What is the best treatment for hip bursitis?

Best Treatment for Hip Bursitis

The optimal management of hip bursitis requires a combination of non-pharmacological and pharmacological treatment modalities, with NSAIDs being the most effective initial pharmacological intervention for pain relief. 1

Treatment Algorithm

First-Line Treatment

1. Conservative Therapy

   • Rest and activity modification to avoid aggravating activities
   • NSAIDs (such as naproxen 500mg twice daily) for 1-3 weeks 1, 2
   • Physical therapy with stretching exercises focused on the lower back and sacroiliac joints 3
   • Weight loss if the patient is overweight 1

2. Duration of Conservative Treatment

   • A structured physiotherapist-led rehabilitation program should last for at least 6-12 weeks
   • Exercise frequency should be at least 3 times per week for 30 minutes per session 4

Second-Line Treatment

If symptoms persist after 3-4 weeks of conservative management:

• Corticosteroid injection into the affected bursa 1, 5
  • Methylprednisolone 20-80mg (depending on the size of the bursa) 5
  • The area around the injection site should be prepared in a sterile way
  • A 20-24 gauge needle should be used to aspirate fluid if present, then inject the steroid 5
  • One injection is often sufficient, but may be repeated if symptoms recur 3, 6

Third-Line Treatment

For refractory cases that don't respond to conservative measures and injections:

• Surgical intervention may be considered for recalcitrant trochanteric bursitis 7
  • Options include iliotibial band release, subgluteal bursectomy, and trochanteric reduction osteotomy 3

Evidence Analysis

Effectiveness of Treatments

1. NSAIDs

   • Demonstrate significant pain relief with an effect size of 0.69 (95% CI 0.12 to 1.26) 1
   • Number needed to treat (NNT) of 4 (95% CI 3 to 6) 1
   • Should be used at the lowest effective dose due to potential GI side effects 1, 2

2. Exercise Therapy

   • Recent evidence shows exercise has similar effects on pain and function compared to oral NSAIDs and paracetamol 1
   • Has an excellent safety profile, especially important for older patients 1

3. Corticosteroid Injections

   • Effective for cases that don't respond to conservative management 1, 3
   • Studies show 80% resolution rate in post-surgical trochanteric bursitis 6
   • About 45% of patients may require multiple injections 6

Special Considerations

Risk Factors for Treatment Failure

• Younger age
• Greater limb-length discrepancy 6
• Inadequate physical therapy

Potential Pitfalls

1. Misdiagnosis

   • Hip bursitis must be distinguished from hip osteoarthritis, fracture, tendinitis, and nerve pathology 7
   • Symptoms may be atypical, making diagnosis elusive 8

2. NSAIDs Risks

   • GI bleeding risk is dose-dependent
   • Consider gastroprotective agents or COX-2 selective inhibitors in patients with increased GI risk 1

3. Steroid Injection Considerations

   • Ensure proper technique to avoid injection into surrounding tissue
   • Treatment failures are often due to failure to enter the bursa space 5
   • Multiple repeated injections should be avoided due to potential tissue damage

Patient Education

• Explain that trochanteric bursitis is characterized by chronic, intermittent aching pain over the lateral aspect of the hip 8
• Emphasize the importance of completing the full course of physical therapy
• Advise on activity modification to prevent recurrence

By following this structured approach to treatment, most patients with hip bursitis can achieve significant pain relief and functional improvement without requiring surgical intervention.