‘Hip bursitis’: what it is and what to do about it

Given this affects around 25% of older women, it’s relatively common, so it’s useful to know how to avoid, recognise, and treat it. (PS. the main issue is rarely the bursa.)

What are we talking about?

A bursa, as many of us have had to learn, is a small fluid-filled sac that provides cushioning between tendons and bone.

If we’re told we have hip bursitis— i.e. inflammation of the bursa — this involves the one on the outside of the hip bone.

Chances are though it’s not an accurate diagnosis, because the bursa is only the main act in about 2% of cases.

In the other 98% what’s happening with the bursa is secondary to what’s happening with the tendons of the two gluteal muscles on the side of the hip.

Those tendons have become stressed or overloaded, and because it’s so close, the bursa can be affected too (though it’s more likely to be thickened or swollen than inflamed).

‘Gluteal tendinopathy’ is the name given to the tendon problem, and ‘greater trochanteric pain syndrome’ (GTPS) is the broad term used to describe pain on the outer hip.

That odd name comes about because the outside knob of the hip bone is called the greater trochanter (the ch has a k sound).

Labels aside, we can suspect we’ve got the condition when we feel pain on the outside of our hip in any of these situations:

• climbing stairs, walking uphill, or getting up from a chair
• lying on our side
• standing on one leg (for example, putting on a pair of pants)
• after sitting for a long time, or
• crossing our legs or doing anything that takes one leg across the midline of the body.

What causes it?

There can be multiple factors, but the first might be menopause.

Although we usually think of menopausal symptoms as hot flushes, night sweats, and maybe brain fog or mood swings, up to 70% of women experience aches, pains, and stiff joints.

The drop in estrogen affects muscle, bone, cartilage, ligament, and tendon. Where tendons are concerned, there can be a loss of collagen and elasticity, and less capacity to handle loads and heal.

It’s no accident that in our 50s and 60s we become more susceptible to soft tissue injuries. Gluteal tendinopathy is one, but others include frozen shoulder, plantar fasciitis, and rotator cuff tears.

Obesity can also be a factor. If we’re carrying extra weight we’re adding to the compression of our hip tendons against the bone, but fat tissue also produces inflammatory chemicals which put our tendons at more risk of damage.

High blood sugar and insulin resistance, poor sleep, and high stress levels also have an inflammatory impact.

A third contributor to this kind of pain is a lack of hip strength. People with gluteal tendinopathy have usually lost tissue in the gluteal muscles.

Fourth, we’re putting too much stress through those tendons with movement. This can come about if we suddenly increase our physical activity, for example, we go on holidays and walk vastly more every day than we usually do.

It might also happen if we’ve changed the way we walk in response to an injury or arthritis, or after a hip replacement.

Falling onto our hip will put a heavy load through that area as well. We’ll injure the tendons and possibly change the way we move to compensate.

Fifth, habits such as standing slumped onto one hip, leg crossing, or sleeping on our side with our top leg drawn across the bottom one put extra pressure on the hip tendons.

And sixth, genes might have a role to play, making some of us more susceptible to tendon problems.

What can we do about it?

Turning this around starts with a specific, graduated exercise regime that increases the strength of the gluteal tendons without overloading them. Tendons are slow to recover, so it takes patience.

In the past, rest and corticosteroid injections have been the first line of treatment, but long-term the success rate of that approach is poor.

Of course, keeping our hips strong helps to avoid the problem in the first place.

Bear in mind too that there’s likely to be a loss of strength in both hips even if the pain only shows up in one.

There might also be some forms of exercise we need to stop during our rehab. In yoga, for example, it’s wise to avoid stretches that take the leg across the body (pigeon pose, cow face pose) and positions in which we put a compressive load through one hip (triangle, tree pose). If you do yoga those’ll mean something.

We might also need to change some habits to avoid compressing the tendons in everyday life. For example, training ourselves not to lean onto one hip when we stand and cross our legs when we sit, instead planting our feet evenly on the floor.

If we’re side-sleepers, a pillow under our top leg will prevent it from stretching across our body.

In addition, we might have to relearn to use the right muscles when we walk and move. Often, we’ve stopped using the gluteal muscles, including the big gluteus maximus that is our backside, and instead overuse the front of the hip.

Third, it makes sense to eat as healthily as we can — skip the sugary snacks and processed carbs — and do our best to manage sleep and stress. It’s hard to build healthy tendon with an unhealthy metabolism.

In recent times there’s been more research into whether hormone therapy or collagen supplements can help the rehab process along.

I dug through the hormone studies a year or so ago, and the evidence, as summed up by one group of researchers, was ‘conflicting and contradictory’.

Interestingly though, Dr Rachael McMillan, a physiotherapist and researcher from Deakin University, is focusing on this question of hormone therapy and tendons.

She carried out a year-long study with 132 women with gluteal tendinopathy. They were aged 60 on average. Everyone undertook a specific exercise program and was taught how not to overload the tendons, but some were given a hormone cream to apply via the skin while others were given a placebo cream.

The cream didn’t make much difference among women with a BMI of 25 or more (i.e. classified as overweight or obese), but it did for women with a BMI of less than 25.

It’s a space to watch, and she’s now investigating the effect of another type of hormone treatment — dissolved under the tongue — on shoulder tendons.

Of course, it’s not easy to find a doctor who’ll give us a prescription for these after we’re 60, but hormones aren’t a frontline measure.

Finally, collagen peptides. The studies in this area tend to be small, short, and involve a mixture of protocols, so it’s hard to get reliable data.

Despite that, there’s a view that collagen (15-30g) along with 50g or more of vitamin C might support tendon health alongside a structured exercise program. Might.

In summary, it’s not primarily about your bursa; it’s about the tendons. And we need to be proactive in fixing it. Mostly with exercise and habit changes.

Photo Source: Bigstock