Trochanteric+Bursitis.+Differential+Diagnosis

=What special tests can be used in the differential diagnosis of trochanteric bursitis?= (ruling out other possible pathologies that could be associated with trochanteric bursitis)

__Quick Information__ From Louden text: Description: Inflammation of the bursa around the hip that generally occurs during middle age. Onset may be gradual or acute following a fall or direct blow to the hip.

Typical Symptoms: -pain over the region of the greater trochanter, particularly posterolaterally -pain radiating down the lateral aspect of the thigh or into the buttock -painful snapping sensation

MOI: -repetitive friction between the greater trochanter and the ITB during flexion/extension movements of the hip -overuse -trauma -often accompanied by other pathologies of the affected area: osteoarthritis of hip/spine -leg length discrepency

Other possible areas of hip bursitis: -Iliopsoas: caused by repetitive hip ER and hip flexion -Ischial: caused by tight hamstrings

=**Trochanteric Bursitis**=

Trochanteric bursitis is a frequently diagnosed inflammatory condition. It most often occurs in middle-aged patients with females more commonly affected than males (4:1). The greater trochanter of the femur is surrounded by many bursae that provide lubrication for the tendons before they reach their bony attachments. A study done by Woodley et al. found that there was an average of six bursae per hip. As many as four were found beneath the gluteus maximus muscle and the tensor fascia lata, including those normally thought of as the "trochanteric" bursae and the gluteofemoral bursa. Two bursae, the anterior subgluteus medius bursa and the piriformis bursa, were typically found beneath the gluteus medius muscle. The subgluteus minimus bursa and the secondary subgluteus minimus bursa were identified under the gluteus minimus tendon. The deep subgluteus maximus bursa is the largest bursa and is consistently referred to as the "trochanteric" bursa. The deep subgluteus maximus and the superficial subgluteus maximus bursae are most often implicated in cases of symptomatic hip bursitis. However, it is worth noting that the subgluteus medius and subgluteus minimus bursae may contribute to trochanteric bursitis pain.





The picture on the left shows the bursae deep to the gluteus maximus muscle and the fascia lata, including the deep subgluteus maximus bursa (A), the superficial subgluteus maximus bursa (B), the secondary deep subgluteus maximus bursa (C), and the gluteofemoral bursa associated with the greater trochanter (D). The middle picture shows the bursae deep to the gluteus medius tendon, including the anterior subgluteus medius bursa (E), the piriformis bursa (F), and the secondary piriformis bursa (G). The picture on the right shows the bursae deep to the gluteus minimus tendon, including the subgluteus minimus bursa (H) and the secondary subgluteus minimus bursa (I).

=**Diagnosing Trochanteric Bursitis**=

Due to the number of pathologic conditions that present with similar symptoms and physical exam findings a clear-cut diagnosis of trochanteric burisitis is difficult to obtain with high specificity. Rasmussen and Fano set the initial criteria for diagnosing trochanteric bursitis. Their criteria included: lateral hip pain, distinct tenderness at the greater trochanter, pain on hip abduction against resistance, pain radiating down the lateral aspect of the affected lower extremity and a positive FABER test. Williams et al reported the prevalence of hip pain to be as high as 10-20% in Americans over 60. Due to the relatively high incidence of hip pain, many studies utilizing MRI or ultrasound as standards have been conducted in order to determine the source of this hip pain. One such study, conducted by Long et al, set out to determine the prevalence of primary bursitis when pain and tenderness at the lateral aspect of the hip was clinically presented. Using sonographic findings as their standard they found only 177 of 877 (20%) of patients with pain and tenderness over the lateral aspect of the hip had trochanteric bursitis. More prevalent conditions included gluteus medius/minimus tendinosis (50%) and a thickened/inflamed ITB (29%). Similar finding have been reported by Kingzett-Taylor et al and Bird et al. These findings are prevalent due to their implications on treatment. Furthermore, the term //**greater trochanteric pain** **syndrome**// is now frequently substituted for trochanteric bursitis due to the myriad of causes that may contribute to symptoms similar to bursitis. As a result, clinical examination is often more focused on ruling out differential diagnoses rather than obtaining a specific diagnosis of trochanteric bursitis.

