HIP BURSITIS

Purpose & Clinical Question:

  • Perform extensive research on reliable search domains (PubMed, Google Scholar) to find the most reliable diagnostic tests and imaging techniques to correctly diagnose Hip Bursitis.

  • What are the most reliable and most accurate diagnostic tests and imaging techniques used to diagnose Hip Bursitis?

Evidence:

  • Search Terms- Variation of “Diagnosis”, “Hip Bursitis”, “Trochanteric Bursitis”, “Diagnostic Tests”, “Medical Imaging”, “Signs & Symptoms”, & “Epidemiology”.

  • Databases- PubMed & Google Scholar

  • Inclusion Criteria-
    • Free full text
    • < 20 years
    • We included all conditions falling under the overarching category of GTPS
      • Importance of Differential Diagnosis
    • Clinical trials, Systematic reviews, Meta-analyses
  • Exclusion Critieria-
    • Case studies

Introduction:
Hip bursitis is typically described by a local inflammation of one or multiple bursae which overlie the greater trochanter. With so many other injuries associated with the hip, it is important to rule out other conditions before diagnosing hip bursitis which is often misdiagnosed.
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Mechanism of Injury:
Hip bursitis can be caused by a number of different mechanisms. Overuse of the surrounding musculature is one of the most common causes of an inflamed bursa. Typically bursitis due to overuse is found in high-impact activities such as running, jumping, etc. The musculature that typically leads to hip bursitis can be a tight IT band or tight hip flexors such as iliopsoas. Hip bursitis can also be caused by trauma to the area and having to stand for prolonged periods of time.

Signs & Symptoms:
There are numerous things to look for when diagnosing hip bursitis. Lateral hip pain and tenderness over/around the greater trochanter is a very common symptom. Pain at end-range of hip rotation as well as pain with resisted hip abduction is often found in patients with hip bursitis. Other common signs and symptoms include erythra, edema, and rubor over the greater trochanter. Activities that often bring about lateral hip pain include lying on the affected side, crossing the affected leg while sitting, and climbing stairs.
Differential Diagnosis:
The symptoms that individuals, young adults ages 18-35 specifically, often present with are vague and nonspecific which may cause a misleading diagnosis. The therapist should first identify findings from the history and physical examination that may lead to a misdiagnosis of GTPS, trochanteric bursitis, or hip bursitis. Some other diagnoses other than hip bursitis may include iliotibial band syndrome, gluteal tendinopathy/tears, and snapping hip syndrome.
  • GTPS: Regional pain syndrome that is characterised by chronic pain of the lateral hip area, involving the greater trochanter, buttock and lateral thigh. The syndrome presents with tenderness on palpation of the greater trochanter area with the patient in the side-lying position. GTPS is the preferred term for lateral hip pain, and classically the cause of lateral hip pain is hip bursitis.a.jpg
  • Iliotibial Band Syndrome: A lower femoral neck shaft angle may also be a predisposing factor, as this increases compression of the gluteus medius tendon on the greater trochanter. A predisposing factor to ITB syndrome may be increased acetabular anteversion. This is because with an excessively anteverted hip the head sits more in the anterior portion of the acetabulum leaving less space in the posterior hip capsule, compressing the tendons and ligaments of the posterior hip complex.
    • The likely cause of GTPS is by repetitive friction between the greater trochanter and ITB, causing repetitive microtrauma of the gluteal tendons that insert into the greater trochanter. This in turn causes local inflammation, degeneration of the tendons and increased tension of the ITB.
    • The greater trochanter is a large quadrangular projection at the junction of the neck of femur with the shaft. It is the main attachment for the strong abductor tendons, which facilitate the complex movement achieved between the abductor mechanism and the bursae. There are approximately 20 bursae in the trochanteric area25; some bursae may be acquired due to excessive friction
  • Snapping Hip Syndrome: Snapping hip, or coxa saltans, is a vague term used to describe palpable or auditory snapping with hip movements. As increasing attention is paid to intra-articular hip pathologies such as acetabular labral tears, it is important to be able to identify and understand the extra-articular causes of snapping hip. Snapping hip may be caused by IT band or iliopsoas tendons.
    • IT band syndrome most often presents in the teens and early 20s, when the gluteus maximus becomes thickened, causing an audible pop as the tendon moves over the trochanter
    • Internal vs. External Snapping Hip Syndrome
      • External- Occurs as gluteus medius tendon is pulled over greater trochanter, or when glute med tendon or ITB becomes thickened or frayed. This is more common.
      • Internal- iliopsoas tendon snaps over femoral head
Gluteal Tendinopathy/Tears: The clinical presentation is chronic activity related pain and impaired performance of a tendon with or without local tendon swelling. The absence of localized swelling is a large difference between this diagnosis and hip bursitis, which does have localized swelling in the bursa. This most often occurs in patients with overuse but may not always be due to repetitive activity. This may also be due to those with abnormal mechanical loads and altered cellular responses, or failed healing.

Epidemiology:
Hip bursitis is most commonly diagnosed in females, in patients who live in more industrialized societies, and in patients aging 40-60.

Risk Factors:
Patients can have a higher predisposition to developing hip bursitis if they have any of the following risk factors.
  • Female
  • Wide pelvis
  • Leg-length discrepancy
  • Excessive hip anteversion
  • Excessive foot pronation
  • Poor running surface
  • Obesity

Diagnostic Tests:

Ober’s Test:
  • Procedure- Patient lies sideline on the uninvolved side with the knees and hips partially flexed. The therapist stands behind the patient and stabilizes the involved side pelvis while bringing the involved leg into hip abduction and extension. The therapist then begins lowering the leg back into adduction while feeling for lateral tilt of the pelvis.
  • Positive Test- When the patient is unable to adduct the leg 10 degrees below horizontal without laterally tilting the pelvis.
  • Indication- A positive test indicates iliotibial band tightness. IT band tightness is a potential cause for hip bursitis and can be used to help rule in the diagnosis.


