What is the initial treatment for greater trochanteric tendinopathy?

Initial Treatment for Greater Trochanteric Tendinopathy

Begin with a structured conservative approach combining activity modification, physical therapy with eccentric hip abductor strengthening, and NSAIDs, as this provides the foundation for successful long-term outcomes. 1

First-Line Conservative Treatment Algorithm

Immediate Interventions (Week 1-2)

• Activity modification is essential—reduce repetitive loading activities that reproduce lateral hip pain, particularly activities involving hip abduction against resistance, prolonged standing, and stair climbing 1

• Cryotherapy should be applied through a wet towel for 10-minute periods to provide acute pain relief 1

• NSAIDs are recommended for pain relief and anti-inflammatory effects, though they provide short-term benefit without altering long-term outcomes 1

Physical Therapy Protocol (Weeks 2-12)

• Eccentric strengthening exercises targeting hip abductor muscles (gluteus medius and minimus) form the cornerstone of treatment and should be initiated early 1

• Iliotibial band stretching exercises must be incorporated to reduce tension on the greater trochanter 1

• Supervised exercise programs focusing on eccentric strengthening are more effective than passive interventions like massage or ultrasound 1

Diagnostic Imaging Considerations

• Plain radiographs should be obtained first to rule out other causes of hip pain including osteoarthritis, stress fractures, or bone lesions 1

• Ultrasound can effectively detect trochanteric bursitis and evaluate gluteal tendons if symptoms persist beyond 4-6 weeks 1

• MRI provides comprehensive assessment of peritrochanteric structures including gluteus minimus/medius tendons and the trochanteric bursa when diagnosis remains unclear 1

Critical Clinical Pitfall

Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis is difficult, and these conditions frequently coexist—treat both pathologies simultaneously rather than targeting only one 1

Second-Line Treatment (If No Improvement After 6-8 Weeks)

Corticosteroid Injection

• Ultrasound-guided corticosteroid injection into the trochanteric bursa provides both diagnostic information and therapeutic benefit 1

• Ultrasound guidance significantly improves injection accuracy compared to landmark-based techniques 1

• Peritendinous injections are preferred over intratendinous injections, as direct tendon injection may have deleterious effects on tendon healing 1

• Corticosteroid injections provide better acute pain relief than oral NSAIDs but do not alter long-term outcomes 1

Combining Therapies

• Physical therapy combined with corticosteroid injection appears more effective for managing acute symptoms than physical therapy alone 2

Alternative Interventions

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathy, with studies showing 68.3% improvement in pain scores 1, 2

Expected Timeline and Outcomes

• Most patients show improvement within 3-6 months with appropriate conservative treatment 1

• In one study, 60.5% of patients reported symptom resolution at 15 months with targeted physiotherapy 2

When to Consider Advanced Treatment

• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1

• Surgical options include endoscopic iliotibial band release and bursectomy, with studies showing significant pain reduction in 10 of 11 patients 3

Special Consideration for Hip Prostheses

In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis—these require different management strategies 1