Hip Bursitis: Why Low Back Dysfunction is the Missing Piece of the Puzzle
The best treatment for hip bursitis involves specifically treating the hip… or so I used to think.
As a Physiotherapist, I’m passionate about trying to better understand the root cause of common musculoskeletal injuries. And I’ve always felt we have a tendency to miss the bigger picture. Usually, because we don’t go looking for it. And this often disadvantages the people we care about the most – our patients.
So, I’ve been looking for this bigger picture on behalf of my patients with hip bursitis over the last 15 years.
And I think I’m onto something.
I’m finding that the onset, persistence, and resolution of hip bursitis has a very strong relationship with specific low back dysfunction. Dysfunction, that is not easy to observe unless you specifically look for it. The back dysfunction may not be overtly symptomatic itself, but closer examination reveals some interesting parallels between hip bursitis patients.
So with this in mind, I’d love to share what I’ve come to understand about the hidden, underlying cause of hip bursitis, and how this should change the way we treat it. I genuinely hope this information provides a new and exciting direction for those struggling to overcome their hip bursitis.
Some Background on Hip Bursitis
Before we get into the things I’m finding clinically, it’s important to give some context about hip bursitis. Below is a quick rundown of the most important information surrounding the cause, symptoms, diagnosis, and treatments for hip bursitis. I’ve deliberately left a few common things off the list, like the use of ice and anti-inflammatories to treat hip bursitis due to their ineffectiveness (I’ll touch on why later).
For those who love a good visual representation, the main local areas involved in hip bursitis are the trochanteric bursa, gluteal muscles, and gluteal tendons due to their close proximity.
Similarly, the common lateral hip pain pattern for hip bursitis is as follows. Having pain here doesn’t mean you have a hip bursitis of course, but there aren’t too many with hip bursitis that don’t have pain in this area.
And lastly, imaging can play a role in helping to diagnose hip bursitis. Options like an MRI and Ultrasound (below) can highlight the presence of hip bursitis whereas an X-Ray can be used to rule out other conditions. However, it’s important to understand that imaging alone should not drive your treatment plan. Like all information, it needs to considered in context with everything else to make sure you don’t waste your time going down an unsatisfactory path.
The above ultrasound, courtesy of Newcastle Sports Medicine, doesn’t show any trochanteric bursitis but does give a great representation of what can be seen with a hip ultrasound.
However, despite all we know and promote about the condition, we might be missing the point. I don’t think we collectively appreciate the role of the lower back in causing and perpetuating hip bursitis.
Lower Back Dysfunction and Hip Bursitis
Citing the low back as a potential root cause of hip bursitis can easily sound strange. After all, many just have hip pain and no additional low back symptoms at all. So you can’t blame anyone for neglecting it.
However, as a Physical Therapist, I have come to understand that not only is the lower back potentially the root cause of hip bursitis, but treating it helps improve how quickly the hip settles. And here’s why:
The thing we often forget in medicine is that everything is connected. Again, not a ground-breaking statement, but it’s true. And not just in a “knee bone is connected to the leg bone” kind of way. But more so that there’s a neural command center responsible for all function and dysfunction. In short, the nerves that supply all hip movement, sensation, and function originate at the base of the rib cage and lower back.
More specifically, the image above shows the distribution of dermatomes. Dermatomes are neural connections developed during fetal growth between spinal levels and areas of the body. Notice how the areas relating to the hip originate from approximately T12-L5, with the T12-L3 more closely covering the site of most hip bursitis.
What I’m Finding Clinically
These dermatomal connections are vital when trying to understand why the hip becomes dysfunctional in the first place.
Clinically, it appears that if the spinal levels associated with these areas become dysfunctional themselves, often through poor spinal habits, bad sitting shapes, and general poor loading of the spine, they can create a chain reaction of dysfunction that flows into the hip – setting it up to fail.
It appears that something as simple as spinal joint stiffness and surrounding muscle tightness can act link a kink in a hose leaving the area it supplies subdued. This makes the area less able to tolerate normal use and activities of daily living.
From what I find, lower back dysfunction seems to deactivate the surrounding musculature setting the bursa to become irritated and overloaded.
And you can test this out for yourself.
The above video highlights a simple test to determine how much your back is interfering with your gluteal function. By initially testing your glute strength (preferably with a partner), freeing up your spinal stiffness, and then re-testing your strength again, you can quickly figure out how involved your back is in the process.
If you free up any lower back stiffness and then see a sudden increase in your gluteal strength, then it’s clear your glutes may have been deactivated by your lower back.
