Hip bursitis or “trochanteric bursitis” has historically been used to describe pain on the outside of the hip. Recent research has found that only 20% of individuals presenting with pain on the outside of the hip have bursal thickening on ultrasound (Grimaldi & Fearon, 2015).
Whereas changes in the gluteus Medius and gluteus minimums tendons are much more commonly observed on scans. Bursal changes are now known to be an incidental finding, with bursal swelling occurring as a protective mechanism to reduce damage to the tendons. As such, hip bursitis is now referred to as gluteal tendinopathy and is recognised as the primary cause of pain and tenderness on the outside of the hip that may extend down the outside of the thigh.
Who gets it?
Gluteal tendinopathy affects 10-25% of the population and is experienced by one in four women aged over 50 years (Mellor et al., 2018).
Females tend to be at the highest risk of developing the condition, with a 4:1 ratio compared to males. Clinically, it is also commonly seen in runners and those with prior hip injuries or hip surgery.
Why does it occur?
Gluteal tendinopathy occurs as a result of repetitive compression of the tendons against the greater trochanter (the bone you can feel on the outside of your hip). Repetitive loading of the gluteus Medius and gluteus minimums can overload these tendons, as they are unable to adequately withstand the demands placed upon them.
Continually applying excessive load to the tendons progressively worsens the condition, as small micro tears occur in the tendons causing inflammation, pain and dysfunction.
Typical activities causing compression and irritation of the gluteal tendons include running, walking upstairs, crossing the legs or sleeping on the affected side at night.
How do I know if I’ve got Gluteal Tendinopathy?
Gluteal tendinopathy is characterised by pain on the outside of the hip and outer thigh. Typically people with gluteal tendinopathy experience at least one or more of the following symptoms –
Pain sitting with crossed legs
Pain going from sitting to standing
Pain with prolonged standing or pain standing on the affected leg
Pain going up stairs
Pain with walking/running
Difficulty lying on the sore side at night
Hip Bursitis causes and exercises
How did I get it?
Gluteal tendinopathy can develop due to a number of contributing factors such as –
Muscular weakness (glutes)
Muscular tightness
Commencing a new activity e.g. gym, vigorous walking
A recent increase in training load
Biomechanical abnormalities e.g. over striding
How do I fix it?
The first stage in managing gluteal tendinopathy is to control pain by minimising the compression on the greater trochanter and managing load on the tendons. Depending on the severity of the condition, this may involve temporarily limiting aggravating activities such as running and stairs, to enable healing and allow time for symptoms to settle.
Once symptoms are better controlled, overwhelming research evidence supports commencing strength training of the gluteal muscles. Studies have shown significant strength deficits of the hip abductors (glute med & glute min) in individuals with gluteal tendinopathy, with those who had gluteal tendinopathy being 32% weaker on the painful side and 23% weaker on the non-painful side (Allison et al., 2016).
Tailored strength programs targeting these muscles can effectively improve pain and restore function, by increasing the capacity of the tendons to cope with the demands of everyday activities.
The good news is the majority of individuals who undergo a progressive strengthening program will recover from gluteal tendinopathy within 3 months.
Two Best Exercises for Hip Pain
What to avoid?
To prevent further irritation, it is necessary to reduce compression of the tendons. This can be achieved through the following management strategies –
Reducing time with legs crossed
Not ‘hanging’ on one hip in standing
Reducing stride length when walking
Using a rail to climb stairs and placing feet wider when walking up stairs
Avoiding stretching of the glutes
Placing a pillow between the knees when sleeping on the side
Should I get an Injection for my hip bursitis?
Corticosteroid injections have traditionally been used to treat help manage pain in gluteal tendinopathy, however recent evidence suggests they may actually prolong recovery.
A 2018 Australian study comparing individuals with gluteal tendinopathy who received corticosteroid injections to those who underwent strengthening exercise, found exercise to be superior both in the short and longer-term. While both groups had similar reductions in pain at both 8 and 52 week follow-up, the exercise group reported a significantly better global improvement in function than corticosteroid injection use (Mellor et al., 2018). Thus, exercise is considered the current cornerstone treatment for non-surgical management of gluteal tendinopathy.
Take home messages:
Gluteal tendinopathy (previously hip bursitis) is an overload problem related to activity
It is reversible and can be improved with non-surgical management
Allison, K., Vicenzino, B., Wrigley, T. V., Grimaldi, A., Hodges, P. W., & Bennell, K. L. (2016). Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Med Sci Sports Exerc, 48(3), 346-352. doi:10.1249/MSS.0000000000000781
Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther, 45(11), 910-922. doi:10.2519/jospt.2015.5829
Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., . . . Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. Br J Sports Med, 52(22), 1464-1472. doi:10.1136/bjsports-2018-k1662rep
Controversy exists regarding the optimal treatment of a torn ACL and whether surgery is necessary.
Australia has an extensive ACL problem with the highest rates of rupture in the world at 10,000 per year (Moses, Orchard, & Orchard, 2012). This is due to grass types and the popularity of cutting/change of direction sports such as netball, AFL and soccer.
Of these ruptures, Australia also has the highest rates of ACL surgery in the world at 90%, with only 10% of patients choosing conservative management. The decision to operate comes as a big one, with surgery costing between $5,000-$15,000.
How Does it Occur?
