Trochanteric Bursitis After Hip Replacement: Causes & Treatment

Trochanteric bursitis develops in roughly 5 to 8 percent of people after a total hip replacement, making it one of the more common reasons patients still have lateral hip pain despite a successful implant.¹ The condition causes aching or burning pain on the outer side of the hip, often noticeable when lying on that side at night, climbing stairs, or simply walking. What makes it frustrating is that the hip replacement itself may be functioning perfectly, yet the surrounding soft tissues tell a different story.

It Is Often More Than Just a Swollen Bursa

The name “trochanteric bursitis” implies that a fluid-filled sac over the bony prominence on the outer hip has become inflamed. That is sometimes part of the picture, but research over the past couple of decades has shown that the pain in this area is frequently driven by damage or degeneration of the gluteus medius and gluteus minimus tendons, with or without actual bursal inflammation.² These two muscles are the hip’s main abductors, responsible for keeping your pelvis level when you stand on one leg or walk. Their tendons attach right at the greater trochanter, the same spot where the bursa sits, so the pain feels identical regardless of what is actually irritated.

Surgeons increasingly use the broader label “greater trochanteric pain syndrome” (GTPS) to capture this overlap. The distinction matters because an inflamed bursa and a torn or degenerating tendon respond to different treatments. A corticosteroid injection can calm an inflamed bursa quickly, but it does little for a structurally damaged tendon. Histological samples taken during surgery for stubborn cases have sometimes shown no inflammation at all, just degenerated tissue.³ Understanding what is actually going on inside the hip helps explain why some treatments work and others fall flat.

Why Hip Replacement Can Trigger It

The surgery itself introduces several potential irritants. Any surgical approach to the hip requires cutting through or retracting soft tissue around the greater trochanter. During a posterior approach, the short external rotators are detached and later repaired, and the gluteus medius is retracted. During a direct anterior approach, different muscles are displaced, but the abductor tendons can still be strained by the retractors holding tissue out of the way. Either route can leave tendons bruised, weakened, or partially torn at their attachment points.

Beyond the direct surgical trauma, a hip replacement changes the mechanical environment. The new implant may restore leg length and offset differently than the native anatomy, subtly altering how forces travel through the abductor muscles and the bursa with every step. Even small mismatches can create repetitive irritation. Patients who had a limp before surgery often spent years walking with altered mechanics, and those compensatory movement patterns do not disappear overnight after the implant goes in. The abductor muscles may have been weak going into surgery and remain so afterward, especially if rehabilitation is incomplete.

When the gluteus medius is significantly disrupted, patients sometimes develop a Trendelenburg gait, in which the pelvis drops on the opposite side during walking. One gait-analysis study of patients with known gluteus medius disruption after hip replacement found persistent trochanteric pain and a positive Trendelenburg sign, and even a surgical muscle transfer did not reliably restore the hip’s abduction strength.⁴ That finding underscores how important the abductor tendons are and how difficult it can be to fix them once they are seriously damaged.

Who Is Most at Risk

Women are considerably more likely to develop trochanteric bursitis after hip replacement than men. A radiographic analysis of risk factors found that women had about 1.8 times the risk compared with men, and sex was the only factor that reached statistical significance in the initial analysis.⁵ The reasons are not entirely settled, but women tend to have wider pelvises, which increases the angle at which the abductor tendons pull on the trochanter. Hormonal factors may also play a role in tendon health, and women are more likely to have pre-existing gluteal tendon degeneration before surgery ever occurs.

Other suspected contributors include higher body weight, which increases the load on the abductor mechanism with every step, and lower pre-operative activity levels that leave the muscles weaker heading into surgery. In surgeon surveys, respondents estimated that on average about 8 percent of their hip replacement patients went on to develop trochanteric bursitis, though individual estimates ranged widely from zero to 20 percent depending on the practice.³ That spread likely reflects differences in patient populations, surgical techniques, and how aggressively surgeons screen for the problem.

How It Is Diagnosed

Most surgeons diagnose post-replacement trochanteric bursitis based on the clinical exam alone, without ordering imaging. In a survey of orthopaedic surgeons, about 69 percent said they relied entirely on a physical examination, and fewer than 5 percent routinely obtained a diagnostic ultrasound.³ The hallmark finding is tenderness when pressing directly over the greater trochanter, with pain that often reproduces or worsens when the hip is moved against resistance in abduction or external rotation.