__Technique__**:** Patient is supine with involved hip placed in flexion, abduction and external rotation so that the foot of the involved extremity is resting on the knee of opposite leg. The clinician places one hand on the patient's ASIS to prevent compensation and the other hand grasps the knee of the involved extremity. The clinician slowly lowers the knee towards the table while stabilizing the contralateral hip and pelvis. __Positive response__ **:** The involved extremity does not reach the table or pain is present in testing position. __Biomechanics__**:** The full excursion of the joint range of motion in this position normally permits the test leg to reach the table. A soft-tissue shortening or articular surface pathology will limit this ROM. (1) __ Implications __ : A positive FABER test can be indicative of multiple diagnoses depending upon the location of the elicited pain. According to Williams et al. (table 5) pain in the anterior hip may be indicative of osteoarthritis. Pain in the posterior hip may be indicative of sacroiliac joint dysfunction. Faber's test was found to have high test-retest reliability according to a study conducted by Ross et al.
 * FABER (Patrick's) Test **

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__Involvement of the Iliotibial band (ITB)__
**Modified Ober Test** __Technique__**:** Patient in side-lying with the involved pelvis stacked above non-involved pelvis. The involved knee and hip should be slightly flexed. Standing behind the patient the clinician stabilizes the patient's pelvis with one hand to prevent the lateral tilt and holds the patient's leg with the other hand. The clinician brings the leg into extension, keeping the femur from rotating internally. The clinician then allows the leg to drop into adduction. __Positive Response__**:** The leg does not drop into adduction or drops less than 10 degrees from horizontal. __Biomechanics__**:** A tight iliotibial band (tensor fascia latae) will cause hip abduction and internal rotation of the femur. (1) __ Implications __** : ** A tight ITB is commonly a source or trochanteric bursae irritation. A negative Ober test can eliminate the possibility of a tight ITB causing GTPS. However, this does not mean that a thickened or "snapping" ITB is not the cause of a patient's symptoms. A study by Ege et al. (3) found the Ober test for ITB tightness is often positive when trochanteric bursitis is present.

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__ Involvement of gluteus medius and minimus __
**Trendelenburg's sign** __Technique__**:** Clinician stands behind the patient and instructs them to stand on only the affected limb. The clinician then observes the alignment of the contralateral limb and the pelvis. __Positive Response__**:** The pelvis on the contralateral side drops when the patient stands on the affected limb. __Biomechanics__**:** The gluteus medius (prime mover) and other hip abductors stabilize the pelvis keeping the femur in the neutrally abducted position. (1) __ Implications __** : ** A positive Trendelenburg sign may indicate involvement of the hip abductors, especially gluteus medius and minimus, in patient's suffering from GTPS.

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The Bird et al. study found the most accurate way to identify gluteus medius and minimus involvement in lateral hip pain was to conduct the Trendelenburg's sign test. Their study found the Trendelenburg's test to have a sensitivity of 72.7% and a specificity of 76.9% for detecting gluteus medius and minimus tears. If a positive Trendelenburg's test was identified in the patient the examiners in the Bird et al. study went on to perform resisted abduction and resisted internal rotation to further confirm their findings of gluteus medius and minimus involvement. Resisted hip abduction had a sensitivity 72.7% and specificity 46.2%. Resisted hip internal rotation had a sensitivity 54.5% and specificity 69.2%.

__Involvement of Intraarticular structures__
**Scours test** __Technique__: The subject should be in supine with the examiner standing on the involved side. The examiner passively flexes and adducts the subject’s hip and places the knee in full flexion. The examiner then applies a downward force along the shaft of the femur while passively adducting and externally rotating the hip. The examiner then passively adducts and internally rotates the hip while keeping the downward pressure through the femur.

__Positive Response__**:** Any pain or apprehension or unusual movements indicate a positive sign. Also note wherein the motion the symptom is present to determine where the pathology is occurring. __Biomechanics__**:** The labrum deepens the acetabulum to prevent dislocation of the femoral head. __Implications__**:** Scours test if found positive rules in labral tears, capsulitis, osteochondral defects, acetabular defects, avascular necrosis and femoral ace tabular impingement syndrome.