ACL injuries usually occur landing from a jump, pivoting or decelerating. The vast majority (70-80%) are non-contact injuries, usually related to biomechanical issues such as poor landing mechanics. The other 20-30% are contact injuries resulting from a direct blow or perturbation, such as a collision or being knocked mid-jump or run. For these reasons, ACL injury is common in sports such as skiing, AFL, netball, soccer, basketball and gymnastics.
Does Gender matter?
While more males suffer ACL injury on the whole, there is a gender bias towards females sustaining ACL injury. When exposed to the same level of activity (training & game time), females have a 2-8x higher risk of rupture.
Other risk factors
Extrinsic – (outside of the individual)
Dry fields, artificial turf
Game intensity – rates compared to training intensity
Grade of match – quality increases risk e.g. elite higher risk vs recreational
Greater torsional resistance – more cleats in shoes = torsion and risk
Intrinsic
Females have a higher rate of ACL injuries due to:
Hormonal effects: laxity, strength, fatigue-ability (however no conclusive evidence of menstrual cycle risk)
Decreased hamstring strength
Biomechanical – landing mechanics (females land stiffer with less hip bend)
Trunk strength / control
Some other intrinsic risk factors apply to both males and females
Greater BMI, weight, age
History of previous ACL reconstruction
Surgery vs Non-Operative Management
Several factors come into consideration when deciding between operative or conservative management. Not all ACL injuries require an ACL reconstruction. With the latest data (up to 2022), it looks like up to 50% of torn ACL’s can heal naturally and this may be aided by the use of a brace to lock the knee at 90deg for at least 4 weeks. We also know that many people can cope without an ACL at all. Each case should be assessed individually and a discussion should be had between the patient, physiotherapist and surgeon as to the best course of action required.
The following factors may help guide the decision to have surgery or not.
The following factors may contribute to a decision to AVOID surgery.
A type 1 tear where the ACL has not pulled away from the femoral attachment
A partial tear
Older age (>40)
Not participating in any sports that require repetitive pivoting
Functional knee stability – no repeat episodes of “giving way”
Success with rehabilitation. The current recommendations are for EVERY athlete who suffers an ACL injury to undergo at least 8-12 weeks of rehabilitation before considering surgery
Isolated ACL injury. E.g. no other tissues were damaged
The following factors may contribute to a decision to UNDERGO surgery.
A type 3 tear with femoral avulsion
Younger age
Participation in pivoting sports
**Knee Instability – recurrent episodes of giving way
Individuals that do rehab (exercise + strengthening) prior to surgery have superior outcomes to those that have early surgery. Delaying surgery allows for better resolution of joint trauma prior to second trauma (surgery) to the knee. It also allows time to develop better pre-op muscle strength and neuromuscular control. This enables the individual to enter surgery with a better knee outcome score, which is prognostic for better 5-year outcome.
Interestingly, a 2019 study showed that 45% of those who were originally classified as being unable to cope without an ACL became a potential coper after just 5 weeks of exercise rehab (Thoma et al., 2019).
Return to Sport Rates
Only 1/3 return to pre-injury level of sport 12 months post-op ACL repair.
90% of patients RTS after an ACL injury, only 50% return to pre-injury activity level
~30% of people never return to sport!
Re-Injury Risk
Graft re-rupture rate after 10 years is 6%
1 in 3 patients <20yrs age that return to sport will sustain a second ACL injury within the first two years after repair – the greatest risk is in 1st year post op
Athletes who return to hard cutting/pivoting sports earlier than 1 year post-op were 6x more likely to sustain a 2nd ACL injury upon return to sport irrespective of age (Grindem, Engebretsen, Axe, Snyder-Mackler, & Risberg, 2020)
Young athletes <25 years who return to high risk cutting/pivoting sports have a 30-40x greater risk of sustaining a second ACL injury.
Long-Term Outcomes
50% of people will develop arthritis 20 yrs post injury regardless of surgery or not
Arthritis risk higher after surgical repair but have better stability and less secondary meniscus tears compared with conservative
The risk of developing arthritis increases if the original injury also involved a meniscus tear
Take home messages
Many people can function normally without an ACL
Surgery can have significant financial costs ($5-$15k) and there is still a risk of re-rupture (6%)
5 weeks of exercise rehab should be performed following ACL injury, prior to considering to identify potential “copers”
Knee function is the same at 2-yrs and 5-yrs post injury, regardless of surgery or not
Surgery may still be the course of best action for high-level, younger athletes who wish to return to cutting/pivoting sports OR those with instability/giving way who have failed at least 5 weeks of rehabilitation.
References
Filbay, S. R., Ackerman, I. N., Russell, T. G., & Crossley, K. M. (2017). Return to sport matters-longer-term quality of life after ACL reconstruction in people with knee difficulties. Scand J Med Sci Sports, 27(5), 514-524. doi:10.1111/sms.12698
Grindem, H., Engebretsen, L., Axe, M., Snyder-Mackler, L., & Risberg, M. A. (2020). Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury – the Delaware-Oslo ACL cohort study. Br J Sports Med. doi:10.1136/bjsports-2019-100623
Moses, B., Orchard, J., & Orchard, J. (2012). Systematic review: Annual incidence of ACL injury and surgery in various populations. Res Sports Med, 20(3-4), 157-179. doi:10.1080/15438627.2012.680633
Thoma, L., Grindem, H., Logerstedt, D., Axe, M., Engebretsen, L., Risberg, M. A., & Snyder-Mackler, L. (2019). Coper Classification Early After ACL Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: Response. Am J Sports Med, 47(11), NP65-NP66. doi:10.1177/0363546519863309