What is the initial management for a patient with trochanteric pain syndrome?

Initial Management of Trochanteric Pain Syndrome

The initial management for trochanteric pain syndrome should include physical therapy, NSAIDs, and corticosteroid injections, with physical therapy showing superior long-term outcomes compared to other interventions. 1

Diagnosis and Assessment

• Trochanteric pain syndrome (also known as greater trochanteric pain syndrome or GTPS) encompasses a spectrum of conditions including trochanteric bursitis, abductor tendinopathy, and external coxa saltans (snapping hip) 2
• Pain is typically located at the lateral aspect of the hip over the greater trochanter and may be reproduced with internal rotation of the hip 3
• Radiographs should be obtained first to rule out other pathologies such as hip osteoarthritis, although they may be normal in isolated GTPS 3
• MRI or ultrasound may be useful for evaluating soft tissue structures when diagnosis is uncertain, with ultrasound being particularly effective for evaluating abductor tendons and trochanteric bursitis 3

First-Line Management

• Physical therapy with targeted exercises for gluteal strengthening and iliotibial band stretching should be initiated as first-line treatment 1
• NSAIDs such as naproxen (starting dose 500 mg followed by 250 mg every 6-8 hours as required, not exceeding 1250 mg on the first day and 1000 mg on subsequent days) should be used for pain management 4
• Activity modification to reduce irritation of the affected structures is recommended during the acute phase 2
• Home exercise programs have shown long-term benefits for most patients, with one study reporting 60.5% of patients experiencing symptom resolution at 15 months 1

Second-Line Management

• Corticosteroid injections into the trochanteric bursa provide short-term pain relief but effects typically don't persist long-term 5
• Combining corticosteroid injections with physical therapy appears more effective than either treatment alone 1
• Injections should be performed under imaging guidance (ultrasound or fluoroscopy) to ensure accurate placement 3
• Low-energy extracorporeal shock wave therapy (ESWT) has shown positive short-term effects with one study demonstrating a 68.3% improvement in pain scores compared to control groups 1

Treatment Monitoring

• Regular assessment using the "four A's" approach is recommended: Analgesia (pain relief), Activities of daily living (function), Adverse effects, and Aberrant drug taking (if applicable) 3
• If no improvement is seen within 8-12 weeks of conservative management, specialist referral should be considered 3
• Patients at high risk of developing chronic pain should be reviewed within 6 months of establishing a management plan 3

Surgical Management

• Surgical intervention should be reserved for cases that fail to respond to conservative measures for at least 6 months 5
• Endoscopic techniques including iliotibial band release and bursectomy have shown good results with significant pain reduction in refractory cases 6, 7
• In one case series of 11 patients treated with endoscopic release, all patients reported significant pain reduction with no complications 6

Common Pitfalls and Considerations

• Avoid prolonged use of oral NSAIDs due to potential gastrointestinal, renal, and cardiovascular complications 4
• Be aware that pain may be referred from lumbar spine pathology or hip joint disorders, requiring careful differential diagnosis 2
• Recognize that analgesic failure is common, and patient response is individualistic; ineffective treatments should be discontinued rather than continued indefinitely 3
• Patients with elevated BMI may benefit from weight management strategies as part of their treatment plan 3

Special Considerations

• For patients with diabetes, hemoglobin A1c optimization (target <7.5%) is recommended before considering more invasive interventions 3
• Smoking cessation should be encouraged as it may affect tissue healing and treatment outcomes 3
• Patients with significant functional limitations affecting work may require expedited specialist referral 3