Sensitivity- 75% Specificity- 43% -LR: .58 +LR: 1.32

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__Involvement of the piriformis__
**Piriformis Test** __Technique__: Left side lying. Flex the test hip to 60 degrees with the knee flexed. The clinician is standing on the side of the patient facing the front side of the patient. The clinician stabilizes the patient's pelvis with the right hand and holds the patient's medial aspect of the knee with the left hand. The clinician applies a downward force to the flexed knee and monitors the onset of resistance. __Positive response__: Sciatica, pain or tightness of the piriformis muscle. __Biomechanics__: The piriformis attaches from the lateral sacrum to the superior/posterior border of the greater trochanter. The sciatic nerve passes directly under the piriformis and in 15% of the population it pierces through it. As the piriformis becomes taught it can impinge on the nerve creating sciatica.(1) __ Implications __ : A positive piriformis test that creates sciatic pain should be distinct from pain at the lateral hip associated with GTPS.

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**Palpation**

Place the patient in the side-lying position with their painful side facing up. A firm palpation should be done over the lateral aspect of the greater trochanter (point A in the figure) for the trochanteric bursa. A positive palpation test would reproduce the pain symptoms in the patient. “Since bony prominences are often mildly tender, similar pressure should be exerted over the anterior and posterior iliac spines. If the trochanter is markedly tender and other bony prominences are not, one has a presumptive diagnosis." It is important to note that gluteus medius/minimus tendiopathy can also have a positive palpation test. In a study by Woodley et al, pain with palpation was elicited in all individuals with either trochanteric bursitis or gluteus medius/minimus tendinopathy.

(Figure from //Canadian Medical Association Journal, 1979)//

__Other Diagnostic Methods__

The injection of corticosteroids or anesthetics can be used as a diagnostic or therapeutic measure when suspecting hip bursitis. If a corticosteroid or anesthetic injection into the trochanteric bursae provides symptomatic relief it is considered a positive test for trochanteric bursitis.

Although not readily available in the clinic it may be necessary to employ medical imaging techniques to reach the correct diagnosis. Radiographs or x-rays are useful for eliminating the possibility of fractures or calcifications rather than positively diagnosing trochanteric bursitis. Karpinski and Piggott reviewed 15 cases of clinically diagnosed trochanteric bursitis and found that 12 cases had normal radiographs, whereas only three displayed minimal soft tissue calcification.

Another imaging technique with diagnostic capabilities is dynamic ultrasound. Ultrasound may be useful in ruling out tendinous injuries to structures located in the symptomatic region. Additionally, ultrasound may help identify inflamed trochanteric bursa and allow the clinician to view the ITB or gluteal structures. The clinician should watch for a snapping sensation of the ITB over the greater trochanter contributing to pain or inflammation. The video below provides an example of how ultrasound can be used to view structures around the hip. At 3:00 they begin to view the lateral aspect and greater trochanteric region.

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In much the same manner MRI may be used to rule out potential tears or to identify inflammation in the area of the trochanteric bursae. A study conducted by Bird et al compared MRI findings in 24 women with greater trochanteric tenderness and lateral hip pain. They found 63% had gluteus medius tendonitis, 46% had gluteus medius tears and only 8% displayed evidence of trochanteric bursitis. This suggests that the use of MRI may not be as useful for diagnosing trochanteric bursitis as it is for ruling out other associated differential diagnoses, especially gluteus medius and minimus tears.

-Below is a quick reference to learn more about several differential diagnoses:
 * [|Femoral Head Avascular Necrosis]
 * [|Femur Injuries and Fractures]
 * [|Hip Fracture]
 * [|Iliopsoas Tendinitis]
 * [|Iliotibial Band Syndrome]
 * [|Osteoarthritis]
 * [|Hamstring Injury]
 * [|Lumbosacral Disc Injuries]
 * [|Lumbosacral Radiculopathy]
 * [|Lumbosacral Spine Sprain/Strain Injuries]
 * [|Meralgia Paresthetica]
 * [|Myofascial Pain in Athletes]
 * [|Piriformis Syndrome]
 * [|Sacroiliac Joint Injury]
 * [|Snapping Hip Syndrome]