What is the best treatment for hip bursitis?

Treatment of 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

First-Line Treatment Approach

Non-Pharmacological Interventions

• Rest and activity modification to avoid aggravating activities
• Weight reduction if patient is overweight or obese
• Structured physiotherapy program:
  • Duration: 6-12 weeks minimum
  • Frequency: At least 3 times per week
  • Session length: 30 minutes per session
  • Focus on stretching exercises for lower back and sacroiliac joints 1, 2
• Supportive devices such as walking sticks or insoles as needed 3

Pharmacological Treatment

• NSAIDs (first-line medication):
  • Recommended dose: Naproxen 500mg twice daily for 1-3 weeks 1, 4
  • Demonstrated effect size: 0.69 (95% CI 0.12 to 1.26)
  • Number needed to treat: 4 (95% CI 3 to 6) 1
  • Use lowest effective dose to minimize side effects 4
• Acetaminophen/Paracetamol (alternative for those who cannot take NSAIDs):
  • Up to 4g/day for mild to moderate pain 3
  • Consider as long-term analgesic if effective

Second-Line Treatment

For Patients Not Responding to First-Line Treatment

• Corticosteroid injection into the inflamed bursa:
  • Indicated when symptoms persist despite 2-3 weeks of conservative therapy
  • Studies show 80% resolution rate in trochanteric bursitis 1, 5
  • Technique is critical - should be guided by ultrasound or x-ray to ensure proper placement 3, 1
  • Typically uses betamethasone 24mg with 1% lidocaine or equivalent 2

For Patients with Contraindications to NSAIDs

• Opioid analgesics with or without acetaminophen may be considered 3
• Should be reserved for patients in whom NSAIDs are contraindicated, ineffective, or poorly tolerated

Physical Therapy Modalities

• Pulsed ultrasound therapy has shown effectiveness even in calcific bursitis 6, 7
• Ice massage for acute pain relief 6
• Interferential current therapy may provide additional pain relief 6

Treatment Considerations and Cautions

• GI bleeding risk is dose-dependent with NSAIDs; consider gastroprotective agents or COX-2 selective inhibitors in high-risk patients 1
• Multiple repeated corticosteroid injections should be avoided due to potential tissue damage 1
• Treatment failures with injections are often due to failure to properly enter the bursa space 1
• Young patients and those with leg-length discrepancy may be less responsive to conservative treatment 5

Surgical Options (Rare Cases)

For intractable symptoms that fail to respond to all conservative measures:

• Iliotibial band release
• Subgluteal bursectomy
• Trochanteric reduction osteotomy 2

Hip bursitis typically responds well to conservative treatment, with most patients experiencing significant improvement within 2-3 weeks of initiating proper therapy. Surgical intervention is rarely needed and should be considered only after exhausting all conservative options.