Bursitis and Myofascial Trigger Points

Pain on the outside of the hip is still commonly called trochanteric bursitis, but imaging studies show the bursa is frequently normal and the gluteal tendon is the problem: in an ultrasound study of 877 people with this pain, only one in five had bursitis, while half had changes in the gluteal tendons 1. The same applies at the shoulder, where subacromial pain is rarely the bursa alone.

This matters because the treatments differ. A tendon needs progressive loading; a genuinely inflamed bursa needs offloading first. Getting the diagnosis approximately right changes what the first six weeks look like.

Identify and modify the aggravating load — sleeping position, sitting posture, training volume, gait pattern. Then progressive strengthening of the muscle group involved. Manual therapy and dry needling for trigger points reduce pain in the short term and are used to make the loading work tolerable, not as the treatment itself.

Repeated corticosteroid injections into the same site weaken tendon tissue. Where an injection is genuinely useful we use it once, deliberately, alongside a loading programme.

A hot, swollen, exquisitely tender bursa with fever can be septic and needs aspiration, not physiotherapy. Pain that does not vary with position or activity, or that wakes the patient every night, is investigated rather than treated as mechanical.

Pain on the outside of the hip and the point of the shoulder is routinely called bursitis. Imaging and surgical series show the problem is usually tendon rather than bursa, with the bursa inflamed secondarily if at all.

The distinction changes the treatment entirely: a tendon needs progressive loading, whereas treating it as bursitis leads to rest and repeated injection, which is why so many of these problems persist for years.

In a randomised trial of 204 people with gluteal tendinopathy, education and exercise did better than an injection 2. The trial compared 14 physiotherapy sessions of education and exercise over eight weeks, a single corticosteroid injection, and a wait-and-see approach 2. At eight weeks, 77% of the exercise group reported success, against 58% after the injection and 29% with waiting 2.

At one year the exercise group was still ahead of both, while the injection group no longer differed from waiting on patients' overall rating 2. The education taught people to avoid positions that press the tendons against the bone at the side of the hip, which is why sleeping and sitting positions are part of treatment 2.

It can reduce pain for a while. A 2017 meta-analysis of 13 randomised trials found very low- to moderate-quality evidence that dry needling by physical therapists reduced pain more than no treatment, sham needling or other treatments over the following 12 weeks 3. The trials covered a range of painful musculoskeletal conditions rather than one region 3. Evidence of longer-term benefit was lacking, and function improved no more than with other physical therapy treatments 3. That is why needling, like massage and other manual techniques, is used to make exercise and changes in load easier to tolerate rather than as a treatment on its own.