Trendelenburg Test:
  • Procedure- The patient will stand on the affected limb and the therapist will observe pelvic alignment.
  • Positive test- Seen when the contralateral pelvis drops or when the patient’s trunk laterally rotates to the same side you are standing on to help compensate.
  • Indication- A positive Trendelenburg test is indicative of weak abductor muscles, particularly gluteus medius and minimus. Hip bursitis is often accompanied by weak or torn abductor muscles which can assist in diagnosing hip bursitis.


Palpation
  • Procedure- Palpate over the greater trochanter.
  • Positive test- Pain and tenderness over the greater trochanter.
  • Indication- Pain with palpation is a very common symptom of hip bursitis.
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FABER Test:
  • Procedure- The patient lies supine and brings the affected limb into flexion, abduction, and external rotation by placing the ankle of the affected leg just proximal to the knee joint of the contralateral leg. The therapist applies a downward pressure to the knee of the affected leg while their other hand is stabilizing at the ASIS.
  • Positive test- pain and/or knee does not meet the level of the other leg (decreased ROM)
  • Indication- Common test to indicate hip inflammation or a hip capsule issue.


Thomas Test:
  • Procedure(and multiple signs of a positive test) - This test is performed with the patient in supine with the legs hanging over the table. The patient brings both legs up to their chest and holds on to the knee of the unaffected side. The therapist then passively drops the affected limb back towards the table while stabilizing the pelvis. If the patient’s leg is unable to reach the table without pelvic rotation, it is indicative of tight hip flexors. The therapist then straightens the knee and passively lowers it again to the table. If the patient is unable to reach the table again, the iliopsoas is tight. If they are able to reach the table, the rectus femoris is tight. You can also check the IT band by abducting the leg and passively bringing it down to the table. If it reaches the table, the IT band is tight.
  • Indication- Iliopsoas tightness, as well as IT band tightness, are potential causes of hip bursitis.


Patellar-pubic percussion test:
  • Procedure- This test involves the subject lying supine while placing the bell of a stethoscope over their pubic symphysis. The therapist placing the subjects symmetrical while stabilizing the patella. The clinician, while listening to the stethoscope, percusses both patellae.
  • Positive Test- When a femoral neck fracture is present, the clinician will hear a much duller, diminished sound compared to the unaffected side.
  • Indication- A positive test indicates a femoral neck fracture. This test can be used to help rule out hip bursitis as the cause of the hip pain. This test is 96% sensitive and 86% specific to a femoral neck fracture.


Craig’s Test:
  • Procedure- This test has the patient in prone with their affected leg in 90 degrees of knee flexion while the therapist palpates the Greater Trochanter. The therapist moves the affected limb into Interal and External rotation, until they feel the Greater Trochanter move most laterally into their hand. At this point the therapist will keep the leg in this position and use a goniometer to measure the angle from the neutral position.
  • Positive test- Excessive Anteversion is seen if the goniometer measures > 15 degrees. Excessive Retroversion is seen if the goniometer measures < 8 degrees.
  • Indication - Excessive anteversion causes decreased space in the posterior hip complex, which can cause general hip pain. Due to this narrowed space, this can cause compensations and other issues elsewhere in the hip, which may cause stress and inflammation to the hip bursa.


Medical Imaging Techniques:
o X-ray:
  • Used to view peritrochanteric calcifications (bone spurs) and joint space narrowing that may be causing hip pain, or pressure/inflammation of the greater trochanteric bursa
  • May be used to diagnose for surgical intervention or conservative treatment

o MRI:
  • Trochanteric bursitis was reported if there was distension of the subgluteus maximus or subgluteus medius bursa on T1- or T2-weighted images. Gluteus medius tendinitis was defined as an increase in signal intensity on T2-weighted images and/or thickening of the tendon on T1-weighted images. Partial gluteus medius tears were reported when there was attenuation or thinning of the gluteus medius tendon on T1-weighted images and increased signal intensity in a corresponding area on T2-weighted images. Finally, a complete tear was identified if there was complete disruption of the tendon on T1-weighted images, with markedly increased signal on T2-weighted images, indicating the presence of fluid or granulation tissue in the defect. For the purpose of the analysis, gluteus medius partial and complete tears were pooled to form one group identified as “gluteus medius tear.”
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  • This table shows the sensitivity and specificity of the 3 assessments and how many patients exhibited a tear in the glut med tendon with these procedures
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  • A positive Trendelenburg's sign provided the highest sensitivity and specificity overall.
  • The intraobserver reliability (kappa score) for each of the 3 physical signs was calculated. Trendelenburg's sign demonstrated the highest intraobserver reliability. Kappa scores were as follows: Trendelenburg's sign 0.676 (95% confidence interval [95% CI] 0.270, 1.08), resisted hip abduction 0.625 (95% CI 0.155, 1.09), and resisted hip internal rotation 0.027 (95% CI −0.016, 1.10).

o Random info- Imaging is not recommended until a conservative treatment protocol is implemented first and shows no signs of progression.
Conclusion:
Hip bursitis can be caused by a number of different mechanisms, and due to the vague symptoms accompanied with it, it can be misdiagnosed as greater trochanteric pain syndrome, iliotibial band syndrome, snapping hip syndrome, or gluteal tendinopathy/tears. Risk factors include being a female, having a wide pelvis, leg length discrepancy, excessive hip anteversion, excessive foot pronation, and obesity. A number of tests can be performed in order to reach a diagnosis, and X-ray and MRI can be used to assist with diagnosis as well.





References

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