What is the recommended treatment for severe left hip bursitis?

Treatment of Severe Left Hip Bursitis

Your proposed regimen of NSAIDs (naproxen) combined with patient education and activity modification is appropriate, but steroids should be reserved for cases unresponsive to initial conservative management, and tramadol should be avoided as first-line therapy due to inferior efficacy and higher side effect rates compared to NSAIDs.

Initial Conservative Management (First-Line)

• Start with naproxen 500 mg twice daily as the primary anti-inflammatory agent, which has demonstrated efficacy for bursitis and musculoskeletal pain 1, 2
• The initial dose may be 750 mg followed by 250 mg every 8 hours for acute severe pain, though this dosing is specifically indicated for acute gout 1
• Ice, activity modification, and rest form the foundation of acute bursitis management 2, 3
• Patient education about avoiding aggravating activities (e.g., prolonged standing, lying on affected side) is essential 2

Role of Corticosteroid Injection

• Local corticosteroid injection should be considered only if the patient responds inadequately to NSAIDs and conservative measures 4
• Intra-articular or bursal steroid injections are recommended for patients with flares unresponsive to analgesics and NSAIDs 4, 5
• For trochanteric bursitis specifically, injection of all four peri-trochanteric bursae with depot corticosteroid may be necessary for complete resolution 6
• Do not inject steroids as first-line therapy—the evidence supports a stepwise approach 2, 7

Why Tramadol Should Not Be First-Line

• Opioid analgesics (including tramadol) are inferior to NSAIDs for musculoskeletal pain and cause significantly more side effects 4
• Opioids with or without paracetamol demonstrated an effect size of -0.18 compared to diclofenac (inferior efficacy) and caused 7.25 times more side effects including GI upset, constipation, and dizziness 4
• Withdrawal rates from opioids are 3.57 times higher than other analgesics 4
• Reserve opioids only for patients in whom NSAIDs are contraindicated, ineffective, or poorly tolerated 4

Optimal Treatment Algorithm

1. Initiate naproxen 500 mg twice daily with food to minimize GI effects 1, 2
2. Add ice therapy, activity modification, and patient education about avoiding provocative activities 2, 3
3. Reassess at 1-2 weeks: If inadequate response, consider adding physical therapy focusing on hip abductor strengthening and iliotibial band stretching 7
4. If still refractory after 2-4 weeks of conservative management, proceed with ultrasound or fluoroscopy-guided corticosteroid injection into the affected bursa(e) 4, 6
5. Only if NSAIDs are contraindicated (e.g., renal impairment, GI bleeding risk, cardiovascular disease), consider tramadol as an alternative analgesic 4

Important Caveats

• Rule out septic bursitis first if there are any signs of infection (warmth, erythema, fever), as this requires antibiotics, not steroids 3
• Consider underlying conditions that may predispose to trochanteric bursitis including hip osteoarthritis, lumbar spondylosis, or leg length discrepancy 7
• Monitor for NSAID-related adverse effects, particularly GI complications in elderly patients or those with comorbidities 4
• Naproxen is contraindicated in patients with creatinine clearance <30 mL/min 1
• Most patients with trochanteric bursitis respond successfully to NSAIDs plus physiotherapy, with or without local corticosteroid injection 7