Can I use steroids for greater trochanteric (greater trochanteric) syndrome?

Steroid Injections for Greater Trochanteric Syndrome

Corticosteroid injections are recommended as an effective treatment for greater trochanteric pain syndrome, with ultrasound guidance preferred for accurate needle placement into the greater trochanteric bursa. 1

Diagnosis and Initial Approach

Greater trochanteric pain syndrome (GTPS) encompasses several conditions including trochanteric bursitis, external coxa saltans (snapping hip), and abductor tendinopathy that cause persistent lateral hip pain 2. Before considering injections, proper diagnosis is essential:

• Radiographs should be the first imaging test for chronic hip pain
• MRI without contrast is recommended when radiographs are negative or nondiagnostic
• Ultrasound is useful for detecting associated trochanteric bursitis and tendinopathy 1

Treatment Algorithm

1. First-line treatment: Conservative management including:

   • Rest and activity modification
   • NSAIDs
   • Physical therapy with eccentric strengthening exercises for hip abductors
   • Deep transverse friction massage 1

2. Second-line treatment: Corticosteroid injections when conservative measures fail

   • Typically using 40-80 mg of methylprednisolone or equivalent corticosteroid
   • Mixed with 2-3 mL of 1-2% lidocaine
   • Ultrasound guidance strongly recommended for accurate placement 1

3. Alternative or third-line options: Consider when steroid injections fail

   • Platelet-rich plasma (PRP) injections (may be more effective than corticosteroids at 2-year follow-up) 3
   • Surgical intervention for patients with persistent symptoms despite 3-6 months of conservative treatment 1

Injection Technique

For optimal results:

• Use 22-25 gauge needle
• Standard needle length of 1.5-inch (3.8 cm) is sufficient for most patients (2-inch/5 cm for obese patients)
• Position patient in lateral decubitus with affected side up
• Insert needle perpendicular to skin at 90° angle
• Aspirate to ensure no blood return before injecting medication 1

Effectiveness and Timing

• Corticosteroid injections provide effective short-term pain relief 4
• May be superior to usual care and "wait and see" approaches in short and medium-term pain improvement
• May not be superior to PRP in medium-term outcomes
• May be inferior to PRP and ESWT for long-term (12+ months) pain improvement 4

Important Precautions and Side Effects

1. Adrenal suppression risk:

   • Approximately 20% of patients may experience transient secondary adrenal insufficiency, mainly in the first week following injection 5
   • This typically resolves within 2 weeks

2. General steroid precautions:

   • Use lowest possible effective dose
   • Consider bone health implications, especially in patients at risk for osteoporosis
   • Use with caution in patients with heart failure, hypertension, or renal insufficiency
   • Use with caution in patients with diabetes as it may affect glycemic control 6

3. Injection frequency:

   • Limit the number of injections to minimize potential side effects
   • Consider alternative treatments if multiple injections are required

Special Considerations

• For patients with hip arthroplasty, be aware that extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 1
• Differentiation between trochanteric bursitis and gluteus medius tendinosis may be difficult as these conditions often coexist 1

Corticosteroid injections remain a valuable tool in managing greater trochanteric pain syndrome, particularly when conservative measures fail, but should be used judiciously with awareness of their potential side effects and limitations in long-term efficacy.