Hip Pain Due To Trochanteric Bursitis

I am often treating distance runners with complaints of hip pain that leads to an active Trochanteric Bursitis.

First the anatomy: The bursae live under the Iliotibial band and over the Greater Trochanter. You can see in the illustration that the Gluteal muscles insert into the hip and iliotibial band. The role of the Bursae is to act as a lubricator for motion of the ITB (iliotibial band) over the boney prominence of the hip so that there is no deterioration of the ITB during motion.

The ITB is the cause of bursitis in my opinion. Typically, a shortened ITB increases the stress of the bursae and with repetitive tasks, like distance running, the bursae can become inflamed. This is what is referred to as Trochanteric Bursitis.

The Iliotibial Band Syndrome is a companion to Trochanteric Bursitis, and we often see them hand in glove. While ITB syndrome typicall causes pain in the ITB and at the knee, a tight ITB leads to increased pressure on the bursa and often causes it to become inflamed.

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It is easy to see the relationship between the hip and the ITB in this illustration which demonstrates the typical sight of pain at the knee in the case of ITB syndrome.

But even if you do not have a true ITB syndrome, you most probably have a tight ITB that causes excessive friction over the bursae leading to trochanteric bursitis.

We treat the bursitis as follows:

• Ultrasound over the bursae to increase circulation around the bursae
• Occasionally, with a prescription we might employ phonophoresis or iontophoresis - both cortisone delivery mechanisms - to help reduce inflammation.
  
• Ultrasound over the tightened spots of the ITB to soften the ITB
• Myofascial release therapy over the ITB using one of our tools like The Stick for instance. The Stick is also very useful at home. See my earlier blog on the use of The Stick to understand how best to use it
• Ice and Electrical Stim over the bursae to reduce edema and pain
• Orthotics to improve the biomechanics
• Kinesio Tape to lift the skin up over the bursae
• Stretching of the ITB
• Strengthening of the Gluteal muscles
• Introduction of cross training strategies for distance runners (running, cycling an swimming are all unidirectional activities - you need to introduce true cross training - ie lateral and rotational activities.
• We also encourage outpatients to take NSAID's as prescribed - but at least at a therapeutic dose - and to discuss this with their doc if the dose prescribed is less than a therapeutic anti inflammatory dose
  

One consideration for runners is that the knee does not really straighten while running, so flexibility of the hamstrings and of the ITB are important to pay attention to in order to avoid both ITB Syndrome and Trochanteric Bursitis.

You can read more about biomechanics on our website

What is a Forefoot Varus?

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- "Supinated" and "pronated" are POSITIONS
- "Supination" and "Pronation" are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.




So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).




When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.

Who Needs Orthotics

Biomechanics is one of my favorite subjects. First of all, I believe that structure governs function. Lets face it, we are not perfectly constructed and so it stands to reason that a little help here and there might be really very helpful overall.

Orthotics, or as I prefer to say, Custom Orthotic Therapy, is appropriate when the biomechanics are such that the knee is thrown into too much valgus or varus.



Custom orthotic therapy modifies a shoe's internal structure so that the foot, ankle and leg are better aligned for efficient movement and force dispersion. Orthotics are custom made because each patient has different biomechanical problems in his or her feet. When orthotics are installed the biomechanics of the lower extremities are altered so that impact loading and movement become more efficient. Athletes can improve their quickness and balance and reduce risk of injury because orthotics improve the energy absorption characteristics of the lower quarter during impact loading activities.



There is a significant difference between off the shelf devices and custom built devices. Custom orthotics therapy is not simply “putting an arch support in the shoe.” Orthotic therapy is a biomechanical solution to a biomechanical problem. We find that in conjunction with good physical therapy rehabilitation strategies, especially hip muscle training, custom orthotics therapy is often the key intervention that helps a person recover fully.

Biomechanics: The Physics of Movement

We live in an environment that forces our bodies to react to gravitational forces. With every step we take, our skeleton's alignment and structure influence the process of absorbing and releasing the energy that motion and gravity create. The feet have two functions in life. The first is be a mobile adapter. And to do this job, our feet are highly adaptable. As they hit the ground and begin to absorb load, the motion they undergo is called pronation. The structure and alignment as well as the flexibility of our joints determine just how much energy the lower extremity chain (foot-ankle-knee-hip-pelvis-lower back) can absorb. Should the foot be restricted, the energy is absorbed higher up the chain. For different reasons, both flat and high-arched feet channel a large amount of energy to skeletal structures high in this chain—especially the knee and the hip—making those structures more susceptible to injury.

For example, it is common for the kneecap (patella) to develop pain because a flat foot forces the patello-femoral joint to absorb more energy. Running sports add "impact loading" to the equation. Running and jumping amplify the effects of failed biomechanics. Sprains and strains are likely to occur when joints are poorly aligned or when they absorb forces that should be directed to another part of the body.

A Real life example: As a down hill skier, our 30 year old male patient discovered that he had a very difficult time trying to make long carving turns. Instead his turns were short and sharp. Our patient presented with a high arch foot that had several other technical structural deficits. The biomechanical consequence of his foot mechanics was that he was unable to easily use his forefoot to control the inside edge of the ski. Instead, he had to roll his knee in to get his inside edge down. He presented in the clinic with knee pain. Manufacturing custom orthotics for his ski boots and exercise shoes that corrected the biomechanical deficit enabled him to use his forefoot to control his inside edge. The result: Long C-shaped curves and more controlled skiing, no more knee pain. Custom orthotics were the solution for his mechanical deficits.

Who benefits from Custom Orthotic Therapy?

While the medical literature does not support the idea that we all need orthotics, in our experience, anyone who is active on their feet can benefit from custom orthotic therapy. Those who stand, walk or run frequently—whether in sports,
at work or at home—will see improved performance and comfort with the aid of custom orthotic therapy. At the Sports Reaction Center, we make custom built orthotics for all types of athletic footwear, dress shoes and working shoes. If you suffer from foot, ankle, knee, hip or back pain, custom orthotics therapy could be the biomechanical solution for you. We make the devices as follows: First we evaluate the mechanical alignment of your foot. Next we cast the foot, placing the foot in a sub-talar neutral position. This position of the foot lets the pod-orthotist construct a cast of your foot in a known position. The cast is sent to a lab we use (Biomechanical Services, in Brea, California). Together with the pod-orthotist, we construct a cast with corrections that will adjust your biomechanics to optimize your function. And from that cast, the orthotics are manufactured. It takes about 3 weeks to get the finished products back, and then there is a break in period to consider as well.