From this study

Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. (2001)

All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg’s sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg’s sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).

The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg’s sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability.

Bursal distension in isolation was not identified in any of the cases reviewed.

Physical therapy may also provide symptom relief, but it is likely that physiotherapy would need to be tailored to strengthen the abductors of the hip and would be preferable to the current techniques of treatment, which includes stretching of the iliotibial band.

Chad’s comments:

This is a study that I wish I had read in 2001!

Trochanteric bursitis was one of those diagnoses that was easy to make: hip abductor weakness, opposite hip dropping when walking, and sharp tenderness with palpation over the side of the hip/greater trochanter, which was and is still frequently referred to physical therapy.

The problem was and still is that there were no studies guiding physical therapists with regards to how to treat trochanteric bursitis, or bursitis of any kind. Rather, just a few descriptions of what therapists did. With this and a few similar studies showing that the condition is primarily tendinopathy, I started applying my tendinopathy treatment program, for which I am well known. The results, since accurately understanding the issue, have been remarkable.

My subsequent treatment includes aggressive hip abductor strengthening, just as authors of this study suggested, with remarkably better results than I get from iliotibial band stretches (also as the authors suggested, but nobody is perfect). So strength is better than stretch (by far), in my experience.

Unfortunately, I still get regular referrals to treat “trochanteric bursitis” and none for “greater trochanteric pain syndrome,” so it takes a while to get the word out. The problem for patients is that improper diagnosis leads to improper treatment, and as this study found, 45% of patients progressed to the point of having tears of the hip abductor muscles. The tears are not so easy to treat and can lead to long-term disability. So a good diagnosis and treatment (early on) is in everyone’s best interest, except maybe your surgeon’s.

The take-home message for patients is that if you have been diagnosed with trochanteric bursitis, you have probably been diagnosed incorrectly, which is a concern if you are treated incorrectly, and you most likely will be.

The good news…

…is that, unlike bursitis, there is extensive research on what to do for tendinopathy/tendinitis on other body parts. That research suggests that RICE (rest, ice, compression, and elevation), various stretches, and painful massage do not help much at all to heal tendons and restore the muscle strength they are attached to. Rather, strengthening exercises heal tendons and restore muscle strength.