Trochanteritis is a group of diseases of paraarticular soft tissues located in the area of the femoral trochanter. They include enthesopathy of the abductor muscles, bursitis of the tendon sac. They are manifested by progressive pains on the outside of the hip joint, which increase or appear during movements, lying on the sick side. There is a restriction of movements. Trigger points are identified. The disease is diagnosed on the basis of complaints, examination data, and the results of hardware studies. Treatment includes drug therapy, non-drug methods.
ICD 10
M76 Enthesopathy of the lower limb, excluding the foot
Meaning
Trochanteritis is a fairly common pathology. It is detected in 0.5-0.6% of adults. Patients with this disease account for 25-30% of the total number of patients who have consulted a doctor about hip pain. It mainly affects people of the older age group and athletes. Women suffer more often than men. Despite the name, “trochanteritis” does not mean inflammation of the corresponding bone structure, so American experts prefer the neutral generalizing name “pain syndrome of the large trochanter area”.
Causes
Lesions of paraarticular tissues can be primarily inflammatory or primarily degenerative. In the first case, trochanteritis occurs against the background of inflammatory lesions of the joint, in the second – it is formed as a result of a single major or repeated minor injuries. It often develops with other diseases of the musculoskeletal system, may be an independent pathology. The main predisposing factors are:
- Female gender. The vast majority of patients are women 40-60 years old. In athletes, symptoms may appear at a younger age. The high prevalence of trochanteritis in the fairer sex is explained by two circumstances. The first is gender–specific features of the pelvic structure. In women, the large spit is located further from the midline of the body, which causes a stronger friction of the tendons on the bone protrusion. The second is changes in the bone–ligamentous apparatus against the background of hypoestrogenism at the end of the reproductive period.
- Monotonous loads. Trochanteritis is often diagnosed in athletes (track and field athletes, tennis players, cyclists, basketball players, volleyball players), ballerinas, circus performers. Repetitive movements, especially high–intensity ones, create excessive stress on the joint, causing permanent microtrauma of connective tissue. Against this background, more severe injuries may occur, which further aggravate the situation. Zones of scar degeneration are formed.
- Diseases of the joints. Trochanteritis often accompanies coxarthrosis. The list of other possible provoking pathologies includes seronegative spondyloarthritis: Reiter’s disease, psoriatic arthritis, Bechterev’s disease, Behcet’s disease, arthritis with intestinal lesions: Crohn’s disease, ulcerative colitis, intestinal lipodystrophy.
- Trophic disorders. Local metabolic disorders in the hip joint area often occur against the background of radiculopathy with lumbar osteochondrosis, intervertebral hernias, spondyloarthrosis, spondylosis. Sometimes the root syndrome is caused by infectious diseases, injuries of the lumbar region. Local circulatory disorders are observed in severe cardiovascular pathology, formed during menopause.
- Weakness of connective tissue. With congenital inferiority of the tendon-ligamentous apparatus, microtrauma appears even due to minor physical exertion. In patients with collagenopathies, trochanteritis is diagnosed earlier, is prone to a more persistent course, can be combined with damage to connective tissue structures of other localizations: bursitis, enthesopathies, tendinitis, tendovaginitis.
- Other reasons. Trochanteritis is often detected in people with malformations of the pelvis and hip joint, shortening of the limb, after leg injuries that cause a violation of the biomechanics of walking. These factors cause an increase in the load on the joint, muscles, tendons. The consequence is an increase in the likelihood of developing arthrosis, inflammatory, degenerative processes in the periarticular tissues.
A certain role in the occurrence of trochanteritis is played by excess body weight, which increases the load on the hip joint and adjacent structures. Rapid weight gain is especially dangerous, because muscles, tendons, ligaments do not have time to adapt to the increasing load, they are more often overloaded and injured.
Pathogenesis
Enthesopathies develop against the background of inflammatory and degenerative changes at the points of attachment of tendons to the bone. There are no own arteries in the entheses, nutrients come from the vessels that supply blood to the area of the large trochanter and tendon. Entheses are characterized by high mechanical strength combined with low elasticity.
A significant load on the tendon causes the rupture of a small number of entesis fibers. Due to insufficient blood supply, complete recovery often becomes impossible, a section of scar tissue forms at the site of inflammation. Due to the small area of damage, microtrauma proceeds asymptomatically, remains unnoticed, however, the more scars are formed in the enthesis, the more its resistance to loads decreases, the higher the probability of subsequent ruptures, expansion of degeneration zones becomes.
The reason for the occurrence of a rarer variant of trochanteritis – trochanter bursitis is a long-term, permanent mechanical irritation of the bursa. Normally, the bag contains a small amount of liquid, due to negative effects, its volume increases, aseptic inflammation develops. With concomitant metabolic disorders in elderly people, salts can be deposited in the bursa, which cause traumatization of the walls, supporting the inflammatory process.
Symptoms
Lesions of the periarticular tissues of the femoral region differ significantly in the severity of symptoms, can be one- or two-sided. Sometimes trochanteritis occurs without pain, manifested only by clicks during movements. The addition of pain syndrome, as a rule, indicates the development of the inflammatory process. Characteristic features are the typical localization of pain, their increase over time, a decrease in the volume of active movements with complete or almost complete preservation of the passive range.
