What is the best treatment for an enthesophyte of the lateral facet of the greater trochanter?

Treatment of Enthesophyte of the Lateral Facet of the Greater Trochanter

The most effective treatment for an enthesophyte of the lateral facet of the greater trochanter is a combination of corticosteroid injection with lidocaine under ultrasound guidance, followed by physical therapy focusing on eccentric strengthening exercises.

What is an Enthesophyte of the Lateral Facet of the Greater Trochanter?

An enthesophyte is a bony projection that forms at the attachment site (enthesis) of a tendon, ligament, or joint capsule to bone. When occurring at the lateral facet of the greater trochanter, it's typically associated with:

• Chronic inflammation at the insertion of the gluteus medius tendon
• Part of greater trochanteric pain syndrome (GTPS)
• Often misdiagnosed as simple trochanteric bursitis
• May cause lateral hip pain that worsens with activity and lying on the affected side

Diagnostic Approach

While primarily a clinical diagnosis, imaging can confirm the presence of an enthesophyte:

• Radiographs: First-line imaging that may show surface irregularities or spurs (>2mm) at the greater trochanter 1
• Ultrasound: Can detect associated trochanteric bursitis and tendinopathy 1
• MRI: Best for assessing peritrochanteric structures including gluteus medius/minimus muscles and tendons 1

Treatment Algorithm

First-Line Treatment:

1. Corticosteroid Injection with Lidocaine:

   • American College of Radiology recommends 40-80 mg methylprednisolone (or equivalent) mixed with 2-3 mL of 1-2% lidocaine 2
   • Should be performed under ultrasound guidance for accurate placement 2
   • Provides both diagnostic confirmation and therapeutic benefit

2. Physical Therapy:

   • Eccentric strengthening exercises for the hip abductors 1
   • Deep transverse friction massage to reduce pain 1
   • Stretching of the gluteal and tensor fascia lata muscles

3. Oral Medications:

   • NSAIDs for pain and inflammation control

Second-Line Treatment (for refractory cases):

1. High-dose pulsed ultrasound therapy:

   • Has shown effectiveness even in cases with extensive calcifications 3
   • May help avoid more invasive treatments

2. Iontophoresis:

   • Can be used as part of a comprehensive non-invasive approach 3

Third-Line Treatment:

1. Surgical intervention (for cases unresponsive to conservative management):
   • Endoscopic or open bursectomy
   • Removal of the enthesophyte
   • Repair of associated gluteal tendon pathology if present

Clinical Pearls and Pitfalls

• Important distinction: Differentiation between trochanteric bursitis and gluteus medius tendinosis may be difficult, and the two conditions often coexist 1, 2

• Potential misdiagnosis: In patients with hip arthroplasty, extracapsular disease associated with adverse reactions to metal debris (ARMD) could be misinterpreted as trochanteric bursitis 1, 2

• Treatment duration: Conservative treatment should be attempted for at least 3-6 months before considering surgical intervention 4

• Medication caution: Long-term use of NSAIDs should be monitored for gastrointestinal and renal side effects

• Injection technique: Accurate placement into the greater trochanteric bursa rather than surrounding tissues is crucial for optimal results 2

By following this structured approach to treatment, most patients with an enthesophyte of the lateral facet of the greater trochanter can achieve significant pain relief and functional improvement without requiring surgical intervention.