Podcast: Are you sure it’s hip bursitis?… Maybe not!

Podcast Transcript

Hello and welcome to The Bone and Joint Playbook with Dr. John Urse, Tips for Pain-free Aging. Today’s topic is, are you sure it’s hip bursitis? Maybe not! Let’s listen in.

Terry: Hey there Dr. Urse, welcome to episode number four of The Bone and Joint Playbook.

Dr. Urse: Hey, thanks Terry. How are you today?

Terry: I’m great. So, what do we have going on today?

Dr. Urse: Well today we are going to start on a new topic in the hip area called, Are you sure its hip bursitis? Maybe not!

Terry: What is hip bursitis? What is bursitis?

Dr. Urse: Bursa’s are little cushioning sacks that the committee on design puts over all of the bony prominences in your body. So, if we feel the outside of our elbow there is a hard bone there, there is also a cushioning sack called a bursa over that. There is one on our kneecap, there is one on the outside of our hip bone and we’re going to talk about that today. We also have bursas in other places, we have them in our shoulder, in our ankles and different locations to cushion or to help pad areas where bones might rub against things, and it helps us with getting through our lives and the different surfaces we encounter.

Terry: And what are the symptoms of bursitis or bursa?

Dr. Urse: Well, we should first talk about what bursitis is. When you hear the word “itis” at the end of anything like bursa, that means inflammation of that structure. So, if you go see your doctor for a sore throat and say you have tonsillitis, my tonsils are inflamed. So “itis” and inflammation usually go hand and hand and it usually means something is red, swollen, painful and uncomfortable. If you have trouble swallowing with tonsillitis a person with hip bursitis may have symptoms of trouble laying on their hip at night, going up and down steps, weakness climbing stairs or difficulty getting in and out of car or getting in and out of bed. These are things we are going to talk about today, because the word bursa helps you cushion things, but when it gets inflamed it becomes angry or red as we talked about with an “itis” at the end of it, like bursitis, then it becomes something that brings people to see their medical provider.

Terry: How do I know I have bursitis versus something else? Maybe another kind of hip problem.

Dr. Urse: Well, that’s a great question Terry. Those are the things your doctor or physician assistant has to sort out by asking you questions. So, we always start with a history, we ask people when it started, what made it worse, did you fall off a horse on a certain day and everything started hurting after that, did it come on gradually, do you feel like there is numbness or tingling. Or is there burning down the leg which could be a sign of a nerve problem, we’ve all heard of the sciatic nerve in the low back, and sometimes that nerve goes right by the hip and mimics a hip problem. It depends where the nerve is being pinched in the low back, if you look in one of our previous podcasts we talked about pinched nerves. Each level of the back has a nerve that goes to a certain part of the body. The low back area has part that goes to the back of the hip, I have a patient that I just saw with a L3 nerve problem and had all pain in her rump or butt but no pain down the leg. If you get lower in the spine like L5 and S1.

Terry: What stands for L? I don’t know what that means.

Dr. Urse: L stands for lumbar. Our spine is broken into different segments called the neck, or cervical, the middle of the check is called thoracic, and the low back is the L for lumbar and your tailbone called the sacrum is the lowest part of the spine. Between each spine bones are little discs that cushion and those can sometimes cause irritation to a nerve that goes out to the right or left side of the body. So, we want to ask questions and see if this could be a low back problem causing referred pain. We have all tapped on our funny bone of our elbow and had some tingling down to our fingers, well you’re hitting your funny bone nerve which is causing a transmission of symptoms which is called referred pain. We have heard of sciatic nerve pain down the leg, well the nerve problem goes all the way to your toes, but it may start in your low back. So, a hip problem may be the hip or the hip joint which is closer to the groin, it may be the low back, or it may could be where that thing called the sacrum meets the back and pelvic bone and that’s called the SI or sacroiliac joint. So, there are a lot of things people can get into trouble with from doing yard work, having babies, getting in car wrecks that wrench their backs, wrench their hips and sometimes these get fixed by your medical providers, your chiropractors, or physical therapists or sometimes it just gets better on its own with a little rest. When the problem persists this is where continued discomfort on the outside of the hip is something that brings people to see us, and that’s what we’re going to talk about today.

Terry: So, are you an expert, I know you’re an orthopedic surgeon, but do you have some specialization in hip replacement or hip bursitis issues?