Enteritis of the large trochanter is more common than bursitis of the trochanter bag. It often accompanies degenerative lesions of the hip joint, is diagnosed mainly in the elderly. It is manifested by pain with an epicenter in the area just below the hip joint, radiating along the outer surface of the thigh. A typical complaint is the inability to lie on the side of defeat. In other positions at rest, the pain disappears or decreases, while walking, foot movements – increases.
Bursitis of the trochanter sac in the clinical picture resembles enteritis. Athletes predominate among the patients. It can manifest suddenly, but more often develops slowly, gradually. Patients complain of pain when climbing stairs, getting up from a chair, bending the hip. As in the case of enthesopathy, the pain syndrome increases when lying on the affected side. At night, people wake up in pain after accidentally turning to the sick side. The main difference from the lesions of enthesis is the constant nature of painful sensations after the formation of a complete clinical picture.
When examining patients with trochanteritis, external changes are hardly noticeable. In some patients, mild limited edema is detected. The area of the large trochanter is sharply painful on palpation. Possible irradiation in the lower back, the outer surface of the thigh. Trigger points are detected on the hip. Unlike coxarthrosis, there is no restriction of internal rotation, as well as severe pain during flexion, internal and external rotation of the hip. In patients with enteritis, soreness is found when resisting the active withdrawal of the leg.
Diagnostics
Determining the nature of pathology is the responsibility of rheumatologists and orthopedic traumatologists. The most important role in the diagnosis of trochanteritis is played by a detailed survey and a detailed external examination of the patient. During the conversation, predisposing factors are identified (sports, professional activity with monotonous movements and heavy loads on the leg, joint diseases, injuries, abnormalities of limb development). Complaints are carefully collected, focusing on the circumstances of the appearance of pain.
In the process of physical examination, local soreness of the trochanter is detected during palpation, the presence of trigger points, and sometimes – indistinctly pronounced edema. Compare the volume of active and passive movements, pay attention to the presence of soreness when resisting movements. As part of the survey , you can be assigned:
- Ultrasonography. Ultrasound of soft tissues with bursitis indicates an increase in the amount of fluid in the tendon bag, sometimes – the presence of inclusions. Against the background of a long course, thickening of the walls of the bursa is possible. With enthesitis, a violation of the structure of the tendon attachment site is first determined, calcifications, bone erosions, ossification of the soft tissue part of the enthesis are subsequently detected.
- Radiography. At the initial stage of trochanteritis, the images are uninformative due to the insignificant severity of the changes. Subsequently, X-rays show ossifications in the fibrous part of the enthesis, discontinuity of the cortical layer at the site of tendon attachment, local osteopenia, signs of bone remodeling.
- Magnetic resonance imaging. It does not visualize enthesis well enough, but it allows you to reliably assess the condition of the surrounding tissues. It is highly informative in the detection of bone edema, and even in the early stages of trochanteritis, even before the appearance of changes on radiographs. With a prolonged course, it confirms the presence of some muscular atrophy.
When indicating a possible connection with other pathologies, an extended examination is performed. To exclude coxarthrosis, the condition of the hip joint is evaluated according to radiography and CT. If spondyloarthritis is suspected, blood test is prescribed, a biochemical blood test to determine non-specific signs of inflammation, CRP, rheumatoid factor. Depending on the expected type of spondyloarthritis, the patient is referred for consultation to a gastroenterologist, urologist, venereologist, spine radiography, gastrointestinal and cardiovascular system studies are performed.
Treatment
Therapeutic measures are complex, carried out on an outpatient basis. Patients with trochanteritis are recommended to limit the load on the leg, avoid overwork, when doing sports or professional activities, pay more attention to warm-up to warm up muscles and joints, observe technique, change motor stereotypes. The following methods are used:
- Periarticular blockages. Recommended in the acute phase for patients with intense pain. They are carried out with a mixture of a local anesthetic with a glucocorticosteroid agent. Quickly eliminate the pain syndrome. Too frequent administration of hormones has a negative effect on the musculoskeletal system, therefore, no more than 3 blockades are carried out during the course of treatment. The method is used no more than once every six months.
- Physiotherapy procedures. Patients are prescribed special complexes of physical therapy. Passive movements are shown in the exacerbation phase. After the improvement of the condition, they proceed to active exercises. Ultrasound, laser therapy, reflexology, shock wave therapy, massage, manual therapy are useful.
- Drug therapy. For pain and inflammation, warming ointments and local remedies containing NSAIDs are used. Nonsteroidal anti-inflammatory drugs of general action in primary trochanteritis are not very effective, but can be used in the case of secondary lesions of the enthesis and bursa in other joint diseases.
Forecast
The forecast is quite favorable. Correction of the mode of motor activity, timely initiation of treatment, rational selection of therapeutic methods can significantly reduce or completely eliminate symptoms. It should be remembered that this zone remains vulnerable to overloads and injuries, therefore, in case of violations of the regime, signs of pathology may appear again. The course of trochanteritis against the background of other diseases largely depends on the nature of the underlying pathology.
Prevention
Preventive measures include reasonable restriction of physical exertion, compliance with the rules of training, techniques for performing movements. It is necessary to treat the provoking pathology in a timely manner, control weight, take care of the tendon-ligamentous apparatus in the presence of collagenosis.
