What is the initial management for a patient with mild gluteal enthesopathy (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)) without significant structural damage, such as a tear or trochanteric bursal fluid collection?

Initial Management of Mild Gluteal Enthesopathy

NSAIDs are the first-line treatment for mild gluteal enthesopathy without tears or trochanteric bursal fluid collection. 1, 2, 3

Treatment Algorithm

First-Line Treatment:

• NSAIDs: Begin with oral NSAIDs for 2-4 weeks
  • Options include ibuprofen, naproxen, or other NSAIDs 1, 3
  • Dosing example: Ibuprofen 400-600mg three times daily with food
  • Continue for 2-4 weeks to adequately control inflammation

If Inadequate Response After 2-4 Weeks:

1. Physical Therapy and Exercise:

   • Progressive strengthening exercises focusing on hip abductors
   • Stretching of the iliotibial band and hip flexors
   • Avoidance of activities that compress the greater trochanter 4

2. Consider Local Interventions:

   • Corticosteroid injection into the affected area if pain persists
   • Evidence shows short-term efficacy (up to 12 weeks) for pain relief 5

Important Considerations

NSAID Safety:

• Monitor for gastrointestinal side effects (abdominal pain, heartburn)
• Use caution in patients with:
  • History of peptic ulcer disease
  • Cardiovascular disease
  • Renal impairment
  • Age >60 years 1, 3
• Consider gastroprotection with proton pump inhibitors in high-risk patients 1

When to Consider Advanced Interventions:

If conservative management fails after 3-6 months:

• Platelet-rich plasma (PRP) injections may be superior to corticosteroid injections for longer-term outcomes 6
• Focused shockwave therapy shows promising long-term results 5
• Surgical intervention only if conservative measures fail and significant functional impairment persists 7, 8

Monitoring and Follow-up

• Reassess after 2-4 weeks of NSAID therapy
• If symptoms persist, progress to physical therapy while continuing NSAIDs as needed
• Evaluate for improvement in pain with activity, ability to bear weight, and functional capacity

Pitfalls to Avoid

1. Prolonged NSAID use without reassessment
2. Failure to implement appropriate activity modification
3. Premature progression to invasive interventions before adequate trial of conservative management
4. Overlooking the importance of physical therapy and rehabilitation in the treatment plan

The most recent evidence suggests that a structured approach beginning with NSAIDs, followed by physical therapy and education, provides the best outcomes for patients with mild gluteal enthesopathy 5.