And this test hopefully highlights an important point. We should not think of hip bursitis (or any injury for that matter) as a specific structure that has suddenly failed. Instead, we need to think of the bursa as the tissue which no longer tolerates the sub-par environment it currently exists in.
And once we can look at hip bursitis in this way, we can take steps to genuinely correct the factors responsible for its onset and bring about sustainable change.
Can Low Back Dysfunction Also Cause Other Hip Bursitis Symptoms?
Similarly, a stiff and dysfunctional back may also contribute to other features associated with hip bursitis.
If a weak or deactivated muscle lacks the ability to create normal strength and stability, it makes sense that a tighter version can.
Clinically, any apparent gluteal ‘weakness’ may be one of the early foundations of gluteal tightness. Similarly, it seems that low back dysfunction may directly cause the glutes to tighten to help out a problematic area.
Hip Bursitis Pain
Not only can lower back dysfunction deactivate and tighten the muscles around the hip, but it may also have a role to play in the characteristics of your pain.
Dysfunction in the spinal levels that relate to the hip can both increase and elongate your painful symptoms. From what I find clinically, there may be an element of referred pain involved. Clearly the bursa becomes pain-sensitive when inflamed, however, a dysfunctional lower back may amplify the pain involved.
And again, you can test this idea via the video above. Take a moment to do an activity that generates your hip pain – it could be as simple as touching the area that hurts, and take note of how it feels. Next, free up your spine and then re-test your original pain-generating activity. Then simply compare the difference.
If you feel any genuine, immediate shift in your pain symptoms, you’ve just uncovered a hidden link to your lower back. Something you can control and hopefully overcome.
Hip Bursitis Treatment
As you can hopefully appreciate, without treating the low back we might be missing the root cause in favor of more obvious symptoms.
And before we get to how I recommend we treat hip bursitis, it’s important to understand our current protocols for treatment. After all, we still need to address many of the same issues regardless of any spinal involvement. However, it does make some approaches more relevant than others particularly if you’re wondering how to fix hip bursitis.
Traditional treatment for hip bursitis usually consists of a mixture of medical and Physical Therapy approaches depending on the severity and duration of symptoms:
- Ice for pain relief
- Medication for pain relief and anti-inflammatories
- Massage of hip muscles
- Hip muscle strengthening exercises
- Hip muscle stretches
- Supportive taping with rigid sports tape or kinesiology tape (KT tape)
- Gradual return to pre-bursitis activities
- Other options like dry needling, acupuncture, prolotherapy, shockwave therapy, and TENS machines may also be used.
And what I’d like to point out a little lower is that many of these ideas should now be considered outdated and lacking perspective.
For persistent or severe hip bursitis pain we often default to the following:
- Trochanteric bursa cortisone injections
- Hip bursitis surgery
With current treatment protocols, hip bursitis can resolve in a matter of days to weeks.
Unfortunately, there are many cases of persistent, or chronics hip bursitis that can take months, if not years, to settle.
How I Recommend We Treat Hip Bursitis
As you can hopefully appreciate, our current approach to the treatment of hip bursitis is quite reactionary. We go after the obvious dysfunction associated with hip bursitis – pain, hip weakness, and hip tightness.
So here are my recommendations.
I want to make something clear right from the start. Rest is not the answer to hip bursitis. However, relative rest is. The body is designed to move and be used. And the key is to find the balance between too little and too much.
Complete rest runs the risk of de-conditioning, muscle atrophy, increased swelling and inflammation, and a longer recovery. This is especially so for those with chronic hip bursitis.
Too much movement can increase pain, inflammation, and delay recovery. Sometimes it can be hard to know whether you’ve done too much at the time. So keep an eye out for an increase in your symptoms after activity or the next day.
It may take a little trial and error to figure out what your comfortable window for movement is. But finding a healthy balance is critical to a smooth and speedy recovery.
Avoid Ice and Pain Relief:
This will sound alarming to some, but we seriously need to reconsider our use of ice and pain medication in all injury management – not just hip bursitis.
I’ve written a separate article on why we shouldn’t ice an injury, but the essence is that while suitable for pain relief, ice actually delays the healing response. This is despite it being a staple of injury management for almost half a century.
Similarly, pain medication and anti-inflammatory drugs may offer short-term pain relief. However, they also handicap long-term progress by negating the body’s natural healing response. Without a pain signal to guide us, we can easily surpass our tissue’s threshold for activity.
This isn’t to say that all pain relief is counterproductive. Clearly there are times when you may need help (severe pain, pain that disrupts sleep, etc). However, we shouldn’t reach for pain meds without first considering and side-effects.
Instead, we need to look for treatment options that respect both what the body is going through and trying to do.
