What are the management options for trochanteric bursitis?

Management of Trochanteric Bursitis

First-Line Conservative Treatment

Begin with NSAIDs, physical therapy focusing on iliotibial band stretching and hip abductor strengthening, and activity modification to reduce pressure on the affected area. 1

• NSAIDs (such as naproxen 500 mg twice daily) provide both pain relief and anti-inflammatory effects 1, 2
• Physical therapy should emphasize eccentric strengthening exercises for hip abductor muscles, which are more effective than passive interventions 1
• Activity modification to decrease repetitive loading of the damaged tendon and bursa is essential 1
• Cryotherapy (ice application for 10-minute periods through a wet towel) can provide acute pain relief 1
• Land-based physical therapy is preferred over aquatic therapy 1

Diagnostic Imaging When Symptoms Persist

• Obtain radiographs first to rule out other causes of hip pain, including fractures or arthritis 1, 3
• Ultrasound effectively detects trochanteric bursitis and can guide subsequent injections, though it may be difficult to distinguish from gluteus medius tendinosis 1, 3
• MRI provides comprehensive assessment of peritrochanteric structures including gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 1, 3

Second-Line Treatment: Corticosteroid Injection

If symptoms persist after 6-8 weeks of conservative therapy, proceed with ultrasound-guided corticosteroid injection into the trochanteric bursa. 1

• Ultrasound guidance improves injection accuracy and ensures proper placement 1, 3
• Use triamcinolone acetonide (or equivalent corticosteroid such as 24 mg betamethasone) combined with 1% lidocaine 4, 5
• Peritendinous injections are preferred over intratendinous injections, as injections directly into the tendon substance may have deleterious effects 1
• The injection provides both diagnostic confirmation and therapeutic benefit 1, 3
• Most patients respond to a single injection (29.9%), though some may require 2 injections (5.7%) or 3-5 injections repeated every 4-6 weeks (4.5%) 6

Advanced Conservative Options for Refractory Cases

If symptoms persist despite corticosteroid injection:

• Extracorporeal shock wave therapy is a safe, noninvasive, and effective treatment for chronic tendinopathies 1
• Continue advanced physical therapy with eccentric strengthening exercises while maintaining relative rest 1
• Orthotics and bracing can reduce tension on the affected tendon during healing 1

Surgical Management

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

• Surgical options include iliotibial band release, trochanteric bursectomy, and trochanteric reduction osteotomy 5, 7
• Endoscopic techniques allow for minimally invasive trochanteric bursectomy 7
• Surgical repair of torn abductor tendons is viable when MRI and clinical findings confirm tendon disruption and weakness 1

Critical Pitfalls to Avoid

• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and these conditions frequently coexist 1, 3
• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 1, 3
• Avoid intratendinous corticosteroid injections as they may cause tendon damage 1
• Do not use corticosteroid injections as first-line therapy—always attempt conservative measures first 1