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Hip bursitis – Causes and treatment

Hip bursitis (medical name: trochanteric bursitis) is often confused with other conditions that also cause outer hip pain, and sometimes it occurs together with one of these conditions. In this article, I explain hip bursitis symptoms and causes as well as how to treat it, including massage and which exercises to avoid. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.


Learn what causes hip bursitis and how best to treat it.

In this article:

  1. What is a bursa and where does hip bursitis hurt?

  2. What is hip bursitis?

  3. How to diagnose hip bursitis

  4. Treatment for hip bursitis

  5. How we can help

We also made a video about this:



What is a bursa and where does hip bursitis hurt?


A bursa is a little fluid-filled sac, and you have them wherever a muscle or tendon is close to a bone. They sit between the muscle or tendon and the bone and in some cases between muscles, and their function is to prevent friction between these various body parts. It’s almost like those inflated marine fenders hanging over the side of a boat to protect it from contact with the dock or jetty.


There are at least 9 different hip bursae that can cause pain when you have trochanteric or hip bursitis.
Adapted from Williams, B. S. and S. P. Cohen (2009). "Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment." Anesthesia & Analgesia 108(5): 1662-1670.

There are plenty of bursae in the hip, because there are so many muscles in that area: the gluteus maximus, medius, and minimus, the piriformis muscle deep inside the hip, as well as quite a few smaller muscles. And these muscles are all attached to the hip bone or the top of the thigh bone with tendons.


Note that there are a total of nine hip bursae in the picture, and quite often it’s more than one bursa that’s causing the pain. This is why injections to relieve hip bursitis pain sometimes don’t work; they often inject the wrong bursa. (More about that later on.)


Interestingly, not everyone has exactly nine bursae – some people have fewer, and others have more.

The main pain your feel when you have hip bursitis is over the outside of the hip, but it can also refer down the lateral thigh.

The circled area in the picture above is where you typically experience hip bursitis pain.


What is hip bursitis?


Bursae have many nerve endings. So, when they become injured or irritated, it causes a lot of pain.


There are two main ways in which a hip bursa can get injured or an existing bursitis can be aggravated.


A sudden impact

This usually happens when you fall on your side, like when you fall off a bicycle or trip and fall. In this case, the pain usually sets in within a few hours to a day after the impact.


Excessive friction or compression

This is the more common cause of hip bursitis.


Yes, a bursa is there to reduce friction, but it can only sustain a certain amount of force. If, for some reason, the compression and friction are a lot more than it can handle, it will get painful and sometimes inflamed.


Note “sometimes” in the previous sentence. The research has shown that bursitis doesn't always go hand-in-hand with inflammation in the bursa. That is why anti-inflammatories don't always help.


Things that can cause excessive compression or friction:


Biomechanics

Think of the way catwalk models walk, with an excessive sideways tilting of the hips. There’s actually a name for it – the Trendelenburg Sign, and walking or running like this stretches the muscles, tendons, and IT band tightly over the outside of the hip bone, which increases pressure on the bursae.


Standing, walking, or running with excessive hip tilting can cause hip bursitis.
Standing, walking, or running with excessive hip tilting can cause hip bursitis.

Merely standing for a long time with your hips in this sideways tilted position could also cause problems. When you’re doing the dishes, waiting in line for something, or standing at the bus stop, it’s better to distribute your weight evenly between your legs.


Another biomechanical cause of hip bursitis is when the knee turns inwards excessively when you run or walk. Again, this pulls the muscles and tendons tightly over the hip bone.

People usually stand, walk, or run like this because it’s become a habit, they have weak glute muscles, or when they’re very tired.


Poor biomechanics can cause hip bursitis while running.

Sudden overuse

This usually happens when you do certain strenuous activities without having built up to it gradually.


Bursae are like many other parts of the body – if you slowly increase the amount of pressure they have to handle, they will adapt to it, but if you overdo it and/or they don’t get enough time to recover between activities, it becomes a problem.


Examples include running a very hilly race without having trained for it properly or suddenly doing a lot of hill walking. The effect on the bursae becomes worse when this makes you really tired and you lose your running or walking form.


Tightness

Excessive tightness in the muscles that cross over the hip bursae will increase the pressure there and irritate them. Tight muscles can also pull the IT band too tightly over the outside of the hip.


There are also certain conditions in the lower back that can cause tightness over the hip – more about that later.


Snapping hip

And lastly, there's a condition called “snapping hip”, where your IT band goes “click-click-click-click” over the outside of your hip. This is quite common in people who are hypermobile or very supple, like dancers.


If your IT band keeps on flicking over the hip bone, it can irritate a bursa.


How to diagnose hip bursitis


Bursitis and conditions with similar symptoms

Bursitis pain is easily confused with other conditions and vice versa. This is because there are several things that can cause pain in the area where the bursae are.


Bursitis pain is usually over the outside of the hip, but it can refer pain down the side of the leg. It can also, if it's very irritated, cause your lower back to tighten up and make that hurt. Then again, if you have lower back pain, this can refer pain into the side of the hip and/or down the side of the leg.


The tendons that attach your gluteal muscles to the hip bone are in exactly the same spot as some of your hip bursae. If you have gluteal tendinopathy it can cause pain in that same area, and you won’t know which is causing it by just pressing on it. The same goes for a torn gluteal tendon.


There’s sometimes a clue in how the pain developed. For instance, when you tear a tendon you usually experience a sudden sharp pain, while bursitis tends to have a more gradual onset. If there’s a history of back pain, then you'd suspect back pain rather than pure bursitis.