Pain is your brain’s interpretation of threat. Interestingly, it’s not necessarily related to the level of injury, damage, or dysfunction at the hip. So in order to effectively decrease your pain, we need to decrease your brain and nervous system’s perception of threat. Not just mask it with drugs and ice.
Following on from this, certain breathing patterns are linked to certain physiological states. When stressed and anxious we tend to take faster, more shallow breaths. When relaxed, we default to slower, deeper breathing patterns. So we can use these deeper, more controlled breathing patterns to cue our body into relaxing and down-regulating, decreasing its threat perception.
Check out the video above for tips on how to use deep breathing to reduce pain.
Similarly, I find massage to be a fantastic treatment for hip bursitis for two reasons.
First and foremost, a respectful massage is highly effective at down-regulating a heightened nervous system. We’ve all had that post-massage sensation of floating on air and we can apply the same ideas to hip bursitis.
A massage for pain relief is not overly deep or brutal. And the sensitivity of someone’s pain may mean that we don’t actually massage over the top of the painful bursa.
Respectfully freeing up any surrounding muscular tightness will also improve hip mechanics. This will then improve bursal loading and help to again reduce the overall threat perception of the area.
Improve Hip Mobility
Better hip mobility often means freeing up the deeper hip rotators and more superficial gluteals. Interestingly, it may also mean freeing up the deep hip joint capsule as well.
As mentioned above, massage is a fantastic low risk, high reward option.
And if you don’t have a spare set of hands lying around, use a tennis ball or lacrosse ball instead.
Below is a video of some of the most impactful deep hip joint mobility exercises I’ve seen. You don’t have to use a power band but they do amplify the impact of these stretches immensely.
And for those who struggle to get down to the ground, here are another five highly effective hip stretches you can do on a chair, table, or bed.
Overall, the goal is to free up the underlying hip joint and release any surrounding hip muscle tightness.
Improve Hip Strength
The challenge here is to improve hip muscle strength without further irritating the bursa. So it pays to have options. In instances where any strength work aggravates your symptoms, it’s important to focus more on hip mobility, pain relief, and improved low back function first. Once things have settled enough you can begin appropriate glute strength exercises.
With this in mind, there are two types of strength exercises you should master.
Isolated Strength Exercises
These exercises target specific muscle groups in the hip – the deep hip external rotators, and the hip abductors. Each plays an important role in stabilizing and moving the hip. The exercises are very basic but can help establish a strong baseline of isolated strength.
How to perform side-lying hip abduction
- Lie on your side and roll your entire body slightly forward
- Gently press a finger/s into your glutes to feel for them working (just above and slightly behind the hip bone)
- Rotate your top foot down slightly so your heel is leading
- Slowly lift your leg up without bending your back
- Lower down with control
- Note: It’s easy to unintentionally roll backward when at the top of your leg lift. Stop before you feel yourself wanting to roll.
Dosage: 3 sets of 12
How to perform side-lying hip external rotations (Clams)
- Lie on your side, with your hips and knees bent to 90 degrees
- Slightly roll your entire body forward
- Gently press a finger/s into your glutes to feel for them working (just behind the hip bone)
- Keeping your feet together, slowly lift your top knee up without rolling backward
- Lower down with control
- Note: It’s easy to unintentionally roll backward with this exercise too. Counter this by trying to take your top knee out and up. You may not have much range of motion with this exercise but that’s OK as long as you feel those muscles working with your fingers.
Dosage: 3 sets of 12
You can make each of these exercises harder with the use of booty bands.
Functional Strength Exercises
While isolated strength exercises certainly have their place in the initial stages of rehab from hip bursitis, they do have a ceiling. The reason for this is the body doesn’t function as a set of isolated muscles. It functions as a whole. In reality, there are no “hip abductors” or “hip external rotators” to the body. There’s just a hip area that functions in conjunction with the rest of the body.
So in order to truly strengthen the hip, we need to challenge the gluteal muscles in a way that asks everything to work together.
And clinically this looks like broader movements like squats, lunges, deadlifts, step-ups, jumping and landing, etc.
And to make sure those gutes are working hard, remember the following words. Feet straight, knees out.
Squats are one of the best functional exercises you can do.
How to Squat Properly:
- Start by standing with your feet straight about shoulder width apart
- Next, rotate your knees out without your feet moving (you should feel your hip muscles activate)
- Squat down as low as you can before you feel your heels lift, knees collapse in, or want to fall backward.
- Note: Your depth is based on the range of motion at your ankles and hips. Going lower than your current range allows will force your legs to compensate. Just squat within your current limitations (if any).
