Are there some hip bursitis exercises that will help my pain?

This question was from a patient after she came back from a trip in which she did a lot of hiking. She wanted some hip bursitis exercises to help her hip pain. She was having pain when going up and down stairs, walking for more than 5 minutes, and lying on that side. While examining her, she nearly jumped off the table when the side of her hip was touched. Her primary care physician told her that she had bursitis. This may not have been wrong but it wasn’t correct either. She had greater trochanter pain syndrome which is a lot more than bursitis. Keep reading to learn more.

What is greater trochanteric pain syndrome?

Greater trochanteric pain syndrome (GTPS) was previously known as trochanteric bursitis or just hip bursitis to most people. The bursae are little sacs of fluid that decrease the friction between the muscles, bones, and ligaments as they glide past one another. They are located around joints and bony prominences where there are multiple muscles and/or ligament attachments. There are several bursa in the hip and it was previously thought that inflammation of the bursa (bursitis) was the main cause of pain on the outside of the hip. More specifically, it was thought that the greater trochanteric bursa was the culprit. Turns out, it was tendinopathy all along.

The greater trochanter is the big boney prominence that comes off the femur bone which is the large thigh bone. It is located on the outside of the upper thigh. The tendons of gluteus medius and gluteus minimus attach to the greater trochanter. These two muscles are located on the outside of the buttocks. Together they move the leg out to the side (abduction), prevent the leg from excessive movement toward the other leg (adduction) and play a key role in pelvis stabilization.

“Radiopaedia – Drawing Iliotibial band – English labels” by Matt Skalski, license: CC BY-NC-ND

When the gluteus medius and gluteus minimus are weak, there is less control of the pelvis and less limitation to hip adduction. The IT band is a thick band of fibrous tissue that runs from the hip to the outside of the tibia (shin bone). With increased hip adduction, the IT band places a higher compressive force on the gluteals tendons. This repetitive friction leads to inflammation and then degeneration of tendons. It also causes increased tension in the IT band. The end result is gluteal tendinopathy. Increased fluid in the bursa may also be present but it is probably a result of the tendinopathy. See the video below for further explanation of this condition.

How do I know if I have GTPS?

There are many symptoms associated with GTPS. These include:

Tenderness when touching around the greater trochanter.
Pain on the outside of the hip that can refer down to the knee.
Pain with lying on the problematic side. Sometimes there is pain when lying on the non-problematic side because it puts the painful side in adduction.
Pain with sitting for a long time.
Pain when sitting with crossed legs.
Pain with activities such as walking, climbing stairs, and standing.
Condition will worsen over time and is exacerbated with physical activity.
No pain with putting on socks or shoes – This is a way to differentiate GTPS from hip osteoarthritis. Those with hip arthritis will have pain putting on socks and shoes.

How common is GTPS?

GTPS is one of the most common causes of hip pain. It is more commonly seen in females ages 40-60 and is highly correlated with obesity. Women are more susceptible to GTPS because of their wider pelvis.

What are the risk factors?

There are a some risk factors for GTPS. These include:

Female sex
Obesity
Performing repetitive activity
Training errors – increasing intensity or mileage too quickly
Sedentary lifestyle
Scoliosis

Who should I see if I have GTPS?

Physical therapist – Conservative, or non surgical, treatment is the gold standard for GTPS. A physical therapist can help decrease the pain and inflammation while working on gluteal strengthening and pelvic stability. For my patient, I dry needled the gluteals and the IT band. This worked very well to help decrease the pain. I followed the dry needling up with manual therapy to improve the motion in the hip and decrease heightened muscle tone. She had a home exercise program targeted at hip and core strengthening with an emphasis on hip abduction. Her rehab did take several months but she went back to walking and hiking without any issues. GTPS is a fairly common condition especially with females ages 40-60. Most PTs are very experienced at handling this condition.

Orthopedist – An orthopedist might also be needed especially if the person is not responding to physical therapy. Anti-inflammatory medication or a corticosteroid injection might be useful in calming down the pain and inflammation. In some cases of GTPS there is a tear in either the gluteus medius or minimus tendon which would require imaging to diagnose. A hip specialist would need to be consulted about possible courses of treatment if a tear is present.

What can I do?

Relative rest – Resting the area to decrease further pain and inflammation from occurring is one of the best ways to treat GTPS. Basically stay away from the activities that are causing pain. This could include avoiding stairs when possible, not walking uphill, or lying on the painful side. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, the pain is going to continue to worsen. Swimming and biking would be good alternative activities that do not put much stress through the hip.
Ice – Ice can help decrease the pain and swelling at the hip. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity. Ice immediately after activity.
Strengthening – Weak gluteals are one of the main causes of GTPS. Lack of strength in hip abduction will cause excessive hip adduction which leads gluteal tendinopathy. Strengthening the hips and core is very important in treating and preventing the reoccurrence of GTPS. Below are videos of hip and core strengthening. Using loop resistance bands can be very useful for increasing difficulty and strength.

Sleep with pillows between the knees – This can help decrease the amount of hip adduction that occurs during the night. Using a body pillow or several pillows between your knees can help with hip alignment, decrease pain, and improve sleep.
Weight management – The hip joint supports loads 6 to 8 times the body weight during normal walking or jogging. The more weight a person has, the more stress that is placed through the hip joint. Because of this, it is important to try to maintain a healthy weight. Even a small amount of weight loss can make a big difference in hip pain.
Shoe wear – Wearing good supportive shoes can also make a difference in hip pain and also hip/knee alignment. Flat feet can change alignment if they are not properly supported. Good soled shoes can also help with shock absorption when walking.

In review

Greater trochanter bursitis is now known as greater trochanter pain syndrome and is actually a tendinopathy that may or may not have associated bursitis.
GTPS causes pain on the outside of the hip that will continue to progress if not treated.
GTPS occurs primarily in women ages 40-60.
It is highly correlated with obesity.
Conservative care using physical therapy and anti-inflammatories is the gold standard of treatment.
There are many things that a person can do at home to help improve GTPS.
- Relative rest
- Ice
- Strengthening
- Leg pillows for sleeping
- Weight management
- Shoe wear