Hip/Groin Bursitis Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for hip and groin bursitis, typically involving the trochanteric bursa (lateral hip) or iliopsoas bursa (groin). It is a guideline, and individual progression will depend on patient presentation, pain levels, and functional goals. All exercises should be performed within a pain-free range.

I. Pathophysiology

Bursae are small, fluid-filled sacs that cushion bones, tendons, and muscles near joints. Bursitis is the inflammation of a bursa, often caused by repetitive motions, overuse, direct trauma, or underlying biomechanical imbalances. In the hip and groin, the trochanteric bursa (located between the greater trochanter of the femur and the gluteus maximus/iliotibial band) and the iliopsoas bursa (located between the iliopsoas muscle and the hip joint capsule) are commonly affected.

• Trochanteric Bursitis: Pain typically presents on the lateral hip, potentially radiating down the thigh. Aggravated by activities like walking, running, lying on the affected side, and stair climbing. Contributing factors can include tight IT band, gluteal weakness, leg length discrepancy, and poor running mechanics.
• Iliopsoas Bursitis: Pain typically presents in the groin, potentially radiating into the anterior thigh. Aggravated by hip flexion, activities like sit-ups, and prolonged sitting. Contributing factors can include tight hip flexors, hip impingement, and repetitive hip flexion activities.

II. Common Special Tests

• Ober's Test: Assesses IT band tightness, which can contribute to trochanteric bursitis.
• Thomas Test: Assesses hip flexor tightness, which can contribute to iliopsoas bursitis.
• FABER (Patrick's) Test: Assesses for hip joint pathology, but can also reproduce pain in iliopsoas bursitis.
• Trendelenburg Test: Assesses gluteus medius strength, weakness of which can contribute to both types of bursitis due to altered biomechanics.
• Resisted Hip Flexion Test: Provokes pain in cases of iliopsoas bursitis. Resisted hip abduction can provoke pain in cases of trochanteric bursitis.

III. Phase I: Protection (Acute Phase)

Goals: Reduce pain and inflammation, protect the affected bursa, prevent further aggravation.

• Duration: Typically 1-7 days, depending on symptom severity.
• Activity Modification: Avoid activities that exacerbate pain (e.g., running, prolonged sitting, lying on the affected side).
• RICE Protocol: Rest, Ice (15-20 minutes every 2-3 hours), Compression (with a supportive bandage), and Elevation.
• Pain Management: Over-the-counter pain relievers (e.g., NSAIDs) as recommended by a physician.
• Gentle Range of Motion (ROM):
  • Examples: Pendulum exercises, gentle hip flexion/extension/abduction/adduction within pain-free range.
  • Frequency: 2-3 times per day.
  • Sets/Reps: 10-15 repetitions.
• Isometric Exercises: Gentle isometric contractions of hip musculature (flexors, extensors, abductors, adductors) performed in neutral hip position. Hold for 5 seconds, repeat 10-15 times, 2-3 times per day.
• Assistive Devices: Use of a cane or crutches may be necessary to offload the affected hip.

IV. Phase II: Loading (Subacute Phase)

Goals: Gradually increase strength, flexibility, and endurance while continuing to protect the bursa.

• Duration: Typically 1-4 weeks, depending on progress.
• ROM Exercises: Continue ROM exercises, gradually increasing the range of motion as tolerated.
  • Examples: Hip circles, hamstring stretches, hip flexor stretches (e.g., kneeling hip flexor stretch).
• Strengthening Exercises: Gradually introduce strengthening exercises, starting with low resistance and progressing as tolerated.
  • Examples:
    • Trochanteric Bursitis Focus: Side-lying hip abduction (with or without resistance band), clam shells, glute bridges, standing hip abduction.
    • Iliopsoas Bursitis Focus: Short arc quads, hip flexor strengthening with resistance band, gentle abdominal exercises.
  • Sets/Reps: 2-3 sets of 10-15 repetitions, 2-3 times per week.
• Proprioceptive Exercises: Begin incorporating balance and proprioception exercises to improve stability and coordination.
  • Examples: Single-leg stance, balance board exercises.
• Continue Activity Modification: Gradually reintroduce activities as tolerated, monitoring for pain and swelling. Avoid overdoing it.
• Soft Tissue Mobilization: Addressing soft tissue restrictions in the IT band (for trochanteric bursitis) or hip flexors (for iliopsoas bursitis) may be beneficial.

V. Phase III: Return to Function (Chronic Phase)

Goals: Return to pre-injury activity level, improve strength and endurance, and prevent recurrence.

• Duration: Variable, depending on activity level and individual needs.
• Progressive Strengthening: Continue to progress strengthening exercises, increasing resistance and complexity.
  • Examples: Squats, lunges, deadlifts (if appropriate), plyometrics (e.g., box jumps, jump rope).
• Sport-Specific Training: If applicable, begin sport-specific training activities, gradually increasing intensity and duration.
• Endurance Training: Incorporate endurance exercises to improve cardiovascular fitness and tolerance to activity.
  • Examples: Walking, jogging, cycling, swimming.
• Flexibility and Stretching: Maintain good flexibility through regular stretching exercises.
• Functional Exercises: Incorporate exercises that mimic the activities you want to return to.
• Monitor Symptoms: Pay close attention to your symptoms and avoid activities that cause pain.
• Gradual Return to Activity: Gradually increase your activity level, avoiding sudden increases that could aggravate the bursa.

Important Considerations:

• This protocol is a general guideline and should be tailored to each individual's specific needs and progress.
• Close communication between the patient, physical therapist, and physician is essential for optimal outcomes.
• Proper warm-up and cool-down routines are crucial for preventing recurrence.
• Address underlying biomechanical imbalances (e.g., leg length discrepancy, muscle weakness) to prevent future episodes of bursitis.
• Patient education on proper body mechanics and activity modification is essential for long-term management.