What are the next steps in treating trochanteric (greater trochanteric) bursitis when initial treatments fail?

Treatment of Trochanteric Bursitis After Initial Treatment Failure

When first-line treatment with NSAIDs, physical therapy, and activity modification fails, proceed with ultrasound-guided corticosteroid injection into the trochanteric bursa, followed by extracorporeal shock wave therapy if injections are unsuccessful, and reserve surgery only after 3-6 months of comprehensive conservative treatment failure. 1

Second-Line Treatment: Corticosteroid Injections

Injection Protocol

• Ultrasound-guided corticosteroid injection into the trochanteric bursa is the next step after failed conservative measures, providing both diagnostic confirmation and therapeutic benefit 1
• Ultrasound guidance significantly improves injection accuracy compared to landmark-based techniques 1
• Peritrochanteric infiltration with glucocorticoids mixed with 2% lidocaine provides long-term symptom relief, though recurrence should be expected and treatment may be repeated 2

Expected Outcomes

• Approximately 80% of patients respond to corticosteroid injections, though 45% may require multiple injections 3
• Symptom resolution rates range from 49% to 100% when corticosteroid injection is used as the primary treatment modality 4
• Injections should be peritendinous rather than intratendinous, as direct tendon substance injections may have deleterious effects 1

Predictors of Injection Failure

• Younger patients show a trend toward poorer response to nonoperative management 3
• Greater limb-length discrepancy is associated with higher failure rates of conservative treatment 3

Third-Line Treatment: Extracorporeal Shock Wave Therapy

If corticosteroid injections fail or provide only temporary relief, extracorporeal shock wave therapy (ESWT) is the preferred next step before considering surgery. 1

• ESWT is a safe, noninvasive, and effective treatment for chronic tendinopathies that provides pain relief 1
• Level II and III evidence demonstrates ESWT is superior to other nonoperative modalities including corticosteroid injections 4
• This modality is particularly appropriate for hip abductor tendinopathy, which frequently coexists with trochanteric bursitis 1

Advanced Physical Therapy

Structured Exercise Program

• Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions 1
• Land-based physical therapy is preferred over aquatic therapy interventions 1
• Continue relative rest while allowing activities that don't worsen pain 1

Adjunctive Measures

• Orthotics and bracing can reduce tension on the affected tendon during healing 1
• Passive interventions (massage, ultrasound, heat) may supplement but should not substitute active physical therapy 1

Surgical Intervention

Surgery should only be considered after failure of 3-6 months of comprehensive conservative treatment. 1

Surgical Options

Multiple surgical techniques have been reported with variable efficacy:

• Bursectomy 4
• Longitudinal release of the iliotibial band 4
• Proximal or distal Z-plasty of the iliotibial band 4
• Surgical repair of torn abductor tendons when MRI and clinical findings confirm tendon disruption and weakness 1

Surgical Outcomes

• All surgical techniques demonstrate superiority to corticosteroid therapy and physical therapy according to visual analog scale (VAS) and Harris Hip Scores (HHS) 4
• Surgery is effective in refractory cases, with outcomes varying by specific technique and clinical outcome measure 4

Critical Diagnostic Considerations

Differentiate Coexisting Conditions

• Trochanteric bursitis and gluteus medius/minimus tendinosis are difficult to distinguish and frequently coexist 1, 5
• Most cases actually result from pathology of the gluteus medius or minimus muscles rather than true bursitis 5
• If not already performed, obtain MRI to comprehensively assess peritrochanteric structures including gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 1

Special Populations

• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris (ARMD) can be misinterpreted as trochanteric bursitis 1
• Consider systemic rheumatic disease if multiple symptomatic bursae are present 6

Treatment Algorithm Summary

1. Repeat or optimize conservative measures: Ensure adequate trial of NSAIDs, structured physical therapy with eccentric strengthening, activity modification, and ice application 1

2. Ultrasound-guided corticosteroid injection: First interventional step, may require multiple injections 1, 3

3. Extracorporeal shock wave therapy: If injections fail or provide only temporary relief 1, 4

4. Advanced imaging: Obtain MRI if not already done to assess for gluteal tendon tears or other structural pathology 1

5. Surgical consultation: Only after documented failure of 3-6 months of comprehensive conservative treatment 1