What is the initial management for greater trochanter pain syndrome?

Initial Management of Greater Trochanteric Pain Syndrome

The initial management for greater trochanteric pain syndrome should include physical therapy with targeted exercises for hip abductor strengthening, NSAIDs for pain relief, and activity modification to reduce pressure on the affected area. 1

Diagnosis

• Radiographs should be obtained first to rule out other causes of hip pain 2, 1
• Ultrasound can effectively detect trochanteric bursitis and differentiate it from other conditions, though it may be difficult to distinguish from gluteus medius tendinosis 1
• MRI is usually appropriate when evaluating for clinically suspected tendon, muscle, or ligament injury as the source of hip pain after negative or indeterminate radiographs 2

First-Line Treatment

Non-pharmacological Approaches

• Physical therapy with targeted exercises for the hip abductor muscles shows superior long-term outcomes compared to other interventions 1, 3
• Activity modification to decrease repetitive loading of the damaged tendon and bursa 1
• Eccentric strengthening exercises for hip abductor muscles 1, 3
• Cryotherapy (ice application for 10-minute periods through a wet towel) can provide acute pain relief 1
• Land-based physical therapy interventions are conditionally recommended over aquatic therapy interventions 2

Pharmacological Approaches

• NSAIDs are recommended for pain relief and anti-inflammatory effects 1, 4
• Acetaminophen should be considered as first-line pharmacologic treatment for mild to moderate pain 2
• Daily dosage of acetaminophen should not exceed 4 grams per day 2

Second-Line Treatment

• Corticosteroid injection into the trochanteric bursa can provide both diagnostic information and therapeutic benefit 1, 5
• Ultrasound guidance improves the accuracy of corticosteroid injections 1
• Combining physical therapy with corticosteroid injections appears to be more effective in managing acute symptoms than physical therapy alone 3
• Extracorporeal shock wave therapy (ESWT) has shown promising results with up to 68.3% improvement in pain scores compared to control groups 3

Important Clinical Considerations

• Greater trochanteric pain syndrome encompasses a spectrum of conditions including abductor tendinopathy, trochanteric bursitis, and external coxa saltans 3, 6
• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the two conditions frequently coexist 1
• The incidence of greater trochanteric pain is approximately 1.8 patients per 1000 per year with higher prevalence in women and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity 4
• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 5
• Platelet-rich plasma (PRP) injections have shown potential in some studies, but evidence remains inconclusive and further research is needed before it can be recommended as standard treatment 3, 7

Common Pitfalls and Caveats

• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 1
• Corticosteroid injections provide only short-term relief and effects do not persist with time 5
• Local injections around the Achilles, patellar, and quadriceps tendons should be avoided given the risk of tendon rupture 2
• High-impact aerobic training involves rapid application of loads across joint structures and should be avoided 2