Dosage: 3 sets of 10-15
If regular squats are a little tough on your knees, consider box squats instead. All it requires is for you to squat down onto a chair and back up again. Having a surface behind you (still at a comfortable depth) allows your shins to remain more vertical, decreasing the amount of sheer going through your knees.
Take your squatting to the next level by adding a booty band or progressing to single-leg squats, box jumps, single-leg hop squats. Add weight (or backpack filled with books, bricks etc) to each of these exercises.
How to Lunge Properly:
- Start by standing with one foot out in front and the other a decent distance behind you.
- Make sure your front foot is facing forward and your knee is rotated out (as per the squat above). Then slowly lower yourself down.
- Maintain an upright trunk and imagine you are “sitting down” on the lunge.
- Note: Despite the name, we don’t want you to lunge forward with your knee traveling over the top of your front foot. This increases the amount of forward sheer on the front knee. Instead, by lowering yourself down, we can keep the shin vertical and keep that front knee happy!
Dosage: 3 sets of 10-15
Treat the Underlying Back Dysfunction
Treating spinal dysfunction associated with hip bursitis is relatively straight forward. The goal is usually three-fold.
- Mobilize lower back joint stiffness
- Improve core strength
- Prioritize good spinal shapes
Mobilize Lower Back Joint Stiffness
A skilled Physical Therapist will be able to gently and effectively mobilize any low back joint stiffness with their hands using a variety of basic techniques.
How to Free Up Your Back With a Ball or Roller:
- Lie on the ground and have the object gently pressing into the area directly next to your spine.
- Compare both sides to find which is the stiffer side.
- Avoid the urge to roll and just let the object press in.
- Move the object up, down or further out to the side to find your immobile areas
- Note: The priority of this exercise is to find and reduce restrictions. If one side feels tender and sore – but does not feel as tight or stiff as the other, you still need to prioritize the other, more restricted side.
Dosage: 15-20 mins
Improve Core Strength
The internet is filled with creative ways to strengthen your core muscles. Some good, many bad. The goal for any core exercise is to improve your ability to maintain a straight spine.
Here are three really simple exercises to improve your core strength without irritating your hip.
Sit on a Fit Ball / Swiss Ball:
This may sound simple because it is. A great way to re-activate and re-organize your core trunk muscles is to sit on a fit ball.
Sitting is usually the enemy of any and all muscle function. However, the unstable nature of an exercise ball promotes constant core stabilization. By replacing the couch or computer chair with an inherently unstable ball, we can build up your foundational core stability when you’d otherwise be losing it.
If you consider the average adult American can spend anywhere between 6-14 hours a day sitting (pre-COVID), then there’s huge potential for improved core stability with this simple hack.
How to Sit on a Fit Ball Correctly:
Sitting correctly on a fit ball isn’t as straight forward as it sounds. I mean, it’s still insanely simple, but there are a few things to be aware of.
- Sit up tall as you would on any regular chair.
- Avoid hooking your feet under the front of the ball to stabilize yourself. If you do, you’ll turn the ball into just another stable surface to sit on – significantly reducing its benefits.
- Feel free to bounce and move around as much as you like. Remember, movement is key and stillness is the enemy.
Just remember that it’s still easy to slouch on a fit ball. So make sure you’re checking in with your posture often to re-adjust when needed.
Grab yourself a fit ball here.
The plank exercise pretty much speaks for itself these days. It should be the staple of any home strength program thanks to its ability to directly challenge your ability to create (and maintain) a stable spine.
How to Plank Correctly:
- On either your feet (harder) or knees (easier) prop yourself up on your elbows.
- Resist the urge to claps your hands together as this will decrease the stability demands of your upper back.
- Squeeze your glutes, draw up your pelvic floor, and draw in your belly to maintain a strong pelvic and spinal shape.
- Note: Make sure you don’t drop your bottom down or poke it up as you fatigue.
Dosage: 5 sets of 15-30 second holds
If too easy, increase the amount of time you spend performing each rep. The average adult should be able to achieve a 60-second hold. So work up to and beyond this number if possible.
Fit Ball Roll-Out:
Another excellent core strength exercise is the fit ball roll-out. It has a fantastic ability to engage your deep trunk muscles and introduces upper body movement into the equation.
How to Do a Fit Ball Roll-Out:
- Start on your knees with your hands (harder) or elbows (easier) resting on the swiss ball.
- Squeeze your glutes, draw up your pelvic floor and draw in your belly to create a stable pelvis and spine.
- Lift your feet up off the ground as you allow the ball to roll out away from you.
- Roll out as far as you feel comfortable, pause and then return.
- Note: The only joints that should be moving here are your shoulders. Everything else should be locked into a good, strong and stable position increasing the demands on your core muscles.
