Hip Bursitis: Conditions That Mimic Its Symptoms and How to Differentiate Them

What can be mistaken for hip bursitis?

Hip bursitis, specifically trochanteric bursitis, is a common cause of lateral hip pain, but its symptoms often overlap with various other musculoskeletal conditions, making accurate diagnosis crucial for effective treatment.

Understanding Hip Bursitis

Trochanteric bursitis involves inflammation of the bursa (a fluid-filled sac) located over the greater trochanter, the prominent bony point on the outside of your upper thigh. This inflammation typically causes pain and tenderness on the outer aspect of the hip, often worsening with activity, lying on the affected side, or prolonged standing. While a common diagnosis, it's often part of a broader clinical picture known as Greater Trochanteric Pain Syndrome (GTPS), which frequently includes gluteal tendinopathy.

Why Misdiagnosis Occurs

The hip joint and surrounding musculature form a complex anatomical region. Pain signals from various structures, including tendons, muscles, ligaments, nerves, and even the lumbar spine, can be perceived as originating from the lateral hip. This anatomical complexity, coupled with the similar presentation of pain (e.g., aching, sharp, or radiating), often leads to the misattribution of symptoms to hip bursitis when another condition is the primary culprit.

Common Conditions Mistaken for Hip Bursitis

Several conditions can mimic the symptoms of hip bursitis, necessitating a thorough differential diagnosis by a healthcare professional.

• Gluteal Tendinopathy: This is perhaps the most common condition confused with, or co-occurring with, trochanteric bursitis. It involves degeneration and inflammation of the tendons of the gluteus medius and/or gluteus minimus muscles, which attach to the greater trochanter.

  • Overlap: Both cause lateral hip pain, tenderness over the greater trochanter, and pain with activity or lying on the side.
  • Distinction: Tendinopathy often presents with pain upon initiating movement, pain with resisted hip abduction, and sometimes a palpable thickening or crepitus in the tendon. Bursitis is more purely inflammatory. Many experts now consider gluteal tendinopathy to be the primary driver of GTPS, with bursitis being a secondary or less common finding.

• Lumbar Radiculopathy (Sciatica): Referred pain from a pinched nerve in the lower back (e.g., L4-S1 nerve roots) can radiate down the buttock and outer thigh, mimicking hip pain.

  • Overlap: Pain can be felt in the lateral hip region.
  • Distinction: Radiculopathy often involves neurological symptoms like numbness, tingling, weakness, or electric-shock sensations in the leg, and pain may be exacerbated by specific spinal movements (e.g., bending, twisting). Pain patterns may follow a dermatomal distribution.

• Hip Osteoarthritis: Degenerative changes within the hip joint itself can cause deep, aching pain, stiffness, and reduced range of motion. While typically felt in the groin, buttock, or anterior thigh, pain can sometimes refer to the lateral hip.

  • Overlap: Chronic hip pain, worse with activity.
  • Distinction: Osteoarthritis typically presents with morning stiffness, pain with weight-bearing activities, and a characteristic limitation of hip internal rotation. The pain is usually deeper and more diffuse than the localized tenderness of bursitis.

• Iliotibial Band Syndrome (ITBS): This condition involves irritation or inflammation of the iliotibial band, a thick band of fascia running along the outside of the thigh from the hip to the knee. While most commonly causing knee pain, irritation at its proximal attachment near the hip can occur.

  • Overlap: Lateral hip/thigh pain, often in active individuals (runners, cyclists).
  • Distinction: Pain is often more diffuse along the length of the IT band, and tenderness may extend distally towards the knee. Specific IT band tests (e.g., Ober's test) may be positive.

• Sacroiliac (SI) Joint Dysfunction: The SI joint connects the sacrum (base of the spine) to the ilium (pelvis). Dysfunction can cause pain in the lower back, buttock, and sometimes refer to the hip or groin.

  • Overlap: Buttock and posterior hip pain.
  • Distinction: SI joint pain is typically localized to the dimple area just above the buttock crease. Specific provocative tests for the SI joint can help differentiate it from lateral hip issues.

• Femoral Acetabular Impingement (FAI): A structural abnormality where the bones of the hip joint abnormally contact each other, leading to pain and limited range of motion. While often causing anterior groin pain, some types can cause lateral or posterior hip pain.

  • Overlap: Deep hip pain, especially with certain movements.
  • Distinction: FAI typically causes mechanical symptoms like clicking, catching, or locking, and pain is often exacerbated by deep hip flexion, adduction, and internal rotation.

• Stress Fractures (Femoral Neck or Pelvis): Less common but serious, these tiny cracks in the bone (often the femoral neck or pubic ramus) result from repetitive stress.

  • Overlap: Deep, persistent hip pain, worse with weight-bearing.
  • Distinction: Pain is typically severe, constant, and significantly worsens with activity, often leading to a limp. Tenderness may be more diffuse, and a "hop test" or single-leg stance may elicit sharp pain. Requires imaging (MRI, bone scan) for diagnosis.

• Muscle Strains or Trigger Points: Strains of the gluteal muscles (e.g., gluteus medius/minimus) or piriformis syndrome can cause localized hip and buttock pain.

  • Overlap: Localized pain and tenderness in the hip/buttock region.
  • Distinction: Pain is often directly related to specific muscle contractions or stretches. Palpation may reveal tight bands or trigger points within the muscle belly, rather than just over the bursa.

Key Differentiating Factors

A thorough clinical assessment is paramount for accurate diagnosis. Key differentiating factors include:

• Pain Location and Quality: Is the pain sharply localized over the greater trochanter, or is it more diffuse? Is it aching, sharp, burning, or tingling?
• Aggravating and Relieving Factors: Does lying on the side worsen it? Is it worse with walking, climbing stairs, or specific hip movements? Are there specific spinal movements that exacerbate symptoms?
• Neurological Symptoms: Is there numbness, tingling, or weakness in the leg or foot?
• Mechanical Symptoms: Are there clicking, catching, or locking sensations in the hip joint?
• Range of Motion: Is hip joint range of motion limited, particularly internal rotation or deep flexion?
• Palpation: Is tenderness exclusively over the greater trochanter, or are there other tender points (e.g., gluteal tendons, SI joint)?
• Special Orthopedic Tests: Specific tests performed by a clinician can help isolate the source of pain (e.g., FADIR test for FAI, FABER test for hip joint/SI joint, resisted hip abduction for tendinopathy).
• Imaging: While X-rays can rule out bony pathology like osteoarthritis or fractures, MRI is often necessary to visualize soft tissue structures like tendons and bursae, and to assess for nerve compression or other subtle pathologies.

When to Seek Professional Diagnosis

Given the wide range of conditions that can mimic hip bursitis, self-diagnosis and treatment are often ineffective and can delay appropriate care. It is imperative to consult a healthcare professional—such as a physician, physical therapist, or sports medicine specialist—if you experience persistent hip pain. A thorough examination, including a detailed history, physical assessment, and potentially diagnostic imaging, is essential for an accurate diagnosis and the development of an effective, targeted treatment plan.