Dr. Urse: Well, I do Terry. A lot of our orthopedic surgeons replace hips, those are what we do for real bad arthritis and a plain x-ray is going to show that. So, if your hip is really bad just like your knee, shoulder, or ankle, we have what is called joint replacements. For the most part we are going to try and exclude those problems today because when the hip is real bad in the joint it can make it hurt around the joint, on the outside, in the front or back. We are not really looking at those problems today. I also have training in what is called hip arthroscopy, where we look into the hip with a light and try to fix problems in the joint or outside the joint. Some of them are in the sitting area called the hamstrings those little muscles you sit on your sitting bone. Some are the outside of the hip where the pocket of your pants would be right by your butt. So, there is a hip bone right there and we can all reach out with our palm and push on what is called the hip bone. I also teach some of these hip arthroscopy courses to doctors around the world who come in to learn about hip arthroscopy, which is a way to look into the hip with a light. The thing that makes it a little tricky is you have to pull on the leg in traction in order to get the hip partway out to get instruments in that are a little more difficult to do so most physicians don’t do that type of surgery, but I do that type of instruction, so I am familiar with a lot of patients with hip issues.

Terry: Would my normal family practitioner understand bursitis? Is that something that is so common in the medical world that everyone knows how to treat it or is it something that is unique about the hip area?

Dr. Urse: Well, the family doctors and the physician assistants and orthopedic surgeons all know what hip bursitis is, just like they know shoulder bursitis. You would not go in for a shoulder problem where you have pain and weakness and have three or four cortisone shots in the bursa without saying “doc, I can’t put a dish on the shelf, couldn’t it be my rotator cuff, that lifts my arm up. Maybe I need an MRI to see if I’ve torn something since, I can’t lift my arm”. Well in the hip we do hip injections over and over from different doctors and providers and they keep putting it in the same place expecting a different result, but that’s not what the problem is. So today we are going to talk about all of the things that aren’t hip bursitis that make the outside of your hip hurt so we can find the right thing that we can do to make the problem better.

Terry: So, help me understand as someone walking into your office for the first time and I have pain in my hip. What is it you do to help eliminate the other things so you can isolate that it is hip bursitis?

Dr. Urse: Remember as we said, so we talk about the history, we ask you how it started, point to where it hurts, does it travel anywhere, what makes it worse, walking, sitting, or standing, is there numbness or tingling? All of those things are important has the hip already been replaced? Some people have a torn muscle on the outside of the hip and you can’t see it on the x-ray, so the x-ray may look like a great hip replacement, but the person is still limping and can’t go up a set of steps because the muscle that lifts the leg is torn. So, the first thing we do is take an x-ray and say “gee, the x-ray don’t show anything in the bones, that’s a problem, it’s not arthritis, the hip replacement looks great and maybe it’s not in the hip itself,” but maybe it could be and we will talk about that. We then do an examination so in the office you want your doctor to check your leg strength when I check your arm called the rotator cuff muscles, I’m pushing against your arm as you hold it away from your body and if you have good arm strength your arm is like a little rope that lifts away from the body with a rotator cuff tendon. Tendons are little rope attachments that the muscle uses to bone to move body parts. So, if we are looking at leg muscle strength I’m going to ask you to stand on one leg and do a knee bend or try and get lift your rump off the table and do a bridge test to see how your glute muscles are. So, if we reach back to our butt, everyone has a little bit of muscle back there, some have extra too. There is a muscle that lifts your leg away and they are called the gluteus medius and gluteus minimus muscles. There are two of them just like the rotator cuff of the arm has different muscles that turn the arm in or out. When your doctor examines you and sees those muscles may be weak or a source of pain then we need to do more than just an x-ray. Thats when an ultrasound test, which uses radio waves and signals from a sound wave, people have seen ultrasound when looking for a baby’s heartbeat. The other test which is the gold standard of hips is an MRI. An MRI is a more detailed test that shows the muscles, the cartilage in the joint of the hip and any problems that might be torn in the joint. We have to be sure some outside hip pain might not be coming from inside the hip joint. If you had seen me for the first time and you have outside hip pain and have had a couple bursa shots, my first thing I’m going to do is put some Novocaine in your hip joint with ultrasound to know that I am in the joint, some doctors do that with an x-ray thing called a fluoroscopy unit, but it causes a lot of radiation for both of us. If the outside of your hip pain goes away with a shot in your hip joint which is in the groin of your rear where your knee bends up and down then that maybe a problem in your hip causing referred pain to the outside of your hip, therefore we talked about looking in your hip with a light, you may need a hip arthroscopy to fix something on the outside of the hip. You ask me what I would do next if I did the shot in your hip and it didn’t help, well we’ve eliminated it being in the hip joint. I would check your back and we don’t think it’s your sciatic nerve, then most of the MRI’s are going to tell you what is going on with that outside hip bone area. Ironically, what percent of the people have this hip bursitis problem as their final diagnosis?

Terry: I have no idea, I would guess it’s a lot of people.

