Initial Management of Greater Trochanteric Enthesopathy
The initial management for enthesopathy along the greater trochanters should include rest, activity modification, physical therapy with strengthening exercises for hip girdle muscles, and NSAIDs for pain and inflammation. 1 Conservative measures should be the first-line approach before considering more invasive interventions.
Understanding Greater Trochanteric Enthesopathy
Greater trochanteric enthesopathy refers to pathology at the attachment sites of tendons, ligaments, and fascia to the bone at the greater trochanter of the femur. This condition:
- Is often part of what's now called Greater Trochanteric Pain Syndrome (GTPS)
- Presents with lateral hip pain that may radiate down the lateral thigh
- Has point tenderness over the posterolateral aspect of the greater trochanter
- Is more common in women and patients with coexisting low back pain, osteoarthritis, and obesity 2
Step-by-Step Management Algorithm
1. Initial Conservative Measures
- Rest and activity modification to reduce inflammation and irritation at the enthesis site 1
- NSAIDs as first-line pharmacological treatment to reduce pain and inflammation
- Ice application to the affected area for 15-20 minutes several times daily
2. Physical Therapy and Exercise
- Strengthening exercises specifically targeting hip girdle muscles 1
- Isometric strengthening for both legs to improve stability
- Gradual progression of exercise intensity as symptoms improve
- Pacing approach with small amounts of exercise performed frequently 1
3. Addressing Contributing Factors
- Weight management if the patient is overweight or obese to reduce mechanical stress 1
- Evaluation of gait mechanics and correction of abnormalities
- Assessment of footwear and possible modifications
4. Assistive Devices
- Walking aids such as a cane used on the contralateral side to reduce mechanical stress 1
- Evaluation for home/work adaptations if necessary
5. Advanced Interventions (if conservative measures fail)
- Corticosteroid injections into the affected area can provide significant pain relief 2
- Imaging studies (MRI or ultrasound) may be warranted if symptoms persist to evaluate for other pathology 3
Special Considerations
Diagnostic Imaging
If symptoms persist despite conservative management, imaging may be necessary:
- Radiographs can identify bone erosion, hyperostosis, or fragmentation 4
- MRI has high sensitivity (approaching 100%) for detecting pathology in the hip region 3
- Ultrasound with high-frequency transducers is cost-effective for detecting enthesopathy 5
Differential Diagnosis
Consider other potential causes of lateral hip pain:
- Trochanteric bursitis (often coexists with enthesopathy)
- Hip osteoarthritis
- Lumbar spine pathology with referred pain
- Myofascial pain syndromes
Monitoring and Follow-up
- Regular assessment of pain levels and functional improvement
- Adjustment of treatment plan based on response
- Consideration of more invasive interventions only if conservative measures fail after 4-6 weeks
Pitfalls to Avoid
- Misdiagnosis: Greater trochanteric pain can mimic pain from other sources including lumbar spine pathology and hip osteoarthritis 2
- Premature invasive interventions: Most cases resolve with conservative measures
- Overlooking contributing factors: Mechanical issues, activity patterns, and weight should all be addressed 1
- Inadequate patient education: Patients need to understand the importance of activity modification and adherence to exercise programs
By following this structured approach to managing greater trochanteric enthesopathy, most patients will experience significant improvement in symptoms and function without requiring more invasive interventions.