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Bursitis of the Hip and Trochanteric Bursitis

If you have a patient lie on their side you can feel the greater trochanter very easily, sticking up on the lateral aspect of the other hip bursitis. It’s one of the most common causes of "hip pain." Patients will come in complaining of hip pain and you ask them - and that’s what you have to do - "Where does it hurt?" and they will point to the lateral aspect of the hip, which is right over the greater trochanter. That is not true hip pain hip bersitus. True hip pain, the patient will complain of groin pain and often they complain of pain with activity, pain when they rolled over in their sleep onto that side - it’s very sensitive. When you examine them you will find point tenderness over this area, in the area of the trochanteric bursa. But the range of motion of the hip should be normal. If you find limitations of rotation then you have to be concerned that there may be a primary arthritis of the hip. But in almost all of these instances the range of motion is completely normal. This also is an instance where injection works very very well. It’s very easy to do. You just stick the needle in where it hurts. I just have the patient lie on their side. It’s very simple and also it’s not very painful. It’s similar to getting an intramuscular injection. It’s not difficult to find the spot, the patient doesn’t complain a lot and it usually goes away. Some patients do have recurrences and this is an area where you can repeat injections because there is not any major structure.

Also, ischial bursitis. That’s the seat of your pants. If you reach around and grab your butt, you’ll feel a little point there. These patients complain of pain in their butt, literally. It hurts when they sit. If you find point tenderness there it’s medial of the sciatic nerve, and that’s something that is very amenable.

Occasionally the iliopectineal bursa, the patient will have groin pain, but they will have completely normal range of motion and tenderness and sometimes even swelling right over the area where the ileus psoas inserts into the hip.

Remember that hip pain can be caused by other problems. Low back pain, radiculopathy, and it is important to differentiate them. Again, the physical examination and sometimes x-rays to document that the patient does have abnormalities of the lower back. Although, that doesn’t absolutely prove that the pain is due to that since many times the x-ray findings in the back do not correlate clinically. But it can be a useful tool. So often, if I’m not sure and I’m ordering x-rays of the hips, I’ll often get lumbosacral spine with that just to make sure if I’m not convinced.

Bursitis of the knee. There are several structures that need to be kept in mind. The anserine bursa, which is along the medial aspect just below the tibial plateau. It is commonly found in patients who also have osteoarthritis. Occasionally rheumatoid arthritis. Patients complain of pain in the specific area, just below the medial aspect of the knee, below the tibial plateau. It may radiate up into the thigh because this is where the muscles course that overlie that bursa.

In examination, you usually find point tenderness over that area if you have the patient try to adduct, which is bring their knees together, they may have pain in that specific area. Again, because these muscles that overlie - I think it’s the sartorius - that overlie that bursa, when they contract they squeeze the bursa and that’s uncomfortable. The main thing is that when you are evaluating a patient with knee pain, you want to differentiate whether it is bursa or is it articular. Usually just a careful examination looking for tender areas will help. If there is no synovitis in the knee joint, and if you have good range of motion without any other findings, that would indicate that it’s a periarticular problem. Also the prepatellar bursa is right on top of the kneecap and the infrapatellar bursa is right behind the patellar tendon just above the insertion on the tibial tuberosity. These can also be inflamed. The prepatellar bursa is quite easy to recognize. This was a gentleman who, I think he had chest pain and they thought myocardial infarction and it ended up being nothing, but he got dizzy after doing a test.

He developed these large swellings on both knees. But you can see the knee joint itself has not much going on there. Obviously, when I directly examined him, there was no true synovitis of the knee joint, the range of motion was normal, but he had these tremendous swellings above the knees. Someone had already - before I saw the patient - had stuck a needle in the knee joint and got nothing, or like an ml of fluid. When I came by he wouldn’t let me tap the prepatellar bursa but he was kind enough to let me take the picture. I was concerned - he also had a fever - whether or not it was septic. We really had no idea what was going on, and he just refused so they just started giving him antibiotics. I think eventually he did improve. You can see it’s quite a striking picture, and again this is usually due to direct trauma. The infrapatellar bursa, which would be located here and the swelling is not so obvious and it does take some clinical experience.

Injection. If it is just traumatic non-septic, injection therapy works very well particularly for anserine bursitis, prepatellar bursitis. Infrapatellar you are a little less ready to do that because of the fact that it is right next to the patellar tendon and there is a potential for rupture. So you might try and reserve that for an otherwise unresponsive patient. Antiinflammatory drugs are also very useful, but the main thing you want to do is differentiate this from knee arthritis or intraarticular problems.

Plantar Fasciitis. That’s why we have a field of podiatry because these problems are very very common. One of the areas, the plantar fascia, can be involved with plantar fasciitis as it inserts into the calcaneus and also the Achilles tendon as it inserts into the back of the calcaneus. These are very common problems. If there is any sense that it is chronic inflammatory in nature and there are other systems involved, really think of a spondyloarthropathy because these areas are very commonly involved with things like ankylosing spondylitis and the like. But I do see patients occasionally and that’s all they have. They just have Achilles tendonitis or plantar fasciitis. Sometimes you can even get bursal inflammation although it’s very difficult to differentiate from direct tendon involvement.