What is the most likely diagnosis and appropriate first-line treatment for a patient with pain localized to the lateral aspect of the proximal femur (greater trochanter)?

Greater Trochanteric Pain Syndrome (GTPS)

Pain localized to the lateral femoral head (greater trochanter) is most consistent with Greater Trochanteric Pain Syndrome (GTPS), and first-line treatment should be targeted physiotherapy combined with NSAIDs, with corticosteroid injections reserved for acute symptom management when combined with physiotherapy.

Diagnosis

The clinical presentation of lateral hip pain with point tenderness over the greater trochanter indicates GTPS, which encompasses abductor tendinopathy (gluteus medius/minimus), trochanteric bursitis, and external coxa saltans 1, 2. This is an extra-articular pain syndrome that must be distinguished from intra-articular hip pathology and referred pain from the lumbar spine 3.

Diagnostic Approach

Start with plain radiographs of the pelvis and hip as the initial imaging study 4. The ACR Appropriateness Criteria explicitly recommend radiographs first in most cases of chronic hip pain 4.

When radiographs are negative or equivocal and you suspect extra-articular soft tissue pathology:

• MRI without IV contrast or ultrasound are the appropriate next steps 4
• Both modalities effectively evaluate trochanteric bursitis, abductor tendinosis/tears, and calcific tendonitis 4
• Ultrasound is particularly useful for targeted evaluation of superficial structures like abductor tendons 4

Key clinical distinction: If the patient has provocative impingement or instability testing on physical exam, consider concomitant intra-articular pathology requiring different management 5. An ultrasound-guided diagnostic injection can help differentiate peritrochanteric from intra-articular pain sources 4.

First-Line Treatment Algorithm

Initial Conservative Management (Weeks 0-6)

1. Targeted physiotherapy - This provides superior long-term outcomes, with 60.5% of patients reporting symptom resolution at 15 months 1

   • Focus on hip abductor strengthening and stretching
   • Activity modification to reduce lateral hip loading

2. NSAIDs - Use for pain control during the initial treatment phase 1, 6

3. Weight loss if obese - Obesity is a significant risk factor 2

For Acute Symptom Management (If inadequate response at 4-6 weeks)

Combine physiotherapy with corticosteroid injection - This combination is more effective for acute symptoms than PT alone 1. The injection should be:

• Image-guided (ultrasound or fluoroscopy) for accurate placement 4
• Targeted to the trochanteric bursa or peritendinous region 4
• Combined with local anesthetic for diagnostic confirmation 4

Important caveat: Corticosteroid injections provide short-term relief but diminishing benefits over time 7. They are most effective when combined with ongoing physiotherapy for sustained benefit 1.

Second-Line Options (If conservative measures fail at 3-6 months)

Extracorporeal shock wave therapy (ESWT):

• Demonstrated 68.3% improvement in pain scores compared to controls 1
• Provides significant long-term pain relief 7
• Low risk of adverse effects 1

Platelet-rich plasma (PRP):

• Evidence remains inconclusive 1
• Some studies show sustained improvement 7
• Cannot be recommended as standard treatment until further research is available 1

Surgical Intervention

Reserved for patients who fail conservative and medical treatments (approximately one-third of patients develop chronic symptoms) 3. Endoscopic techniques include local decompression, bursectomy, and tendon repair 3.

Common Pitfalls

1. Misdiagnosing as "trochanteric bursitis" - This term is outdated and inaccurate, as the pathology is primarily tendinopathy rather than inflammatory bursitis 3, 2

2. Using imaging alone for diagnosis - Never diagnose based on imaging without correlating with symptoms and clinical signs 8. Incidental findings are common in asymptomatic individuals 8

3. Failing to screen for referred pain - Always evaluate the lumbar spine and pelvis, as GTPS commonly coexists with low back pain 2

4. Relying solely on corticosteroid injections - These provide only short-term benefit and must be combined with physiotherapy for sustained improvement 1, 7

5. Premature surgical referral - Most cases are self-limited with conservative measures 2, and surgery should only be considered after exhausting non-operative options 6