Dr. Urse: That would be a wrong answer, Terry. I ask my students and residents that same question. The answer is less than 10% of people have hip bursitis as the main problem. So that means 45% of people have a complete tear of the hip muscle that lifts your leg away called the glute tendon. So, if you think of a rope that lifts an awning, if that rope is not attached to the awning it’s not moving that awning up, right? If people have a rotator cuff tear of their shoulder and they can’t lift their arm, that has to be fixed sometimes. So, when there is a tear of a tendon or a ropey structure that is going to cause most surgeons to say it needs to be fixed or it’s never going to really lift that leg away from the body. There are two ways to fix it, you can open it with an incision and put stitches in like a shoelace, I have a technique I use with a scope with little holes, and we still put in little stitches and these little stitches in called anchors like we do a shoulder. In fact, this procedure for the hip is called the rotator cuff repair of the hip because the rotator cuff is something people know lifts your arm and these muscles called the glute tendons lift the hip away.

Terry: Now I know you own a patent for something, is this the thing that you own the patent for?

Dr. Urse: I do own a patent on one of the repair techniques for using two rows or what’s called a double row anchor repair of this gluteus medius tendon tear. It’s just a technique I developed about ten years ago and it’s not something other people can’t use, it’s just something I developed at the time.

Terry: Ok, so continue you were telling me about how we go about repairing these things.

Dr. Urse: So again, we are going to look at that MRI report and say one of three things are the most common problem in the hip. One of them is the bursa, but the name of this podcast is, Are you sure its hip bursitis….maybe not. The reason is that it’s only hip bursitis 8% of the time. So, 92% of people don’t have hip bursitis, they either have a full tear, we talked about a complete tear 40 some percent of the time, but fortunately about 60% of the people or a little more than that, have what’s called a partial tear of the tendon. Now we talked about a tendon being a ropey structure, so if you take a rope and rub it on the edge of a jagged rock it may start fraying, that’s called a partial tear or maybe it’s half a rope and it’s not completely torn, you could hang off a cliff with that rope if you wanted. In those cases, there are some less invasive ways to help that tendinitis problem, and again this tendon is now inflamed or partially torn. One reason we think this is a common problem, particularly in women who tend to get this problem five times more common than men is because of the way their pelvis is made to have babies. The outside hip bone rubs against one of the bands of fascia they call it and people have talked this thing called the IT band on the outside of your thigh. It runs all the way down to your knee much like a barber shop strap and that can rub against the tendon like that rope against the rock, and they think that’s why some of these tendons get partially torn or frayed, more commonly in women than men.

Terry: So, let me ask you an odd question. I always heard there is folklore of when the weather turns bad peoples bursitis acts up. Is there any truth to that?

Dr. Urse: Well, it’s probably not as much as their bursitis as it is their arthritis. So, if you have bad knees or bad hips from cartilage wear, and cartilage is the white stuff or the gristle at the end of a chicken bones that cushion our joints. Most people that have arthritis will tell you well it’s going to rain later today. So, it’s really more the arthritis in the joint than the bursitis outside the joint. The bursas again are the areas where the bony prominences rub like on the outside of your kneecap, we have a knee bursa. There is a thing called housemaids knee where somebody who is on their knees cleaning a carpet may rub that cushioning sack and get it inflamed or swollen and it becomes a painful knee bursitis. So, I think the weather question is related more to arthritis than bursitis.

Terry: So, is this an old persons condition?

Dr. Urse: Not necessarily. It’s more common probably over age 40, and again we compare this a lot to the shoulder because the shoulder muscles lift the arm away, those rotator cuff muscles. So, when we are in our 20’s and 30’s helping our college roommate move into a dorm, we may have some shoulder pain that is just a little inflammation of the tendon that lasts a few days and when you’re young most things like that don’t just tear. Over time that rope against the jagged rock starts getting more and more irritation and finally it breaks or tears. We see the gluteus medium tears or what’s called the rotator cuff of the hip, usually in patients over 50 and commonly older than that about 60 or 70. As people are living longer to their 90’s these are much more common problems that I think are mostly unrecognized.

Terry: So, tell me the treatments that you have, I know that you talk about PRP Injections for other things, is that something we can use for the conditions people might have when they suffer from bursitis or they think it’s bursitis. Tell me how that would work.