We also want to look at how the symptoms behave over the 24 hours after exercise. For instance, if you are okay to do lots of weight-bearing activities and it doesn't really make it worse, I would not really suspect bursitis. The same if you can stand for extended periods of time without pain, because bursitis doesn’t really like this.


But if you find that stretching the hip hurts, e.g. you can’t sit with your legs crossed, I would think that there could be a bit of bursitis there, although this can also irritate gluteal tendinopathy.



Treatment for hip bursitis


Hip bursitis often needs to be treated together with something else. For example, someone with back pain might have hip bursitis that is caused by the back pain. And research has shown that 35% of people with glute med tendinopathy also have hip bursitis. This combination of conditions is called greater trochanteric pain syndrome, and Alison has made a series of videos about this.


As with most conditions, there's no one-size-fits-all treatment. A conservative treatment approach that takes into account the sub-headings below can work really well. A small percentage of people don't react to this approach, and then hip bursitis surgery is an option, but none of my patients have needed surgery – the most invasive thing some have had to go for is a cortisone injection.


Identify the cause(s)

It is always important to try and identify the cause for your hip bursitis (biomechanics, overuse, etc.). If you only focus on treating the symptoms and don't address the underlying cause, you may get rid of the pain in the short term, but it will just come back later.


Work on bad habits

Linked to this, we need to look at bad habits, like putting most of your weight on one leg when you stand. I get all my patients with hip bursitis or any other pain on the outside of the hip to make sure that they're always standing on both feet equally, because otherwise you just annoy that sensitive tissue all the time.


The same goes for crossing your legs when you’re sitting. This will also stretch the muscles and tendons over the outside of the hip, which will just keep the pain cycle going if you have a sensitive bursa or even a sensitive gluteal tendon.


Exercises for hip bursitis – and which hip bursitis exercises to avoid

Strengthening exercises are not my first choice for this condition. The bursae have to be properly calmed down first before strength exercises are introduced, otherwise you tend to make it worse.


However, if biomechanics or something like a lack of glute strength contributed to the hip bursitis, those muscles will have to be strengthened at a later stage.


It is best to avoid exercises like clams or side-leg lifts during the early stages of rehab. These exercises can often irritate the irritated bursae more because they can pinch the bursae when your leg moves out and compress the bursae by stretching the muscles and tendons over the outside of the hip when your leg moves back in.


Exercises like glute bridges or leg presses will still strengthen the gluteal muscles, but because the legs move in a straight line, you avoid the positions that are most likely to irritate the bursae. Also, something like isometric wall sits would be better to start with than the repetitive motion of doing squats, where you are more likely to rub your bursa.


Stretches for hip bursitis are best avoided

I tend not to give my patients stretches to do, because stretching increases the compression, and nine times out of ten you will just make it worse. If stretching does not make the pain over the outside of your hip worse, it was likely not a proper bursitis and it may have just been sensitive from other things. Here's a video with more details:



But what to do if you think that tightness could be a cause of the bursitis?


Massage for hip bursitis

Massage, whether you do it yourself or a physio or massage therapist does it, works really well, because if you can get the muscles to relax, you'll take the pressure off the bursa.


However, it's not about pressing onto the bony bits where the really sensitive spots are. You want to start in the less sensitive areas and work on the trigger points. You don't want to elicit a strong pain, especially not in the first session, because if you go too heavy on it in the first session, you won't know how it's going to react, and it may cause it to flare up.


A tennis ball is very handy if you want to do it yourself. Target the soft, squishy, muscley bits in your bum, not the bony bits on the hip itself. It’s better to do it against a wall than on the floor – that way you have more control. Relax the leg that is closest to the wall, press yourself into the wall with the other leg, and move the area around over the tennis ball. Here’s a video demo:



How vigorously should you do this? I tell my patients that it has to feel no worse than “comfortably uncomfortable”. Sometimes, if you've had pain for a long time, it can feel quite satisfying to replicate that pain and feel how it burns. Don’t do it! Rather go gently and see how it reacts in the next 24 hours. If the pain isn’t worse than before the massage, you can go a little bit harder the next time, and vice versa if the pain is worse.


Dry needling

I find that, especially in the very painful early stage when you can't apply a lot of pressure, not even with massage, acupuncture can provide really good pain relief and relaxation of the muscles.


I have even come across one study that found that dry needling produced similar results to cortisone injections. However, I would want that study to be replicated before I believe this 100%, because I've definitely seen in practice that, for some people, dry needling just doesn't work, and they do need to go on to injections.


Hip bursitis injections

We're talking hip bursitis cortisone (steroid) shots here.


You can do a cortisone injection in two ways. The doctor or physio can either go on the landmarks of the body, pressing to find the painful spot and inject it “blind”. Or they can do the injection under ultrasound guidance (where they use an ultrasound scanner to locate the injured bursa) to ensure that they get it exactly in the correct spot.


These scans work the same as when scanning a foetus, and you can use them to see several types of soft tissue, including bursae. I always try to refer my patients to somebody who will be doing the injection under ultrasound guidance.


Anti-inflammatories

Again, hip bursitis is one of those weird conditions where sometimes there's inflammation, sometimes there's not. So, for some people anti-inflammatories work really well, while for others they don’t really work.


Always check with your GP before you take these, because there's certain medications that they interact with. Also, anti-inflammatories have a way of upsetting stomachs. So, it’s always better if you can get away without using them.


How we can help


Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

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About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.



References:

  1. Barratt, P. A., et al. (2017). "Conservative treatments for greater trochanteric pain syndrome: a systematic review." British Journal of Sports Medicine 51(2): 97-104.

  2. Rothschild B. Elusive trochanteric bursitis relief. Clinical Rheumatology 2019:1-1.

  3. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia 2009;108(5):1662-70.