Let’s Chat About Bursitis… How to Use the Pool to Cure Your Lateral Hip Pain
It seems bursitis must be contagious, because everyone has it right now… or at least they think they do! But is it really bursitis? And is rest, ice & activity avoidance the best treatment? In today’s post, we’ll share evidence-based recommendations for dealing with lateral hip pain, including specific ways aquatic exercise can help you feel better faster!
Hip pain has a wide variety of causes - from labral tears and osteoarthritis to muscle strains and fractures. Hip pain might not even be coming from the hip at all: it could be referred from the lower back! Insidious onset of pain at the outer part of the hip (the greater trochanter) is often labeled as “bursitis,” and the longstanding advice was to “rest and ice.” However, research shows that true bursitis is actually not as common as we once thought, and lateral hip pain is more often associated with gluteal tendinopathy.
If you’re looking for a comprehensive article (with photos, research links, etc.) about greater trochanteric pain, we recommend this one by Physiopedia. If you want the CliffsNotes version, keep reading below!
What is bursitis?
A bursa is a small, fluid-filled sac that provides cushioning between bones, muscles, tendons, and/or skin. Bursae (that’s the plural of bursa, not bursas!) reduce friction between these structures and allow for smooth movement. The adult human body has approximately 150-160 bursae, including three near the greater trochanter (that’s the bony projection on the outer femur). The are three bursae that are positioned under the gluteal tendons (the gluteus medius, gluteus minimus, and gluteus maximus) and provide cushioning between the greater trochanter and the iliotibial band, a thick band of tissue that runs from the hip to the knee. Various factors can cause compression and irritation of these bursae, including IT band tightness, trauma (like a fall directly onto the hip), muscle imbalances, and repetitive stress.
Bursitis is the term used to describe inflammation of the bursa, which is typically linked to pain and tenderness. Middle-aged women, overweight individuals, and people who have recently changed their gait because of another injury are most likely to develop trochanteric bursitis. But how often is the bursa actually inflamed? Previously, any pain at or near the greater trochanter was referred to as bursitis. However, over the past decade, studies have shown that bursitis is found in just 20% of lateral hip pain cases whereas gluteal tendinopathy is much more prevalent. (Pianka, et. al 2021; Reid, 2016; Long, 2013)
What’s tendinopathy?
Tendinopathy is a term used to describe tendon dysfunction, or changes within the tendon (like microtears and degeneration of the collagen fibers) after the tendon’s capacity is exceeded. This usually occurs as a result of overuse, overloading, or repetitive movements, and tendinopathy can lead to pain, stiffness, and reduced function. Gluteal tendinopathy specifically describes dysfunction of the gluteal muscles and their tendons where they attach to the greater trochanter on the outside of the hip. The gluteus medius muscle is most often to blame, although the gluteus minimus and gluteus maximus muscles are sometimes involved, too. Gluteal tendinopathy is most common in women, overweight individuals, and those who have recently changed their training volume (like doing a lot more walking or hiking while on vacation) or starting a new activity (like gardening or climbing stairs frequently in a new home).
How do I know if it’s gluteal tendinopathy or bursitis? Does it matter?
Both tendinopathy and bursitis will produce pain at the lateral hip, with symptoms ranging from a dull ache at rest to sharp pain with activity. Advanced diagnostic imaging is able to show tissue tears and inflammation (simple x-rays will only show issues with the bones, like fractures, FAI, and arthritis). Skilled physical therapists and sports medicine practitioners can also perform detailed evaluations to determine the true cause(s) of your symptoms. However, the treatment, regardless of diagnosis, is usually quite similar (and yes - you can have both tendinopathy AND bursitis!).
There are basically three phases of rehab for lateral hip pain:
PHASE ONE – GOAL: Reduce pain & maintain/improve mobility
Start with activity modification. Whether you’re dealing with bursitis or tendinopathy, activity modification in the initial stages of healing can be helpful. Reducing compression of the bursae or the gluteal tendons on the greater trochanter should help to relieve symptoms. Here are a few tips:
Avoid sleeping on the affected hip. If possible, sleep on the unaffected side with a pillow between your knees to limit hip adduction.
Avoid sitting cross-legged or sitting in deep hip flexion (in a low chair or car seat) for extended periods of time.
Temporarily avoid piriformis and IT band stretches. Stretching those structures across the bursa or tendons can cause compression & tissue irritation. Add gentle piriformis stretching to your routine as your symptoms improve.
If you’re in quite a bit of pain, consider using a crutch or cane on your unaffected side to offload your hip. Similarly, hold a handrail on the unaffected side when climbing stairs.
Back off a bit with walking or running. Track how many steps you can take without exacerbating your symptoms (i.e. no more than 3/10 pain), and increase your step count gradually over the next few days/weeks.
