Trochanteric bursitis is the term we use to describe the pain which is felt on the outer aspect of the upper thigh that develops spontaneously mostly in middle aged females. It is of gradual onset but on very rare occasions, is associated with an injury. Often the pain progressively worsens, eventually becoming quite disabling. It may prevent the sufferer from lying on either the affected or the opposite side causing sleep disturbance and limiting walking distance because of pain. The pain is usually quite well localised, is made worse by standing and walking and as it progresses, there can be the associated development of a limp.
Current treatment
For a long time, this pain has been attributed to inflammation of the lubricating sack (bursa) called the “Trochanteric Bursa” which covers the bony prominence of each hip. The treatment instituted for this pain has always been directed at reducing the irritation in the bursa and involves local anaesthetic and cortisone injections, physiotherapy, muscle stretches, massage, chiropractic and osteopathy treatments. These modalities of therapy can result in some improvement in the pain and have, up to now, been the main method of treatment for this pain.
The problem
If you have had any of these treatments or perhaps even all of them and you are no better, you have fallen into that group of patients whose pain is not due to bursitis at all but is caused by a tear in the underlying hip tendons which separates the tendon from its bony attachment and results in abrasion of the tendon on rough bone. The irritation of the bursa is just “collateral damage” because the tendons are frayed by the tear and irritate the bursa. If the treatment is directed only to the bursa, then the underlying cause remains untreated and the pain will persist and perhaps worsen.
The cause
There is a simple and obvious reason for this condition to develop. When we take a step, we are standing with all our weight on one leg. To balance ourselves, the muscles around the hip joint which attach to that bony bump which can be felt on the side of the upper thigh, must contract. The force they need to exert to work properly, varies between one and a half to three time our body weight. For the average 70 kg individual this is 150-200 kg. That is close to the weight of a 750-cc motor bike. If we take on average about 1,000,000 steps each year, it should not come as a surprise that the tendons in some individuals wear out and break down. Such tendon problems are familiar to many of us in the form of a ruptured Achilles tendon (heel tendon) and torn/ruptured rotator cuff (shoulder tendon). The size of the tear varies greatly from one individual to another but can be a few square centimetres to the entire tendon being separated. Interestingly, the amount of pain felt is not closely related to the actual size of the tear.
Treatment
When the tendon is torn, Cortisone and oral medication may help the pain but won’t specifically deal with the problem which will persist and slowly worsen. Washing your car will not make it go better if the gear-box is broken. Put simply, if the pain is severe enough and disabling enough, only surgical reconstruction of the tendon will fix the problem and permanently settle the pain.
Operation
The operation is a reasonably big procedure as is any operation involving a large joint like the hip. The tendon is exposed and the damaged area is removed leaving a clean healthy tendon surface. Then the bone surface is prepared and the tendon is reattached by sutures passed through tunnels in the bone. The hospital stay is generally three to four days. It is important to prepare for the operation by practising the use of crutches or a walking frame depending on your age, fitness and balance. You will need to protect your weight-bearing on the operated side for about six weeks after the surgery. This will give the tendon time to heal onto the bone and it is essential to the success of the operation for this to happen.
Complications
All operation can have complications and this is no exception. The most common complication is that which is common to all hip operations and that is a blood clot in the vein (DVT). The chance of this happening is about 3%. Other complications are infection, worsening of pre-existing medical problems such as diabetes and failure of the repaired tendon to stay attached to the bone (3%). Although this seems a lot, it also means that you have better than 97% chance of having no problems at all and losing all your pain.
Rehabilitation
After leaving hospital, arrangements can be made for you to go to a specialist rehabilitation centre. Most patients are well enough to go straight home. While weight-bearing on the leg is not advised, it is desirable that you move around as much as possible on the walking aid to maintain good muscle tone. After five weeks, weight-bearing commences by graduating 25% weight and then at six weeks to one crutch on the opposite side of the operation, then onto a stick and finally full weight-bearing. The best exercise by far to train your hip muscles is walking on flat ground. However, physiotherapy, hydrotherapy and a dedicated home exercise programme will help to restore your normal tendon and muscle function more quickly. Initially the muscles become quite sore because they are weak and unfit but this improves with regular exercises.
Outcomes
Even long-standing “bursitis” pain can be relieved by surgery. Our longest duration of pain has been 180 months (15 years) and this patient was rendered pain free after the repair.