“It’s Just the Bursitis.” Or is it?

Do you have trigger words in the clinic? I know I do. One of mine is “bursitis.”

I get a little miffed because I anticipate determining that it’s not just bursitis (if at all), which makes for an interesting discussion with the patient. The hip is tough to evaluate, though, which is why this Physio Weekly is dedicated to lateral hip pain.

Putting Bursitis to the Test

What are the odds of a patient having bursitis? That’s tricky.

In a study of forty patients with unilateral hip pain, researchers performed MRIs for both hips. Of the symptomatic hips, the largest proportion had a combination of bursitis and gluteal tendon pathology, not just bursitis.

But here’s the funny part: Out of the 40 hips with no pain, 22 of them had radiographic bursitis. The prevalence of bursitis was the same for the hips with pain and without pain. 

By the way, three of the 40 patients had no pathology in either hip. …What would you say to them?

A Hip Precautionary Tale 

In the recent issue of the Orthopaedic Physical Therapy Practice magazine, there is a fascinating case report about a patient who underwent surgery for gluteus medius tendon rupture. The patient injured her hip after slipping on ice and falling on an outstretched hand. Two weeks after her fall, she consulted an orthopaedic surgeon. The surgeon’s diagnosis? Trochanteric bursitis.

The patient participated in physical therapy for 4 weeks without benefit, then received a cortisone injection with only slight benefit, and took ibuprofen as needed.

Eight months after the initial injury, she returned to her physician with increased hip pain, and the physician ordered an MRI. The MRI revealed gluteus medius tendinosis with small partial thickness tearing and no evidence of trochanteric bursitis. The gluteus medius tendon was surgically reattached, and the patient participated in a second round of physical therapy. The patient got better.

What would have happened if the orthopaedic surgeon or first physical therapist could have detected the tear? Probably a faster recovery, less suffering, and lower costs to the patient.

The authors of this case report present five special tests that were not performed initially and could have yielded a more informative evaluation in the clinic. Here are the tests in order of the easiest to most difficult. The first four are all with the patient lying on the uninvolved side, and the last is in standing.

  1. Isometric hip abduction test: (sensitivity: 80%, specificity: 71%). The patient performs isometric hip abduction without any external resistance. Reduced abductor contraction and/or increased pain indicates a positive test for gluteus medius tendinosis.
  2. Resisted abduction(sensitivity: 73%, specificity: 46%). With the involved leg in abduction and slight extension, the examiner applies moderate resistance against the involved leg. Elicited weakness is positive for greater trochanteric pain syndrome, specifically tendon involvement.
  3. Ober’s test: (sensitivity: 41%, specificity: 95%). The examiner brings the involved led into adduction and allows it to fall toward end range. Restricted range and/or pain provocation is positive for iliotibial band tightness or trochanteric bursitis.
  4. The hip lag sign: (sensitivity 89%, specificity: 97%). The involved leg is passively brought into abduction, slight extension, and internal rotation. The patient is asked to hold the position, and a positive test occurs if the patient’s foot drops 10 cm or more and indicates gluteus medius tear.
  5. The single leg stance test: (sensitivity: 23%, specificity: 94%). The patient stands on the involved leg for 30 seconds with minimal hand support of the examiner. A positive occurs if patient is unable to lift the uninvolved leg off the ground or is unable to maintain the position for 30 seconds, and indicates gluteus medius tendinosis.

Put This in Your Gluteal Folder

The odds are that when you see lateral hip pain, you will be seeing gluteal tendon pathology without actual tear. So what do you do?

A randomized trial published this year found that a combination of exercise and education outperformed corticosteroid injections or no treatment at 12-month follow up. For your exercises, think heavy and slow, using bridging, squatting, band sideslides, and sidestepping. The patients started with a daily HEP of 1-2 sets of each exercise, only 5-10 repetitions but between somewhat hard and very hard RPE depending on patient’s response to loading.

Looking for more? The authors’ protocol is free. By the way, sidestepping is a solid gluteus medius exercise, but the stance leg’s gluteus medius is actually loaded more than the gluteus medius of the moving leg.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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