What is the recommended treatment for Greater trochanteric tendinopathy?

Treatment of Greater Trochanteric Tendinopathy

Begin with 3-6 months of conservative management including relative rest, NSAIDs, eccentric strengthening exercises, and consider corticosteroid injections or extracorporeal shock wave therapy for refractory cases before surgical evaluation. 1, 2

Initial Conservative Management (First-Line Treatment)

• Relative rest is essential—reduce activities that provoke pain while maintaining some movement to prevent muscle atrophy and deconditioning 1
• NSAIDs (oral or topical) provide effective acute pain relief, with topical formulations preferred to eliminate gastrointestinal hemorrhage risk 1
• Ice therapy through a wet towel for 10-minute periods reduces swelling and provides short-term pain relief 1
• Eccentric strengthening exercises are the cornerstone of treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1
• Stretching exercises of the iliotibial band and gluteal muscles are widely accepted and generally helpful 1, 2
• Orthotic devices including insoles and walking aids can help unload the affected tendon 2

Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment. 1

Second-Line Interventions (If Conservative Measures Fail)

Corticosteroid Injections

• Corticosteroid injections with local anesthetics are among the most effective treatments, providing superior pain relief compared to NSAIDs in the acute phase 2, 3
• Symptom resolution ranges from 49% to 100% with corticosteroid injection as primary treatment 3
• Critical pitfall: Avoid direct injection into the tendon substance as this inhibits healing, reduces tensile strength, and may predispose to rupture 1
• Image-guided infiltrations using ultrasound or fluoroscopy improve accuracy and outcomes 2
• Note that corticosteroids do not alter long-term outcomes despite short-term benefit 1

Extracorporeal Shock Wave Therapy (ESWT)

• Low-energy shock wave therapy is highly effective and superior to other nonoperative modalities according to level II and III evidence 3, 4
• At 12 months, ESWT produces mean visual analog scores of 2.7 compared to 6.3 in control groups (P < 0.001) 4
• 79% of patients achieve excellent or good results with ESWT versus traditional conservative therapy 4
• ESWT is safe with extremely rare complications and can be performed without anesthesia 2, 4
• Treatment protocol: 2000 shocks at 4 bars pressure (0.18 mJ/mm²) with total energy flux density of 360 mJ/mm² 4

Platelet-Rich Plasma (PRP) Injection

• PRP injection is an emerging treatment option for greater trochanteric tendinopathy 2
• Evidence is still evolving but shows promise for refractory cases 2

Percutaneous Ultrasound-Guided Tenotomy

• For iliotibial band tendinopathy specifically, percutaneous ultrasound tenotomy (PUT) using TENEX® device shows 70% pain relief at one year 5
• Median pain scores improve from 9/10 to 5/10 at one year (P < 0.001) 5
• Functional improvements: 57% in side-lying, 78% in sit-to-stand, and 66% in walking tolerance 5
• This bridges the gap between failed conservative management and surgical candidates 5

Surgical Management (Third-Line Treatment)

Surgery is warranted only if pain persists despite 3-6 months of well-managed conservative treatment. 1, 3

Surgical Options Include:

• Endoscopic iliotibial band release and bursectomy at the greater trochanter level is effective and safe with significant pain reduction and functional improvement in 10 of 11 patients 6
• Open Z-plasty of the iliotibial band (proximal or distal) 3
• Bursectomy (open or endoscopic) 3
• Repair of gluteus medius/minimus tears when identified 3
• Excision of abnormal tendon tissue with longitudinal tenotomies to release scarring and fibrosis 1

All surgical techniques show superior outcomes to corticosteroid therapy and physical therapy according to visual analog scale and Harris Hip Scores in comparative studies. 3

Proposed Treatment Algorithm

1. Months 0-3: Relative rest, NSAIDs, ice, eccentric exercises, stretching, orthotics 1, 2
2. Months 3-6 (if inadequate response): Add corticosteroid injection (image-guided preferred) OR extracorporeal shock wave therapy 2, 3, 4
3. After 6 months (if refractory): Consider percutaneous ultrasound tenotomy for ITB tendinopathy OR surgical evaluation 6, 3, 5

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the tendon substance—this weakens the tendon and increases rupture risk 1
• Avoid multiple corticosteroid injections as they may compromise tendon integrity despite short-term symptom relief 1
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 3
• Do not completely immobilize the hip as this leads to muscle atrophy and deconditioning 1

Diagnostic Considerations

• Greater trochanteric pain syndrome affects 10-25% of people in developed countries 2
• The underlying etiology is most commonly gluteus medius/minimus tendinosis or tendon tear at the greater trochanter 2
• Inflammation is not a major feature—this is a degenerative tendinopathy, not tendinitis 2
• Ultrasound or MRI confirms diagnosis and identifies tendon tears requiring different management 2