What is the role of physiotherapy (physical therapy) in the management of greater trochanteric bursitis?

Physiotherapy for Greater Trochanteric Bursitis

Physical therapy is strongly recommended as a first-line treatment for greater trochanteric bursitis, with emphasis on active interventions including stretching exercises for the iliotibial band and strengthening of hip abductor muscles. 1

Diagnosis and Initial Assessment

• Radiographs should be obtained first to rule out other causes of hip pain such as arthritis or bone tumors 1, 2
• 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 provides comprehensive assessment of peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa when symptoms persist 1

Physiotherapy Approach

Active Interventions (Recommended)

• Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions 3, 1
• Stretching exercises for the iliotibial band should be included in the treatment protocol 1
• Activity modification to reduce pressure on the affected area is essential during the rehabilitation process 1
• Land-based physical therapy interventions are conditionally recommended over aquatic therapy interventions 3

Passive Interventions (Supplementary)

• Passive interventions such as massage, ultrasound, and heat can supplement but should not substitute active physical therapy 3
• Cryotherapy (ice application for 10-minute periods through a wet towel) can provide acute pain relief 1

Comprehensive Management Algorithm

First-Line Treatment

• Begin with active physical therapy interventions focusing on stretching and strengthening exercises 1
• NSAIDs for pain relief and anti-inflammatory effects 1
• Activity modification to reduce pressure on the affected area 1

Second-Line Treatment

• If symptoms persist after 4-6 weeks of first-line treatment, consider corticosteroid injection into the trochanteric bursa 1, 4
• Ultrasound guidance improves the accuracy of corticosteroid injections 1
• Continue physical therapy following injection for optimal outcomes 4

Refractory Cases

• For persistent symptoms, extracorporeal shock wave therapy (SWT) has been shown to be superior to other nonoperative modalities 5
• Advanced physical therapy with continued focus on eccentric strengthening exercises 1
• Orthotics and bracing may help reduce tension on the affected tendon during the healing process 1
• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 5

Efficacy of Physiotherapy

• Physical therapy has moderate-quality evidence supporting its efficacy in treating conditions similar to trochanteric bursitis 3
• Combined approach of corticosteroid injection followed by physical therapy has shown effectiveness in 49% of patients with trochanteric bursitis 4
• Symptom resolution and return to activity ranges from 49% to 100% with multimodal conservative therapy including physiotherapy 5

Common Pitfalls and Caveats

• Differentiation between trochanteric bursitis and gluteus medius tendinosis can be difficult, and the two conditions may coexist 1
• Physical therapy alone may be insufficient for some patients, necessitating additional interventions such as corticosteroid injections 4, 5
• Up to one-third of patients fail initial therapy and may require more advanced interventions 6
• Avoid aggressive stretching or strengthening exercises that exacerbate pain during the acute phase 1
• Patients should continue relative rest while allowing activities that don't worsen pain 1