What is the recommended management for a patient with trochanteric bursitis and likely calcific tendinosis of the gluteus medius?

Management of Trochanteric Bursitis with Calcific Tendinosis of Gluteus Medius

For trochanteric bursitis with calcific tendinosis of gluteus medius, a stepwise approach starting with conservative management including corticosteroid injection under ultrasound guidance is recommended, followed by physical therapy and only considering surgical options if conservative measures fail.

Initial Assessment and Diagnosis

The ultrasound findings in this case reveal:

• Trochanteric bursitis (fluid, thickening, and tenderness)
• Calcific tendinosis of gluteus medius
• Anterior labrum irregularity
• Normal gluteus minimus
• Positive FADIR and FABER tests

These findings are consistent with greater trochanteric pain syndrome (GTPS), which often involves both bursitis and tendinopathy components.

First-Line Management

Corticosteroid Injection

• Ultrasound-guided corticosteroid injection into the trochanteric bursa is the most effective first-line treatment 1
• The injection may include:
  • Local anesthetic (lidocaine) for immediate diagnostic confirmation
  • Corticosteroid for anti-inflammatory effect
  • Ultrasound guidance ensures accurate placement

Physical Therapy

Following injection, implement a structured rehabilitation program:

• Relative rest to decrease repetitive loading of the damaged tendon 1
• Stretching of the iliotibial band
• Strengthening of hip abductors (gluteus medius/minimus)
• Core stabilization exercises
• Gait training to correct any biomechanical issues

Second-Line Management

If symptoms persist after 4-6 weeks of first-line treatment:

Advanced Physical Therapy

• Intensive pulsed ultrasound therapy 2
• Interferential current therapy 3
• Manual therapy including soft tissue mobilization

Additional Interventions

• NSAIDs for pain management 4
• Activity modification to avoid aggravating activities
• Consider addressing any leg length discrepancy if present

Third-Line Management

For cases refractory to conservative management after 3-6 months:

Advanced Imaging

• MRI hip without IV contrast to further evaluate the extent of tendinopathy and rule out tears 1
• MRI can better assess gluteus medius/minimus muscles, abductor tendons, and the trochanteric bursa 1

Surgical Consideration

• Endoscopic debridement of calcifications may be considered for persistent cases 5
• Arthroscopic or open repair for cases with confirmed tears of gluteus medius 6

Important Clinical Considerations

1. Differential Diagnosis: Differentiation between bursitis and gluteus medius tendinosis may be difficult, and the two conditions often coexist 1

2. Monitoring: Follow-up assessment should evaluate:

   • Pain levels during activity and rest
   • Tenderness over greater trochanter
   • Range of motion
   • Functional limitations

3. Prognosis: Most patients respond well to conservative treatment, even with calcifications present 3, 2

4. Common Pitfalls:

   • Failing to address underlying biomechanical issues
   • Premature return to aggravating activities
   • Overlooking gluteus medius pathology by focusing only on bursitis
   • Multiple injections without adequate rehabilitation can lead to tendon weakening

Remember that even extensive calcifications can resolve with appropriate conservative management, making non-invasive approaches worth pursuing before considering surgical intervention 2.