Is a patient's persistent hip pain after falling, unrelieved by trochanteric bursae (greater trochanter bursa) injections and initially attributed to arthritis, but significantly relieved by self-treatment with a vibrating ball on the ischiogluteal bursa, a case of misdiagnosis?

Yes, This Appears to Be a Case of Misdiagnosis

The patient's dramatic response to self-treatment targeting the ischiogluteal bursa strongly suggests the primary pathology was ischial (ischiogluteal) bursitis, not trochanteric bursitis or hip arthritis as initially diagnosed. The 75% pain relief from direct treatment of the ischiogluteal bursa is both diagnostic and therapeutic, indicating the original injections were directed at the wrong anatomical site.

Why This Represents Diagnostic Error

Anatomical Misdirection

• The greater trochanteric bursa and ischiogluteal bursa are distinct anatomical structures with different pain patterns. 1
• Trochanteric bursitis typically causes lateral hip pain, while ischiogluteal bursitis causes deep buttock and posterior hip pain, particularly with sitting 1
• The patient's response pattern—failure of trochanteric injection but success with ischiogluteal treatment—indicates the wrong bursa was targeted initially

Common Diagnostic Pitfalls in Hip Pain

• Diagnostic errors in medicine are substantially underrecognized, with physicians rarely perceiving their own error rates as problematic 2
• In hospitalized patients, harmful diagnostic errors occur in approximately 0.7% of admissions, with a wide range of common diseases being missed 3
• After radiographs, MRI or ultrasound is appropriate for evaluating extra-articular soft tissue abnormalities such as bursitis when the diagnosis remains unclear 1

The Diagnostic Sequence That Should Have Occurred

Initial Evaluation After Failed Trochanteric Injection

• When trochanteric bursa injection fails to relieve pain, the diagnosis must be reconsidered rather than attributing symptoms to arthritis 1
• Ultrasound can examine soft tissue structures around the hip for specific diagnoses including different types of bursitis 1
• The pain location (sitting on the ischium vs. lateral hip) should have guided anatomical localization

Red Flags That Were Missed

• Pain persisting after appropriately placed trochanteric injection suggests either:
  • Wrong anatomical diagnosis (as in this case)
  • Additional pathology requiring advanced imaging 1
• Simply attributing persistent pain to "arthritis" without further workup represents premature diagnostic closure 2

Clinical Implications

For This Patient

• The patient essentially performed their own diagnostic test by treating the ischiogluteal bursa directly
• Formal treatment should now include targeted injection of the ischiogluteal bursa under imaging guidance if symptoms recur 1
• Consider ultrasound or MRI to confirm the diagnosis and exclude other pathology 1

System-Level Learning Points

• Diagnostic errors need systematic identification and addressing through quality assurance surveillance, including second opinions on difficult cases 2
• When initial treatment fails, clinicians must actively reconsider the diagnosis rather than defaulting to alternative explanations like arthritis 2
• Physicians need feedback on their diagnoses to improve calibration and recognize cognitive biases like premature closure 2

Preventing Similar Errors

• Use imaging (ultrasound or MRI) to confirm bursa location before injection when clinical examination is equivocal 1
• Consider multiple potential pain generators in the hip region rather than assuming a single diagnosis
• When a therapeutic injection fails, question the anatomical target before questioning the diagnosis category 1