In the pool, reduce your range of motion as needed with lower body exercises, like deep water jacks and side leg lifts. All too often, our clients feel they should skip all exercises that require some hip abduction (abduction means moving out to the side; away from the body), but this is not true. The water can be very forgiving, and you can often perform exercises in the pool that you’re not ready for on land.
Skip the modalities (or use sparingly). You might try using cold packs or hot packs for temporary pain relief. If your hip pain is not due to actual inflammation, then passive modalities like ultrasound and bursa injections are unlikely to help. And remember - tendinopathy will not heal with activity modification alone! Gradual tissue loading is necessary to increase the tendon’s tensile strength... so exercise is imperative for healing & prevention.
Begin a daily stretching/mobility program. At home, start with a supine knee to chest stretch, hamstring stretch, and hip flexor stretch, holding each for 30-60 seconds and repeating 2-3 times. You can also introduce standing mobility exercises to tolerance (2-3 sets of 10-15 reps, holding at end range for a few seconds), such as a standing march and side leg lifts. Avoid pain – move as far as you can but stop before you experience symptoms!
Keep moving. Hip pain is not an excuse to stay in bed. Deconditioning occurs quickly, so continue with your workouts while you address your pain. In the pool, you may be able to perform your usual upper body, core, and selected lower body exercises without exacerbating symptoms. You can also incorporate the stretching and mobility exercises (listed above & pictured below) quite easily.
PHASE TWO - GOAL: REDUCE PAIN, INCREASE MOBILITY, AND STRENGTHEN HIP MUSCLES
If you have no pain at rest and no more than 3/10 pain with exercise, it’s time to add hip strengthening exercises to your routine! Addressing muscular imbalances and progressively loading your muscles will improve the tensile strength of your tendons. Glute strengthening is the KEY to getting better, otherwise your symptoms will return again when you resume your daily activities. Aim to perform your strengthening exercises 3-4 times a week.
Recommended land-based exercises typically include bridges, banded hip flexion/abduction, squats, and side planks, but check with your physical therapist to find out what exercises are best for you.
Get in the pool! Aquatic exercise is a great way to start strengthening without irritating your hip since buoyancy reduces joint compressive forces. Plus, performing exercises in a standing position (in the pool) simulates functional activities and easily allows for gradual loading of the gluteus medius (Need more loading? Go shallower! Want less loading? Go deeper!).
Aim for 3 sets of 10-15 reps of each of the following shallow water exercises (and repeat on both legs):
Side leg lifts with ankle fins*
Donkey kicks with ankle fins*
Squats on 4” block or bottom pool step (optional: band above knees)
Forward step ups onto 4” block or bottom pool stair
Lateral step ups onto 4” block or bottom pool stair
(*No fins? Increase the resistance of water by simply moving faster. We do not recommend using ankle weights in the pool.)
PHASE THREE - GOAL: CONTINUED STRENGTHENING FOR INJURY/PAIN PREVENTION
Want to reduce the chances of a flare-up? Keep getting stronger! Progressive loading of the hip muscles, 3-4 times per week, will decrease the likelihood of another tendinopathy (or bursitis) episode. When your symptoms are well-controlled and your exercises are beginning to feel easy, it’s time to move into phase three of your strengthening program.
Here are some of our preferred shallow water exercises: (aim for 2-3 sets of 15-20 reps)
Standing side leg lifts & front leg lifts with ankle fins, moving as quickly as possible
Reverse lunge to forward kick
Single leg squats or multidirectional reaches (on 4” block or bottom pool stair)
Forward step ups to single leg balance (add weighted ball or resistance bungee for more challenge)
Lateral step ups to single leg balance (add weighted ball or resistance bungee for more challenge)
Banded sidestepping (with loop above ankles or with anchored cord/waist belt)
Banded backward walking (with loop above ankles or with anchored cord/waist belt)
Balance training and plyometric exercises are also quite effective for long-term strengthening and injury prevention.
If you’re dealing with lateral hip pain, there’s a good chance your doctor will tell you it’s bursitis. Whether you truly have bursitis or it’s something else (like gluteal tendinopathy), keep moving. Rest alone is not a cure. If you’re in the acute/initial phase of pain, modify your activities & perform gentle hip mobility exercises and stretching. Once you’re feeling better, begin a targeted hip strengthening program to strengthen the muscles/tendons near your greater trochanter. Ongoing, progressive exercise is key to injury prevention. If you’ve had more than one episode of hip pain in the past year, you’re not sure what exercises to do in the pool, or you think your alignment (exercise form) might be contributing to your pain, seek the guidance of an aquatic physical therapist or aquatic personal trainer.
Content provided on this website is for informational and educational purposes only; it does not constitute providing medical advice or professional services. Always seek the advice of your physician regarding your health conditions and prior to initiating an exercise program.