Dr. Urse: Well, we talked about on one of our earlier podcasts about platelet rich plasma and that’s mercifully abbreviated to PRP. That takes a person’s own blood and we spin it and concentrate it in order to get these thousand or more anti-inflammatory and healing proteins that are in the blood and we can put them into an area of injury like the hip tendon called the gluteus medium tendinitis. So, we are going to look at three of the things that the MRI may have shown. Bursitis, maybe just a cortisone injection helps that. Unfortunately, about 90% of people won’t get permanent relief with that. We always want to try something like therapy, physical therapy and there are some new technologies like shock therapy or what’s called extracorporeal shock wave therapy can help hip tendinitis which is another form of that inflamed tendon. If we then go to more current technologies the PRP has been studied in people with tendinitis and so that group of people, not the people where the muscle is completely torn and where the tendon is detached, those probably need to be fixed through a scope procedure. If you have just a partial tear which is probably about 60% of the people with outside hip pain, which is the majority of people. Fortunately, some of the newer laser technologies of putting a laser in or adding some of the platelet rich plasma of their own blood in some studies shown it gives patients up to two years relief with a very minimally invasive procedure. An ultrasound is used to find the little area of tendinitis or the tear out by the outside hip bone, then the blood is drawn from a person’s arm using their own blood proteins and after we spin it in a spinner device called a centrifuge, we put that platelet rich plasma right into that area where the tendon is torn. The studies show some people get up to two years relief with that which is just a simple needle injection through the skin into the inflamed tendon area.

Terry: How long does a cortisone shot last?

Dr. Urse: A cortisone shot may only last you weeks or maybe a month or two. Number one it isn’t going to fix the problem because it’s not the bursa, cause the MRI said the bursa is only the problem less than 10% of the time. That is why having repetitive bursa shots with cortisone doesn’t make a lot of sense. Let me give you another example, if you had hip bursitis which some people have, and you get a cortisone shot, you may get a years relief with that. Then I would say come and see your doctor every year and get a shot in the bursa, that’s fine. I’m talking about the people that don’t get relief or have very short-term relief of only a week or two. They’ve tried therapy and something is just not getting better on the outside of their hip, they can’t go up a set of steps, they can’t sleep on their hip at night, they can’t get out of a car. Then you have to dig a little more to find the problem

Terry: Thats fascinating that PRP can help that long of a time. I know cortisone shots are relatively inexpensive, but what does a PRP injection, you do not need to tell me the cost, but is is more expensive than a cortisone shot?

Dr. Urse: Well insurance companies pay for cortisone because that is a steroid what’s called an anti-inflammatory medicine and we use cortisone all over the place, we use it in your knee, your shoulder, your tennis elbow, or an inflamed bursa in other parts of the body, there is a knee bursa. Unfortunately, some of the newer technologies called platelet rich plasma and stem cells are not all on board with all of the insurance companies, so the patient may have to pay part of the coverage for their care if they use the PRP. There are ways that it’s combined with a procedure, we talked about the laser, and we call it a through the skin tendon injection called a tenotomy. That can sometimes be done as a procedure where the anesthesia gives a medicine to a person as an outpatient, which is a minimally invasive thing where the patient gets a sedative or relaxing medicine and then we put the PRP in with the hospital bill and let the hospitals fight it over with the insurance companies. I think we are going to see an emerging use of these technologies. We’re in Dayton Ohio with Wright Patt Air Force Base and the military is insured by Tricare and some of the other carriers and they are very on board for some of these PRP and stem cell procedures as they are insuring a lot of people who can’t all take time off for surgeries and they have seen the benefits of that and they are one of the more emerging carriers that help cover some of the costs for these procedures. For instance, in Dayton, Tricare pays for a PRP injection for your tennis elbow which is pretty neat because it’s better than therapy or a cortisone shot. That is a new technology that some insurances haven’t adopted, but one of them has.

Terry: As we come to a close for this episode, is there anything that we should make sure the listener knows about a bursa or bursitis that we haven’t covered.

Dr. Urse: I think they should just realize that if their problem isn’t getting better, they probably haven’t found what the problem is, and they need to look a little harder. I always tell my patients that someone somewhere knows what is wrong with you. We send people up to the Cleveland Clinic and Mayo Clinic and some difficult diagnosis are only found in some places. Either way the idea is that somebody should be able to find out why you have pain, and if the results you’re getting aren’t improving your condition, I think you need to look a little harder, or ask your doctor to do a few more tests, or refer you to someone who might be able to help you with the problem.

Terry: Alright Dr. Urse, thank you very much and this has been another episode of The Bone and Joint Playbook with Dr. John Urse. Thank you very much Dr. John Urse.

Dr. Urse: Thanks Terry. I will give a plug for the website DrJohnUrse.com. There is a blog section that has some article reviews about using some of these injections for the hip and people can review those if they would like.

Terry: Very good, thanks again.

Dr. Urse: Thank you.

Thank you for joining us today on this episode of The Bone and Joint Playbook with Dr. John Urse, Tips on Pain-free Aging. Please join us again for another episode. This has been a production of Doctors Unmasked, produced by Terry O’Brien.