What is the treatment for acetabular bursitis?

Treatment of Acetabular Bursitis

The treatment of acetabular bursitis should begin with conservative measures including NSAIDs as first-line drug treatment, physical therapy, activity modification, and local corticosteroid injections directed to the site of inflammation. 1

Initial Conservative Management

• NSAIDs should be used as first-line pharmacological treatment up to the maximum dose, considering risks and benefits, to address pain and inflammation 1
• Open-backed shoes to reduce pressure on the affected area, particularly if pain is aggravated by footwear and relieved when walking barefoot 1
• Orthoses, heel lifts, or accommodative padding to reduce pressure and provide support 1
• Physical therapy including stretching exercises to improve flexibility and reduce tension 1
• Activity modification and decreased activity to reduce irritation to the inflamed bursa 1
• Weight loss if indicated, as excess weight can increase pressure on the affected area 1

Medication Management

• For patients with persistent pain despite NSAIDs, analgesics such as acetaminophen (≤4g/day) or opioid-like drugs may be considered for residual pain 1
• A stepped care approach should be followed, starting with the lowest risk medications (acetaminophen) before progressing to higher risk options 1
• In patients with increased gastrointestinal risk, consider using acetaminophen, topical NSAIDs, nonselective oral NSAIDs plus gastroprotective agent, or COX-2 inhibitors 1

Interventional Treatments

• Corticosteroid injections directed to the local site of inflammation may be considered when conservative measures fail 1
• Bursa injection should be performed carefully, avoiding the Achilles tendon if the bursitis is in proximity 1
• If symptoms do not improve within 6-8 weeks of conservative treatment, consider immobilization with a cast or fixed-ankle walker-type device 1

Surgical Management

• For refractory cases that do not respond to conservative treatment after 2-3 months, surgical intervention may be necessary 1, 2
• The surgical procedure typically involves resection of the prominent aspect of the bone and removal of the inflamed bursa 1
• Some patients may require osteotomy to correct alignment issues contributing to the bursitis 1

Treatment Monitoring

• Treatment should be guided according to a predefined treatment target 1
• Disease monitoring should include patient-reported outcomes, clinical findings, and imaging as appropriate 1
• The frequency of monitoring should be decided on an individual basis depending on symptoms, severity, and treatment 1

Important Considerations and Pitfalls

• Recent research suggests that what is clinically diagnosed as "bursitis" may actually represent pathology of the surrounding muscles rather than true inflammation of the bursa 3, 4
• Avoid systemic corticosteroids for treatment as they are not supported by evidence 1
• When using corticosteroid injections, be cautious about potential adverse effects on surrounding tendons 2
• If symptoms change significantly or do not respond to treatment, consider alternative diagnoses and appropriate evaluation, including imaging 1
• Shock-wave therapy may be considered as an alternative non-operative treatment in refractory cases 5