Hip Bursitis Physiotherapy Treatment Guide

Understanding Hip Bursitis and GTPS

Hip bursitis, clinically recognized as a component of Greater Trochanteric Pain Syndrome (GTPS), refers to pain localized over the lateral aspect of the hip. While historically attributed solely to inflammation of the trochanteric bursa, modern clinical research demonstrates that GTPS is primarily caused by insertional tendinopathy of the gluteus medius and minimus muscles, which lies adjacent to the bursa. The repetitive friction and compression of the overlying iliotibial (IT) band against these structures lead to micro-tearing and secondary bursal inflammation.

Treatment must look beyond passive modalities to resolve the underlying biomechanical deficits. A structured program of physiotherapy and pain management is the cornerstone of successful, long-term recovery, helping to restore normal hip stability, gait mechanics, and functional load tolerance.

The Compressive Load Principle in Hip Bursitis

A critical factor in treating lateral hip pain is managing compressive load. Compression occurs when the IT band is pulled tight over the greater trochanter, squeezing the gluteal tendons and bursa against the bone. This occurs during hip adduction (when the leg crosses the midline of the body).

To allow the irritated tissues to heal, patients must modify daily activities to minimize compression:

• Sleeping: Avoid sleeping on the affected side. When sleeping on the unaffected side, place a thick pillow between the knees to keep the hip in a neutral position (preventing the top leg from dropping into adduction).
• Sitting: Do not sit with crossed legs or in low, deep chairs that force the hips into excessive flexion and adduction.
• Standing: Avoid standing with your weight shifted to one side (hanging on one hip), which increases lateral tension.
• Stretching: Avoid traditional IT band stretches that pull the hip into deep adduction (such as crossing the leg behind and leaning sideways). These stretches press the IT band hard against the bursa, exacerbating the inflammation.

Phases of Hip Bursitis Physiotherapy

Rehabilitation is structured into progressive phases to rebuild tissue capacity while avoiding symptom flare-ups. A guided program typically moves through the following stages:

Phase 1: Symptom Control and Isometric Activation

The initial goal is to settle the reactive tissue while preventing muscle wasting. Isometric exercises are utilized as they recruit muscle fibers and stimulate tendon remodeling without moving the joint, which avoids compression.

• Isometric Side-Lying Hip Abduction: Lie on the unaffected side with the top leg straight and in line with your body. Gently lift the top leg 2 inches (keeping the hip in neutral, not rotated). Hold for 10-15 seconds, and repeat 5 times.
• Standing Hip Hitch (Pelvic Drop): Stand on a small step with the affected leg. Let the unaffected foot hang off the side. Gently lower the pelvis on the hanging side, then pull it back up using the hip muscles of the standing leg. Perform 2 sets of 10 repetitions.

Phase 2: Dynamic Strengthening (Isotonic Loading)

Once isometric exercises can be completed with minimal pain, dynamic movements are introduced to rebuild the strength of the gluteus medius and minimus.

• Clamshells: Lie on your side with knees bent at 90 degrees. Slowly raise the top knee while keeping your feet touching. Perform 3 sets of 15 repetitions. Add a resistance band above the knees to increase difficulty.
• Double-Leg Gluteal Bridges: Lie on your back with knees bent and feet flat. Squeeze your glutes and lift your hips until your body forms a straight line from shoulders to knees. Perform 3 sets of 12 repetitions.
• Side-Lying Hip Abduction (Dynamic): Lie on your side and lift the top leg straight up to about 30 degrees, then slowly lower. Ensure the leg remains slightly back to engage the posterior gluteal fibers. Perform 3 sets of 10 repetitions.

Phase 3: Functional Loading and Balance

This phase integrates hip strength into standing, weight-bearing activities to prepare for daily tasks and sports.

• Lateral Band Walks: Place a resistance band around your ankles. Step sideways while maintaining a slight squat position. Focus on keeping your knees tracking over your toes. Perform 2 sets of 15 steps in each direction.
• Single-Leg Balance: Stand on the affected leg on an unstable surface (like a foam pad) for 30–60 seconds to build deep proprioceptive control and pelvic stability.

GTPS Rehabilitation Phases Summary Table

| Phase | Goal | Key Exercises | Things to Avoid | Progress Criteria | | :--- | :--- | :--- | :--- | :--- | | Phase 1: Analgesic | Pain control & tendon quietening | Side-lying isometric abductions, Supine bridges | Crossing legs, sleeping on side, ITB stretches | Pain at rest stable < 3/10 | | Phase 2: Isotonic | Rebuild gluteal muscle volume | Clamshells with bands, Standing abductions, Step-ups | High-impact running, deep hip flexion | 3 sets of 15 reps of clamshells pain-free | | Phase 3: Functional | Restore pelvic stability during movement | Lateral band walks, Single-leg balance, Split squats | Sudden agility changes without warm-up | Symmetry in balance and gait mechanics |

Medical and Injection Therapy Considerations

While conservative physical therapy resolves the majority of hip bursitis cases, some patients may experience persistent pain. Corticosteroid injections into the trochanteric bursa can provide significant short-term pain relief (typically lasting 4 to 12 weeks), which can open a window of opportunity for patients to perform their rehabilitation exercises. However, repeated injections are not recommended as they can weaken the gluteal tendons and increase the risk of tendon tearing. For chronic, non-responsive cases, advanced options like shockwave therapy or regenerative medicine may be discussed.