Becky Hanna: A 27-Year-Old Female With Severe Left Hip Pain

Learning Objectives

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Learn the common causes of hip pain.
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Develop an understanding of the unique anatomy of the hip joint.
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Develop an understanding of the bursae of the hip.
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Develop an understanding of the causes of trochanteric bursitis.
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Develop an understanding of the differential diagnosis of trochanteric bursitis.
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Learn the clinical presentation of trochanteric bursitis.
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Learn how to examine the hip and associated bursae.
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Learn how to use physical examination to identify trochanteric bursitis.
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Develop an understanding of the treatment options for trochanteric bursitis.

Becky Hanna

Becky Hanna is a 27-year-old sales representative with the chief complaint of, “My left hip is killing me.” Becky stated that she was traveling to a sales meeting in Hilton Head about 3 weeks ago when she developed left hip pain after jogging on the beach. “Doctor, I am really fit. I had on pretty good shoes. I jog every day, but I’m not used to running on sand. I knew better than to run on sand, but the beach was just so beautiful—but I knew better.” I told her not to be too hard on herself, that we would figure out what was going on.

I asked Becky about any antecedent hip trauma and she just shook her head no, but went on to say that from time to time, her left hip would bother her a little after completing a marathon, but a couple of Advil and she was good to go. This time, the pain just wouldn’t go away in spite of using the Advil and a heating pad. Becky said the side of her hip was somewhat swollen and “squishy,” and that it felt hot to touch. I asked Becky what made her pain worse and she said, “Any time I start to walk or run, I feel a sudden, sharp pain and a kind of catching sensation. Doctor, my hip really hurts and the pain is messing with my sleep. Every time I roll over onto my left side, the pain in my left hip wakes me up.”

I asked Becky to point with one finger to show me where it hurt the most. She pointed to a spot just over the greater trochanter on the left and said, “Doctor, it hurts right here!”

On physical examination, Becky was afebrile. Her respirations were 18 and her pulse was 64 and regular. Her blood pressure was 118/68. Becky’s head, eyes, ears, nose, and throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the left lateral hip revealed mild swelling. The area over the left greater trochanter was warm but did not appear to be infected. The left hip felt “boggy” on palpation, and there was marked point tenderness over the greater trochanter. Palpation of the left greater trochanter area exacerbated Becky’s pain. Range of motion of the hip joint, especially resisted abduction of the joint, caused Becky to cry out in pain. I performed a resisted abduction release test, which was markedly positive on the left and negative on the right ( Fig. 5.1 ). The right hip examination was normal, as was examination of her other major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. I asked Becky to walk down the hall, where I noted a Trendelenburg gait was present ( Fig. 5.2 ).

Key Clinical Points—What’s Important and What’s Not

The History

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Acute onset of left hip pain following running on a soft, sandy surface
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Pain localized to the area of the left greater trochanter
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Pain associated with a catching sensation
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No other specific traumatic event to the area identified
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History of mild self-limited left hip pain after running marathons
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No fever or chills
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Sleep disturbance
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Difficulty walking or running

The Physical Examination

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The patient is afebrile
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Point tenderness to palpation of the area over the trochanteric bursa
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Palpation of left hip reveals warmth to touch
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The left lateral hip is swollen with “bogginess” over the left greater trochanter
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No evidence of infection
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Pain on range of motion, especially resisted abduction of the affected left hip
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The resisted abduction release test was positive on the left (see Fig. 5.1 )
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A Trendelenburg gait was present (see Fig. 5.2 )

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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Examinations of other joints other than the left hip were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the left hip
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Ultrasound of the left hip

Test Results

The plain radiographs of the left hip were reported as normal. Specifically, there was no calcification in the area of the trochanteric bursa suggestive of chronic bursitis. Ultrasound examination of the left hip revealed an effusion around the trochanteric bursa ( Fig. 5.3 ).