What is the initial treatment for mild trochanteric bursitis with mild gluteus minimus/medius tendinosis?

Initial Treatment for Mild Trochanteric Bursitis with Mild Gluteus Minimus/Medius Tendinosis

The initial treatment for mild trochanteric bursitis with mild gluteus minimus/medius tendinosis should include relative rest, NSAIDs, physical therapy, and corticosteroid injection if conservative measures fail. 1

First-Line Conservative Measures

• Activity Modification: Reduce activities that aggravate symptoms to decrease repetitive loading of the damaged tendon and bursa 2, 1
• NSAIDs: Ibuprofen 400-800 mg three to four times daily (not exceeding 3200 mg total daily dose) for pain relief and anti-inflammatory effects 1, 3
• Physical Therapy:
  • Stretching exercises for the iliotibial band 1
  • Eccentric strengthening of hip abductor muscles (gluteus medius/minimus) 2, 1
  • Progressive loading protocols that gradually increase tendon stress 4

Second-Line Treatment

• Corticosteroid Injection: If symptoms persist after 4-6 weeks of conservative treatment 1, 5
  • Ultrasound-guided injection improves accuracy and effectiveness 1, 6
  • Provides both diagnostic information and therapeutic benefit 1
  • Can be highly effective with symptom resolution rates ranging from 49% to 100% 5

Adjunctive Therapies

• Cryotherapy: Application of ice for 10-minute periods through a wet towel for acute pain relief 2
• Therapeutic Ultrasound: May be beneficial, particularly in cases with calcifications 7
• Low-Energy Shock Wave Therapy: Superior to other non-operative modalities in comparative studies 5

Diagnostic Considerations

• Imaging: If symptoms persist despite treatment, consider:
  • Radiographs to rule out other causes of hip pain 1
  • Ultrasound to detect bursitis and evaluate gluteal tendons 2, 1
  • MRI for comprehensive assessment of peritrochanteric structures if symptoms persist 2, 1

Important Clinical Pearls

• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the two conditions frequently coexist 2, 1, 8
• Most cases respond well to conservative treatment within 4-12 weeks 4
• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 2, 5
• The condition is often self-limiting but may require multiple courses of treatment in refractory cases 5
• In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris as trochanteric bursitis 2, 1

Treatment Algorithm

1. Weeks 0-4: NSAIDs + relative rest + cryotherapy + initiation of physical therapy
2. Weeks 4-8: Continue physical therapy with progressive loading + consider corticosteroid injection if minimal improvement
3. Weeks 8-12: Intensify physical therapy + consider second corticosteroid injection or shock wave therapy if needed
4. Beyond 12 weeks: For refractory cases, consider advanced imaging and referral for surgical evaluation