What is the recommended management for trochanteric bursitis?

Management of Trochanteric Bursitis

Begin with NSAIDs, physical therapy focusing on hip abductor strengthening and iliotibial band stretching, and activity modification; if symptoms persist after 4-6 weeks, proceed to ultrasound-guided corticosteroid injection. 1, 2

Initial Diagnostic Workup

• Obtain plain radiographs first to exclude other causes of hip pain such as fractures, arthritis, or bone lesions 1, 2
• Consider ultrasound if diagnosis is uncertain, as it effectively detects trochanteric bursitis, though distinguishing from gluteus medius tendinosis can be challenging 1, 2
• Reserve MRI for cases with persistent symptoms or when comprehensive assessment of peritrochanteric structures (gluteus minimus/medius muscles, abductor tendons, trochanteric bursa) is needed 1, 2

First-Line Conservative Treatment (4-6 Weeks)

Pharmacologic Management

• Start NSAIDs for pain relief and anti-inflammatory effects 1, 2
• For naproxen specifically: initiate 500 mg twice daily for acute bursitis, with maximum initial daily dose of 1250 mg, then not exceeding 1000 mg daily thereafter 3
• Consider acetaminophen as first-line for mild-to-moderate pain, particularly in elderly patients, not exceeding 4 grams daily 2

Physical Therapy (Superior Long-Term Outcomes)

• Supervised exercise programs with eccentric strengthening of hip abductor muscles are more effective than passive interventions 1
• Include stretching exercises for the iliotibial band 1, 2
• Land-based physical therapy is preferred over aquatic therapy 1, 2
• Passive interventions (massage, ultrasound, heat) may supplement but should not replace active therapy 1
• Apply cryotherapy (ice for 10-minute periods through wet towel) for acute pain relief 1

Activity Modification

• Reduce repetitive loading of the damaged tendon and bursa 1, 2
• Avoid high-impact aerobic training that rapidly applies loads across joint structures 2

Second-Line Treatment: Corticosteroid Injection

If conservative measures fail after 4-6 weeks, proceed to ultrasound-guided corticosteroid injection into the trochanteric bursa 1, 2

• Ultrasound guidance significantly improves injection accuracy and should be used routinely 1, 2
• Inject peribursal rather than intratendinous to avoid deleterious tendon effects 1
• Typical regimen: 24 mg betamethasone with 1% lidocaine (or equivalent) 4
• This provides both diagnostic information and therapeutic benefit 1, 2
• Success rates range from 49% to 100% with corticosteroid injection 5

Alternative Second-Line Option: Extracorporeal Shock Wave Therapy

• Low-energy shock wave therapy is superior to other nonoperative modalities for chronic cases 1, 5
• Consider as safe, noninvasive, effective treatment after failed physical therapy and NSAIDs 1

Surgical Intervention (Last Resort)

Reserve surgery only after failure of 3-6 months of comprehensive conservative treatment 1, 2

Surgical options include:

• Endoscopic trochanteric bursectomy with iliotibial band release 6, 5
• Longitudinal release of iliotibial band 5
• Proximal or distal Z-plasty 5
• Surgical repair of torn abductor tendons when MRI confirms tendon disruption with weakness 1
• All surgical techniques show superior outcomes to conservative therapy in refractory cases based on VAS and Harris Hip Scores 5

Critical Clinical Pitfalls

• Trochanteric bursitis and gluteus medius/minimus tendinosis frequently coexist and can be difficult to differentiate 1, 2
• In patients with hip prostheses, adverse reactions to metal debris (ARMD) can mimic trochanteric bursitis—maintain high index of suspicion 1, 2
• Avoid injections around Achilles, patellar, and quadriceps tendons due to rupture risk 2
• In elderly patients, use lowest effective NSAID dose due to increased unbound plasma fraction 3
• Avoid naproxen in patients with creatinine clearance <30 mL/min 3