Physical Therapy Helps Patient with Hip Pain Avoid Surgery

Figure 1: AP radiograph of the left hip with a greater trochanteric bursitis with a 2.5 cm calcification lateral to the greater trochanter and distal to the iliotibial band. The anatomy of the GT bursa is almond shaped and 4–6 cm in length.

A 51-year-old man reported that he had been experiencing hip pain for the previous 18 months as a result of lifting a desk. He was diagnosed with hip bursitis and attained little relief with a trial of chiropractic care, three cortisone injections and physical therapy (PT) treatment consisting of modalities and soft tissue mobilization.¹ Due to failed conservative treatment, radiographs were ordered to rule out fracture, degenerative joint disease or calcium deposition in soft tissues.² They revealed a greater trochanteric calcific bursitis (see Figure 1).²

The patient refused surgery, which was recommended by the orthopedist, and he was referred to PT. The patient had been informed the calcifications were severe enough that removal of the bursa was the only treatment option available after failure of conservative treatment.³ Upon viewing the images, the physical therapist observed the extent of the calcification and identified a more isolated pathology than what was provided on the referral prescription (see Figures 2 and 3).

The Assessment & Treatment Approach

Subjectively, the patient was unable to sit longer than an hour, ascend stairs or sleep without nightly discomfort. Objectively, the patient had severe tenderness throughout his hip musculature, decreased tissue length and significantly weak hip abductors. Imaging explained why the hip abductors were weak and why the hip musculature was tender to palpation. This led to the decision to take a more active approach than his previous PT, with a focus on active assisted stretching, strengthening and functional movement training.

Figure 2: AP radiograph of pelvis revealing left calcification at the greater trochanter.

Figure 3: Frog leg radiograph of the left hip shows no calcification at the lesser trochanter and no associated hip pathology.

Outcomes

The patient was treated for eight visits over four weeks. He returned to premorbid activity levels and was independent with a home exercise program.

In summary, the radiographs provided his therapists with a detailed look into the pathology, which resulted in a more specific plan of care.

Alycia M. Markowski, PT, DPT, MPhySt (Manipulative), FAAOMPT, OCS, earned her BSPT and tDPT at Northeastern University and earned a masters in manipulative physiotherapy at the University of Queensland in Australia. Presently, Dr. Markowski is an associate professor in the Department of Physical Therapy, Movement and Rehabilitation Sciences at Northeastern University, Boston. Her research is presently focused on the use of diagnostic imaging technology and the scholarship of teaching and learning.

Lauren Gorgol, PT, DPT, graduated from Northeastern University in 2013 with a doctorate in physical therapy. She is certified in the Graston Technique and Trigger Point Dry Needling. Lauren primarily works in the outpatient orthopedic population, with a strong emphasis on manual techniques.

References

1. Kelly L, Minty L. The occasional injection for trochanteric bursitis. Can J Rural Med. 2011 Winter;16(1):20–22.
2. Lustenberger D, Ng V, Best T, Ellis T. Efficacy of treatment of trochanteric bursitis: A systematic review. Clin J Sport Med. 2011 September;21(5):447–453.
3. Williams B, Cohen S. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg. 2009 May;108:1662–1670.