What is the management for trochanteric bursitis?

Management of Trochanteric Bursitis

The first-line treatment for trochanteric bursitis includes conservative measures such as rest, activity modification, NSAIDs, and physical therapy, with corticosteroid injections recommended for persistent cases. 1, 2

Diagnostic Approach

• Diagnosis is primarily clinical, with pain and tenderness over the lateral aspect of the hip at the greater trochanter
• Imaging may be helpful in refractory cases:
  • Radiographs should be the first imaging test ordered 1
  • Ultrasound can detect trochanteric bursitis, though differentiation between bursitis and gluteus medius tendinosis may be difficult 3, 1
  • MRI without contrast is recommended when radiographs are negative or equivocal, and can assess peritrochanteric structures including the gluteus muscles, tendons, and trochanteric bursa 3, 1

Treatment Algorithm

Step 1: Conservative Management (First 6-8 weeks)

• Rest and activity modification to reduce pressure on the affected area
• NSAIDs (e.g., naproxen 500 mg twice daily) 4
• Physical therapy focusing on:
  • Eccentric strengthening exercises for hip abductors 1
  • Stretching exercises for lower back and sacroiliac joints 2
  • Deep transverse friction massage 1
• Accommodative padding and orthoses 3
• Weight loss if indicated 3

Step 2: Corticosteroid Injection (If symptoms persist after 6-8 weeks)

• Ultrasound-guided injection into the trochanteric bursa 1
• Recommended injection:
  • 40-80 mg methylprednisolone or equivalent corticosteroid
  • Mixed with 2-3 mL of 1-2% lidocaine 1
  • Use 22-25 gauge needle, 1.5-inch length (longer for obese patients) 1
  • Patient positioned in lateral decubitus with affected side up 1
• Avoid injecting into the Achilles tendon if treating posterior heel bursitis 3

Step 3: Advanced Conservative Measures (For persistent symptoms)

• Immobilization with cast or fixed-ankle walker-type device in severe cases 3
• Consider high-dose pulsed ultrasound therapy 5, 6
• Low-energy shock wave therapy has shown superior results compared to other nonoperative modalities 7

Step 4: Surgical Intervention (For refractory cases after 3-6 months of conservative treatment)

• Endoscopic trochanteric bursectomy and iliotibial band release 8
• Other surgical options include:
  • Open bursectomy
  • Longitudinal release of the iliotibial band
  • Z-plasty
  • Repair of gluteus medius tears if present 7

Treatment Outcomes and Prognosis

• Conservative treatment resolves symptoms in 49-100% of cases 7
• Corticosteroid injections provide significant relief in most patients with persistent symptoms 2
• Surgical outcomes show significant improvement in pain and function for refractory cases 1

Important Considerations

• Trochanteric bursitis is often self-limiting but may become chronic if not properly managed
• Differentiate from other causes of lateral hip pain, including gluteus medius tendinopathy, which may coexist with bursitis 3, 1
• In patients with hip arthroplasty, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 3
• For patients with calcific trochanteric bursitis, conservative treatment including intensive ultrasound therapy may lead to resolution of calcifications and should be attempted before invasive treatments 5, 6

By following this algorithmic approach, most patients with trochanteric bursitis will experience significant improvement in pain and function, with surgical intervention reserved only for those who fail comprehensive conservative management.