Approach Cautiously…

Q: I have a 65 y.o. student with bursitis in right hip next to Greater Trochanter. After x-ray & MRI to rule out other complications, her Doc says give up the vigorous gym workouts and do more yoga classes!  She has been regular once a week yoga for 14 years in classes small enough to adapt poses as needed. What actions or poses are contraindicated during the healing of the inflammation? What else to consider during healing process?  Love that her doc recommends more yoga!

A: Funny you should ask! This is a very common cause of pain in the hip area, and just last week one of my students on retreat in Mexico mentioned that she had been having pain near the bony prominence at the side of hip known as the greater trochanter of the femur bone. I asked if she had had it evaluated yet, and she said no. But the location of her pain brought your student’s condition to mind. I see this a couple times a year in my students and patients. According to the Cleveland Clinic:

“Trochanteric bursitis is inflammation of the bursa (fluid-filled sac near a joint) at the outside (lateral) point of the hip known as the Greater Trochanter. When this bursa becomes irritated or inflamed, it causes pain in the hip. This is a common cause of hip pain.”

It might be helpful to provide some information about the condition before we dive into my yoga recommendations. First off, what are the most common symptoms of the condition? Well, the most helpful in differentiating it from other causes of hip pain would be the location, as described above, along with pain in that area when lying on that side of pelvis or when touching over the greater trochanter. Less specific but still helpful symptoms include pain when getting out of a deep chair or out of your car, or when walking up stairs. And pain located on the lateral thigh or in the buttock area could still be this kind of bursitis. Normally the bursa, a fluid-filled sac that usually lies between tendons and bones to provide more cushion and smooth movement over the bones, is not very big and doesn’t hurt. 

Bursitis (when the bursa becomes inflamed and painful) can result from a variety of situations. One cause can be an acute injury to the hip joint, such as from falling onto the side of your hip, running into something with your hip, or lying for too long in a side lying position. Another cause can be overuse of the hips from work or play, especially if activities include standing up for extended periods, running up stairs, and/or climbing. Incorrect posture that results from scoliosis or lumbar spine conditions, or leg length discrepancies could also lead to bursitis. And past surgery to the hip joint, including hip replacement, could increase the risk of developing it.Bursitis can also be caused by other health conditions, for example, from gout, rheumatoid arthritis, psoriasis, and thyroid disease.

Usually, most cases of bursitis of the greater trochanter resolve on their own with little or no intervention in a few weeks. In all likelihood, your student either had persistent or recurrent bursitis that led her to seek medical attention. Western medical treatments start with modified activity and anti-inflammatory medications like ibuprofen. If that does not work, a steroid injection into the affected bursa and/or physical therapy to maintain range of motion would follow, adding splinting if necessary. In rare cases, surgery might be recommended. 

And what about preventive approaches for the Western model? The Cleveland Clinic says that “because most cases of bursitis are caused by overuse, the best treatment is prevention. So avoid or modify the activities that cause the problem, and correct underlying conditions, such as leg length differences, improper posture, or poor technique in sports or work, that cause the problem. “

They also make the following recommendations:

  • “Take it slow at first and gradually build up your activity level.*
  • Use limited force and limited repetitions.*
  • Stop if unusual pain occurs.*
  • Avoid repetitive activities that put stress on the hips.*
  • Lose weight if you need to.
  • Get a properly fitting shoe insert for leg length differences.
  • Maintain strength and flexibility of the hip muscles.*
  • Use a walking cane or crutches for a week or more when needed.”

* The recommendations above that I marked an asterisk are great guidelines for how to approach your student and her practice, as well as for most students in general.

As to your approach to yoga, the most obvious places to avoid or use caution would include any side lying positions, such as Anantasana (Vishnu’s Couch pose), where you put direct contact on the greater trochanter. Fortunately, there are not a lot of poses like that in our modern yoga practices.  However, in an acute phase of bursitis, even a strong stretch over that area could slow or reverse healing, so poses such as Standing Side Stretch (sometimes called Half Moon pose) shown on the left, the back hip in Triangle pose, and the top bent leg hip in Marichyasana 3 and Ardha Matsyendrasana should be approached cautiously, and propped a bit higher then usual. You’d want to ask your student regularly if any pose is worsening the symptoms, and play with variations to eliminate the pain.

Half Moon pose (Ardha Chandrasana) comes to mind as a potential challenge for both legs, but for different reasons: the top leg because the muscles over the greater trochanter are pulling down on the bursa, and the bottom leg due to possible compression in that area of the hip. Because climbing stairs and getting out the car can worsen the pain, approach Fierce pose (Utkatasana) and Garland pose (Malasana) with a watchful eye, especially when the student returns to a standing position.

Because physical therapists teach range of motion exercises for this condition, doing yoga warm ups for the hip in a reclining position would be helpful. In addition, a few of the recommended stretches I found online from a physical therapy site included Marichyasana 3 and Thread the Needle pose, which are part of many yoga classes. For strengthening, they recommended abduction the affected leg while standing, such as the action of the top leg in Half Moon.  So, some of the poses you need to be cautious with during the acute phase may end up being important as healing progresses for either stretching or strengthening the area. Take your time, go slow, and progress gradually.

And tell her doctor if things improve quickly. Let’s get more of those MD recommendations for yoga!

—Baxter

 

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