Dosage: 3 sets of 10 (plus 1-3 second pause)
If too hard on your knees, feel free to place a pillow underneath, or do this on an exercise mat or bed. To make it harder, let the ball roll out further and increase the pause at the end.
Prioritize Good Spinal Shapes
In short, this could really just say “don’t slouch” but there is some nuance to the idea.
Clinically, we can trace the basis of almost all spinal dysfunction back to the positions you put your back in throughout the day. These positions may not directly injure your back, but they will set it up to fail or become dysfunctional over time.
For many, these crappy shapes relate specifically to your sitting habits, but can also refer to how you bend your back or lean forward. It all depends on what you spend the most time doing.
Take note of the differences between a good posture and a bad posture in the video below.
While slouching, take note of one specific thing – the sharpness of the curve in the mid-low back. Clinically, this is the area that undergoes the most load and also the area we unknowingly ask to stiffen.
There’s every chance that the areas you find have become the stiffest when using a ball or foam roller, are the exact areas you hinge through the most when slouching, leaning, or bending.
Similarly, a slouchy posture is so comfortable for many because you’re just hanging off the passive tension of your tissue. Spinal stiffness and tightness is often just your body’s way of touching this area up to withstand the added load. Not only this but it requires little to no muscle activation to maintain. So we lose it.
So if you’re working hard on your spinal mobility and core strength, you must also invest time and energy into fostering better positions. Otherwise, you’ll be stuck in a perpetual cycle of stiffening, weakening, loosening and strengthening – to no end.
So as you can hopefully appreciate, hip bursitis is far more than just an inflamed hip bursa. Following current treatment protocols certainly can, and does, help many people, however, we might be missing the bigger picture here.
If we aren’t trying to uncover and rectify any underlying low back dysfunction we may be missing both the original cause of hip bursitis and any currently hidden handbrakes to its swift regression and long-term elimination.
So if you have found this article looking for that final piece to your hip bursitis pain puzzle, hopefully, this is it. I’d love to help so please feel free to contact me on the social or by leaving a comment below!
Frequently Asked Questions
Under the right conditions, we should always expect hip bursitis to go away. As it is an overload and irritation of the hip bursae, any long-term success relies upon treating the underlying cause of the bursal inflammation. Just treating the hip-related symptoms neglects the importance of the lower back in setting the bursa up to fail in the first place. Those expecting hip bursitis to go away on its own may not always get what they wish for. In some instances hip bursitis will absolutely go away on its own, however, without investigating and addressing its underlying root cause, we can’t guarantee the hip bursitis won’t return at a later date.
Before searching for the best mattress or best mattress topper for hip bursitis, it’s important to understand two things. The first is that the underlying cause of hip bursitis is often low back dysfunction. The second, is that any increase in your hip symptoms come morning is more likely due to factors from the day before rather than the quality of your mattress.
If you wake with increased hip pain, it’s more likely you’ve done something the day before, ie. had your low back in a bad position or overloaded your hip, more so than your mattress or mattress topper suddenly being wrong for you. The key to improving how your hip bursitis feels in the morning is to make sure you pick up on, and improve these features from the day before. Otherwise there’s a strong chance a new mattress won’t solve things long-term.
Having said that, it makes sense that a mattress or mattress topper that is neither too soft or too firm may help the management of your hip bursitis while you work hard on solving the broader issues at play. A soft mattress may not support good spinal posture potentially overloading an already dysfunctional lower back. Alternatively, a hard mattress may compress and further irritate an already irritated and inflamed trochanteric bursa.
Those with hip bursitis can also experience knee pain. However, any knee pain is unlikely to be caused by hip bursitis directly. Traditionally, any knee pain the coincides with hip bursitis usually occurs two ways.
The first can occur as a consequence of the mechanical dysfunction associated with hip bursitis. Weak and tight hip muscles can cause a chain reaction of dysfunction felt at the knee. Similarly, any guarding or change in movement patterns due to hip bursitis pain can also alter the way either knee is loaded, potentially leading to pain in the future.
Alternatively, knee pain associated with hip bursitis can also be referred from the lower back. Considering hip bursitis is often caused and amplified by low back dysfunction, it’s not uncommon for similar pain to extend down into the knee as well.
Losing weight may help your hip bursitis symptoms. However, it’s important to note that the onset of hip bursitis is not directly weight-related, so by definition it may not solve your hip pain. The main benefit of losing weight is to decrease the load going through the inflamed trochanteric bursa, potentially improving the management of your condition.
Traditional Chiropractic approaches such as cracking and adjusting are not usually beneficial for the symptoms associated with hip bursitis.