Imaging comes into play when the diagnosis is unclear or the pain does not respond to treatment. Standard X-rays are the first step to rule out implant loosening, fracture around the prosthesis, or abnormal positioning of the components. When radiographs look normal and the pain persists, the American College of Radiology considers ultrasound or MRI to be the appropriate next studies.⁶ Ultrasound is quick and can visualize fluid in the bursa and partial tears of the abductor tendons in real time, while MRI gives a more detailed picture of tendon integrity, muscle atrophy, and any fluid collections that might suggest other problems. In a replaced hip, MRI requires metal-reduction protocols to minimize artifact from the implant, so the images are never quite as clean as they would be in a native hip, but modern techniques handle it well enough to be clinically useful.

One important job of imaging is to separate trochanteric bursitis from other sources of pain that can mimic it. Iliopsoas bursitis, for instance, causes anterior groin pain but can occasionally overlap with lateral symptoms. In one reported case, a large iliopsoas bursal fluid collection after hip replacement compressed the femoral nerve, causing thigh weakness and numbness that initially clouded the diagnosis.⁷ Implant loosening, infection, and referred pain from the lumbar spine are other diagnoses that need to be excluded before settling on a trochanteric bursitis label.

First-Line Treatment

Conservative management is where nearly everyone starts. In surveys of surgeons who treat this condition, the most commonly used first-line options were oral anti-inflammatory medications, structured physiotherapy, and corticosteroid injections, each used by roughly half or more of respondents as an early step.³ In practice, many patients are started on all three simultaneously or in quick succession.

Physiotherapy focuses on strengthening the hip abductors, stretching the iliotibial band, and correcting any gait abnormalities that put extra stress on the trochanteric area. Surgeons typically prescribe about six weeks of structured therapy before reassessing. If therapy has not produced meaningful improvement by around 12 weeks, most consider it to have failed.³ Roughly a third of patients with post-replacement trochanteric bursitis do not get adequate relief from physiotherapy alone.

Simple lifestyle adjustments also help. Sleeping with a pillow between the knees reduces pressure on the affected bursa at night. Avoiding prolonged standing on hard surfaces and switching to lower-impact exercise like swimming or cycling takes repetitive load off the lateral hip. Ice applied to the outer hip after activity can temporarily reduce inflammation, and many patients find that consistent icing in the early weeks does as much good as anti-inflammatory pills.

When Injections Help and When They Do Not

Corticosteroid injections are one of the most widely used tools for this condition. Surgeons estimate that roughly 30 percent of patients with post-replacement trochanteric bursitis eventually receive one.³ The injection delivers a potent anti-inflammatory directly to the area, and when bursal inflammation is the primary driver of pain, the relief can be dramatic and sometimes lasting.

The catch is that not all trochanteric pain after hip replacement stems from inflammation. As noted earlier, tissue samples from stubborn cases have sometimes shown fibrosis and tendon degeneration rather than an inflamed bursa. If there is no inflammation to suppress, a steroid injection offers only temporary numbing from the local anesthetic that is mixed in, and the pain returns once it wears off. There is also a theoretical concern about repeated steroid injections near a prosthetic joint raising infection risk, although one study of intraoperative steroid use during hip replacement found no increase in infection rates.⁸

Platelet-rich plasma (PRP) injections have emerged as an alternative, particularly for cases thought to involve tendon damage. The logic is that PRP delivers growth factors that may stimulate tendon healing, addressing the structural problem rather than just dampening symptoms. Surgeons have expressed interest in PRP as an option when corticosteroids fail, and some use it as a bridge between conservative treatment and surgery.³ High-quality evidence specifically in post-hip-replacement patients is still limited, but the rationale is reasonable given what we know about the tendon-based nature of many of these cases.

Surgical Options for Stubborn Cases

When months of conservative care have not resolved the pain, surgery becomes part of the conversation. Several procedures are used, and the choice depends on what is found on imaging and during the operation.

Arthroscopic bursectomy: A scope is inserted to remove the inflamed or thickened bursa. In a study of 12 patients with recalcitrant bursitis after hip replacement, average pain scores dropped from 9.3 out of 10 to 3.3 at about three years of follow-up, and 10 of 12 patients said the relief was enough that they would have the procedure again.⁹ The procedure is minimally invasive and has a shorter recovery than open surgery, but it only addresses the bursa. If the underlying tendon is torn, removing the bursa alone may not be enough.
Gluteus medius tendon repair: When imaging or surgical exploration reveals a tear of the gluteus medius tendon, the torn end can be reattached to the bone using suture anchors. A study of 40 patients who had their gluteus medius repaired at the same time as their hip replacement found that their functional scores and pain levels improved to a level comparable to patients whose tendons were intact.¹⁰ Both anterior and posterior surgical approaches appear to produce similar functional improvements when the tendon is repaired during the procedure.¹¹
Iliotibial band release: In some patients, a tight iliotibial band snaps over the trochanter repeatedly, keeping the bursa irritated. Surgically lengthening or partially releasing the band can eliminate that mechanical snapping and reduce the chronic inflammation it causes.

