Treatment for Right Insertional Gluteal Tendinopathy and Enthesopathy
The recommended first-line treatment for right insertional gluteal tendinopathy and enthesopathy with bilateral trochanteric bursa prominence includes activity modification, physical therapy with eccentric strengthening exercises, NSAIDs for pain relief, and cryotherapy. 1
Initial Conservative Management
- Activity modification to decrease repetitive loading on the damaged tendon and bursa is essential to prevent further damage and promote healing 2, 1
- Physical therapy focusing on eccentric strengthening exercises for hip abductor muscles and stretching of the iliotibial band can help reverse degenerative changes and improve function 2, 1
- NSAIDs are recommended for short-term pain relief, though they do not affect long-term outcomes 2, 1
- Cryotherapy through application of ice with a wet towel for 10-minute periods provides effective acute pain relief 2, 1
Diagnostic Considerations
- Radiographs should be obtained first to rule out other causes of hip pain 1
- Ultrasound can effectively detect trochanteric bursitis and help differentiate it from other conditions, though it may be difficult to distinguish from gluteus medius tendinosis 1
- MRI provides comprehensive assessment of peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 1
Second-Line Interventions
- Corticosteroid injections into the trochanteric bursa can provide both diagnostic information and therapeutic benefit when first-line treatments fail 1, 3
- Ultrasound guidance significantly improves the accuracy of corticosteroid injections, with greater trochanteric bursa injections showing better pain reduction (median pain reduction of 3) compared to subgluteus medius bursa injections (median pain reduction of 0) 1, 3
- Extracorporeal shock wave therapy is a safe, noninvasive, and effective option for chronic tendinopathies that haven't responded to initial management 2, 1, 4
Advanced Treatment Options
- Platelet-rich plasma injections have shown good evidence for effectiveness in grades 1 and 2 tendinopathy 5
- Therapeutic ultrasound may be considered, though evidence for consistent benefit is limited 2, 6
- Orthotics and bracing can help reduce tension on the affected tendon during the healing process 1
Surgical Management
- Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 2, 1
- Surgical options include bursectomy with or without iliotibial band release for grades 1 and 2 tendinopathy, and tendon repair for partial or full-thickness tears 5
Common Pitfalls and Caveats
- Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the two conditions frequently coexist 1
- Corticosteroid injections should be used with caution as injections directly into the tendon substance may have deleterious effects 1
- Most patients with overuse tendinopathies (about 80%) fully recover within three to six months with appropriate outpatient treatment 2
- In patients with hip prostheses, it's essential to be cautious of misinterpreting adverse reactions to metal debris as trochanteric bursitis 1