What is the initial management for enthesopathy along the greater trochanters of the right and left femur?

Initial Management of Greater Trochanteric Enthesopathy

The initial management for enthesopathy along the greater trochanters of the right and left femur should include rest, activity modification, physical therapy with strengthening exercises for hip girdle muscles, and NSAIDs for pain and inflammation. 1

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• MRI or ultrasound is recommended if symptoms persist to confirm the diagnosis and rule out other pathologies 1
• A biopsychosocial approach should be used for initial assessment, including:
  • Physical status evaluation
  • Impact on daily activities
  • Assessment of comorbidities that may contribute to symptoms 1

First-Line Treatment Algorithm

1. Conservative Management (First 4-6 weeks):

   • Rest and activity modification to reduce inflammation 1
   • NSAIDs for pain control and reducing inflammation 1, 2
   • Physical therapy focusing on:
     • Strengthening exercises for hip girdle muscles
     • Isometric strengthening for both legs 1
   • Pacing approach: "small amounts often" exercise strategy 1

2. Supportive Measures:

   • Consider walking aids (walking stick used on contralateral side) to reduce pain and increase mobility 1
   • Weight management if the patient is overweight or obese 1
   • Evaluate need for adaptations at home or work 1

3. Monitoring and Progression:

   • Regular assessment of pain levels and functional improvement
   • Gradual increase in exercise intensity as tolerated 1
   • Consider more invasive interventions only if conservative measures fail after 4-6 weeks 1

Advanced Interventions (If Conservative Treatment Fails)

• Local corticosteroid injections may be considered 2, 3
• More invasive surgical interventions should only be considered when all conservative measures have failed 3

Important Clinical Pearls

• Greater trochanteric enthesopathy can mimic pain from other sources including myofascial pain, degenerative joint disease, and spinal pathology 3
• The condition is more common in women and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity 3
• Untreated enthesopathy can lead to considerable morbidity 2
• Mechanical issues, activity patterns, and weight should all be addressed for optimal outcomes 1

Common Pitfalls to Avoid

• Failing to rule out inflammatory enthesopathy associated with seronegative spondyloarthropathies 2
• Overlooking metabolic, drug-induced, or occupational causes of enthesopathy 2
• Jumping to invasive treatments before giving conservative management adequate time (at least 4-6 weeks) 1
• Not addressing contributing factors such as obesity or biomechanical issues 1