & Protection
Managing your pain. Pain is the main reason that you seek treatment for trochanteric bursitis. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.
Managing your inflammation. Bursa inflammation it best eased via ice therapy and techniques or exercises that deload the inflammed structures.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include: ice, electrotherapy, acupuncture, deloading taping techniques, soft tissue massage and temporary use of a mobility aid (eg cane or crutch) to off-load the affected side.
PHASE II – Restoring Normal ROM, Strength
As your pain and inflammation settles, your physiotherapist will turn their attention to restoring your normal hip joint range of motion, muscle length and resting tension, muscle strength and endurance, proprioception, balance and gait (walking pattern).
Hip researchers have discovered the importance of your hip muscle recruitment patterns with a normal order of: deep, then intermediate and finally superficial muscle firing patterns in normal pain-free hips. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.
PHASE III – Restoring Full Function
The final stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their hips that will determine what specific treatment goals you need to achieve. For some it be simply to walk around the block. Others may wish to run a marathon.
Your physiotherapist will tailor your hip rehabilitation to help you achieve your own functional goals.
PHASE IV - Preventing a Recurrence
Trochanteric bursitis does have a tendency to return. The main reason it is thought to recur is due to insufficient rehabilitation.
In addition to your muscle control, your physiotherapist will assess you hip biomechanics and start correcting any defects. It may be as simple as providing your will core abdominal exercises or some foot orthotics to address any biomechanical faults in the legs or feet. Your physiotherapist will guide you.
Fine tuning your hip stability and function by addressing any deficits in core strength and balance, learning self-management techniques and achieving the ultimate goal of safely returning to your previous sporting or leisure activities!
Trochanteric Bursitis Surgery
Surgery is not a common path. However, in persistent cases, arthroscopic removal of the bursa; a bursectomy, can be performed.
How Can You Prevent Trochanteric Bursitis?
Muscle weakness or fatigue is a major cause of trochanteric bursitis. So addressing your strength and endurance is necessary to avoid a recurrence.
Wearing adequate footwear which supports any biomechanical imbalances in your feet is a key preventative measure.
Successful weight management, minimises excess stress on the hip joints which can alleviate pressure on the bursa. If you need advice regarding your weight-loss please discuss with your doctor or dietitian.
What Results Can You Expect for Trochanteric Bursitis?
While some people can respond quickly to physiotherapy treatment within a few weeks, more chronic cases where a tendinopathy exists in the gluteal muscle group under the bursa can require a few months to achieve recovery.
Trochanteric bursitis is successfully managed in the vast majority over a period of approximately six week. It is important to not stop your rehabilitation exercises as soon as you pain abates.
Excellent hip muscle control is your best rehabilitation and prevention strategy. Please follow the advice of your physiotherapist or doctor. Physiotherapists at CARE Institute/Sabga Physiotherapy can get your started on the right track to recovery! If you have any specific questions, please ask them.
The most common onset of gluteal tendinopathy is due to poor hip and gluteal muscle control that leads to overstressing of the gluteal tendons, causing pain and hip-pelvis instability.
Continued hip instability can cause you to walk or run with poor control, which causes you hip bursa to become under friction load, leading to trochanteric bursitisWhat are the Symptoms of Gluteal Tendinopathy?
Gluteal tendinopathy usually causes lateral hip pain, muscular stiffness, and loss of strength in the hip muscles.
The pain may get worse when you use the tendon eg running or hopping.
You may have more hip pain and stiffness during the night or when you get up in the morning.
Pain is often worse when you lie on your affected hip.
The lateral hip may be tender, red, warm, or even swollen if there is inflammation of the hip bursa.
How is a Gluteal Tendinopathy Diagnosed?
In most cases, your doctor or physiotherapist will accurately suspect your gluteal tendinopathy diagnosis in their clinic.
If your symptoms are severe or you do not improve with early treatment, specific diagnostic tests may be requested, such as an ultrasound scan or MRI.Gluteal Tendinopathy Treatment
In most cases, you can start treating your hip tendon injury at home using a RICE regime.
Rest the painful area, and avoid any activity that makes the pain worse.
Apply ice or cold packs for 20 minutes at a time, as often as second hourly, for the first 72 hours. Keep using ice as long as it helps.
Do gentle hip range-of-motion exercises and stretching to prevent stiffness.
Have your your hip joint and muscle function assessed by your physiotherapist.
Undertake a “Hip Core Stabilisation Program”. This is vital to prevent a recurrence.
Visualise and retrain your hip muscle control.
Modify your return to sport under the advice of your physiotherapist.
Despite the common use of painkillers and anti-inflammatory medications the cause is related to hip control, so it is your control that should be retrained as a priority. Persisting tendon injuries are best managed by exercise under the guidance of your physiotherapist.
Should your tendinopathy be slow to improve you have the option of a steroid injection under ultrasound guidance. For the best long-term results, you should continue to strengthen your hip rather than rely solely of the steroid effects.
In severe cases, hip surgery may be required.How to Return to Sport after Gluteal Tendinopathy
As soon as you are cleared by your physiotherapist, you can return to your activity, but take it easy for a while.
Don’t start at the same level as before your injury. Build back to your previous level slowly, and stop if it hurts.
Warm up before you exercise.
After the activity, apply ice to prevent pain and swelling.
Continue your hip stabilisation exercises.
If these steps don’t help, you may require a re-visit to your physiotherapist.
It may take weeks or months to fully rehabilitate a gluteal tendinopathy.
Be patient, and stick with your treatment. If you start using the injured tendon too soon, it can lead to more damage and further time delays.
If you have any concerns please seek the advice of your physiotherapist.