It is worth being realistic about surgical outcomes. A study comparing results of surgery for greater trochanteric pain syndrome found that patients whose pain developed after hip replacement had substantially worse outcomes than patients with the same condition who had never had a hip replacement. Post-replacement patients reported satisfaction scores of about 38 out of 100 compared with 88 for the non-replacement group, and their pain scores remained significantly higher.¹² The altered anatomy, scar tissue, and ongoing mechanical factors around a prosthetic hip appear to make surgical correction more difficult. This does not mean surgery is never worthwhile, but it does mean expectations should be carefully managed.

Prevention During the Original Surgery

Some surgeons are exploring whether steps taken during the initial hip replacement can reduce the chance of trochanteric bursitis developing in the first place. One approach is to repair or excise the trochanteric bursa during the replacement rather than leaving it intact. A retrospective study found that excising the bursa at the time of hip replacement resolved lateral buttock pain in seven of eight patients who had both bursitis and hip arthritis going into surgery.¹³

Another strategy involves administering a corticosteroid with local anesthetic directly into the trochanteric region at the end of surgery, combined with careful repair of the bursal tissue. A cohort study of patients who received this treatment during a posterior-approach hip replacement found improved early pain scores and patient outcomes, with the benefit being most noticeable in the first months after surgery. Importantly, the steroid did not increase the rate of surgical-site infection.⁸ These preventive measures are not yet standard practice everywhere, but they represent a shift toward recognizing trochanteric bursitis as a predictable complication worth heading off rather than simply treating after it shows up.

Why Post-Replacement Cases Are Harder to Manage

People sometimes assume that if the prosthetic hip is well positioned and stable, any remaining pain should be easy to fix. The reality for trochanteric bursitis after hip replacement is less encouraging than for the same condition in people who never had surgery. The poor comparative outcomes documented in surgical series are echoed in the experience of patients who cycle through multiple injections and therapy programs without lasting relief.¹²

Several factors conspire against an easy fix. The surgical dissection itself creates scar tissue in the layers around the trochanter, which can tether tendons and restrict their gliding. The implant changes the geometry of the hip in subtle ways that may chronically overload certain tendon fibers. Muscle weakness that predated the surgery may never fully reverse, especially in older patients or those who were relatively sedentary before the operation. And the gluteus medius tendon, which is the workhorse of lateral hip stability, often had some degree of degeneration even before the arthritis was bad enough to warrant a replacement. The surgery takes place in tissue that is already compromised.

For patients dealing with this, the practical message is that persistence matters. Working through a structured rehabilitation program with a physiotherapist who understands the post-replacement hip can make a meaningful difference even when progress feels slow. If one injection type does not help, a different approach may. And if surgery becomes necessary, choosing a surgeon experienced specifically in abductor tendon repair around prosthetic hips improves the odds, because it is a technically different operation from repairing the same tendon in a native hip.

Other Sources of Lateral Hip Pain to Rule Out

Not every pain on the outer side of the hip after a replacement is trochanteric bursitis, and getting the diagnosis wrong means getting the treatment wrong. A few conditions share similar territory and deserve mention.

Implant loosening can cause pain that radiates to the outer hip, particularly with weight-bearing. It usually shows up on X-rays as a progressive radiolucent line around the stem or cup, but early loosening can be subtle. Low-grade infection around the implant sometimes presents as unexplained hip pain without obvious signs of infection like fever or redness. Blood tests for inflammatory markers and occasionally a joint aspiration are needed to rule it out.

Iliopsoas impingement occurs when the front edge of the acetabular component rubs against the iliopsoas tendon, causing deep groin pain that can sometimes be confused with lateral hip symptoms. As mentioned earlier, it can occasionally produce dramatic presentations involving nerve compression. Lumbar spine problems, particularly disc herniation or spinal stenosis at the upper lumbar levels, can refer pain to the lateral hip and buttock that feels identical to trochanteric bursitis. If the pain does not respond to treatments directed at the hip, it is worth looking at the spine.

Snapping hip syndrome is another mimicker. The iliotibial band or gluteus maximus tendon can catch and snap over the trochanter with certain movements, producing a palpable or audible pop along with lateral pain. This condition often coexists with bursitis since the repetitive snapping irritates the bursa, but treating only the bursitis without addressing the snapping gives incomplete results. A careful physical examination, where the surgeon watches and feels the hip move through its range, usually sorts this out without the need for advanced imaging.