What is the treatment for trochanteric bursitis?

Treatment of Trochanteric Bursitis

Begin with conservative therapy including NSAIDs, physical therapy with hip abductor strengthening exercises, and activity modification; if symptoms persist after 6-8 weeks, proceed to ultrasound-guided corticosteroid injection into the trochanteric bursa. 1, 2

Initial Diagnostic Approach

• Obtain plain radiographs first to exclude other causes of lateral hip pain such as arthritis, fracture, or bone lesions 3, 1
• Consider ultrasound if diagnosis remains unclear, as it effectively detects trochanteric bursitis and can differentiate it from gluteus medius/minimus tendinopathy, though these conditions frequently coexist 3, 1
• Reserve MRI for cases where ultrasound is inconclusive or when comprehensive assessment of peritrochanteric structures (gluteus medius/minimus tendons, abductor muscles) is needed 3, 1

First-Line Conservative Treatment (0-6 Weeks)

Non-Pharmacological Interventions

• Physical therapy with eccentric strengthening of hip abductor muscles is the cornerstone of treatment and shows superior long-term outcomes compared to passive interventions 1, 2
• Activity modification to decrease repetitive loading of the affected bursa and tendons 1, 2
• Cryotherapy with ice application for 10-minute periods through a wet towel for acute pain relief 1
• Land-based exercises are preferred over aquatic therapy 1, 2

Pharmacological Interventions

• NSAIDs for pain relief and anti-inflammatory effects 1, 2, 4
• Acetaminophen may be considered for mild to moderate pain, not exceeding 4 grams daily 2

Second-Line Treatment (After 6-8 Weeks of Failed Conservative Therapy)

Corticosteroid Injection

• Inject 20-80 mg of methylprednisolone (or equivalent corticosteroid) into the trochanteric bursa 5
• Use ultrasound guidance to ensure accurate placement and improve therapeutic outcomes 1, 2
• Expect symptom relief within 6-48 hours, with effects persisting for several days to weeks 5
• Single injection is effective in approximately 29-49% of patients; some may require 2-5 injections at 4-6 week intervals 6, 7

The evidence shows that corticosteroid injection combined with conservative measures achieves symptom resolution in 49-100% of cases 6. A retrospective study of 157 patients found that local corticosteroid therapy was effective in 49% when followed by physical therapy and 39% with injection alone 7.

Alternative Non-Invasive Option

• Low-energy extracorporeal shock wave therapy (SWT) is superior to other non-operative modalities in comparative studies and should be considered for patients who fail initial conservative treatment 6

Critical Pitfalls to Avoid

• Differentiate between trochanteric bursitis and gluteus medius/minimus tendinopathy, as these conditions frequently coexist and may require different treatment approaches 3, 1, 2
• Avoid injecting corticosteroids directly into tendon substance, as this increases risk of tendon rupture; peritendinous injections are safer 2
• In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis 1, 2
• Avoid high-impact activities during the acute phase, as rapid loading across joint structures exacerbates symptoms 2

Surgical Intervention (After 3-6 Months of Failed Conservative Treatment)

Surgery should only be considered after comprehensive failure of conservative treatment for 3-6 months 1, 2. Surgical options include:

• Endoscopic or open trochanteric bursectomy 6, 8
• Iliotibial band release (longitudinal release or Z-plasty) 6, 8
• Repair of gluteus medius/minimus tears if MRI confirms tendon disruption with associated weakness 1, 6

Surgical outcomes show superior results compared to corticosteroid therapy and physical therapy alone in refractory cases, with efficacy varying by technique but generally achieving good patient satisfaction 6.