What is the diagnosis and treatment for a patient with left outer hip pain, weakness going up stairs, and walking difficulties after a traumatic injury, with concerns for tendon inflammation and possible tear?

Diagnosis: Greater Trochanteric Pain Syndrome with Gluteus Medius/Minimus Tendinopathy

This patient most likely has gluteus medius/minimus tendinopathy (hip abductor tendon pathology) rather than isolated trochanteric bursitis, and given the traumatic mechanism, weakness with stairs/walking, and lateral hip pain, you should obtain MRI of the hip without contrast to evaluate for tendon tear before proceeding with treatment. 1, 2

Why This Is NOT Simple Trochanteric Bursitis

• Isolated trochanteric bursitis is rare—only 2% of patients with refractory lateral hip pain have isolated greater trochanteric bursitis without relevant hip abductor tendon pathology 3
• The presence of weakness going up stairs and walking is a red flag for gluteus medius/minimus tendon tear or significant tendinopathy, not simple bursitis 1, 2
• The traumatic mechanism (roundhouse kick) makes acute tendon injury or tear much more likely than inflammatory bursitis 4
• When bursitis is present, it typically coexists with hip abductor tendon pathology (25% of cases), not as an isolated finding 3

Critical Diagnostic Algorithm

Step 1: Obtain plain radiographs first

• The American College of Radiology recommends plain radiographs (AP pelvis and frog-leg lateral hip) as the initial imaging to exclude osseous pathology, arthritis, or structural abnormalities 1, 5

Step 2: Proceed directly to MRI hip without contrast

• MRI is the definitive imaging study for suspected gluteus medius tendon pathology, with sensitivity ranges of 33-100% and specificity of 92-100% for detecting tendon tears 1
• The American College of Radiology explicitly states that MRI without contrast is "usually appropriate when evaluating for clinically suspected tendon, muscle, or ligament injury as the source of hip pain" 1
• MRI provides comprehensive assessment of all peritrochanteric structures including gluteus medius/minimus muscles, abductor tendons, and trochanteric bursa 1
• MRI can classify the location, extent, degree (partial versus complete), and chronicity of tendon injuries 1

Do NOT rely on ultrasound as primary diagnostic tool:

• Ultrasound has lower sensitivity (79%) for detecting gluteus medius/minimus tendon tears 1
• There is insufficient evidence to support ultrasound as the next imaging study for suspected tendon injury according to the American College of Radiology 1
• It is difficult to distinguish between gluteus medius tendinosis and bursitis on ultrasound 1

Why Immediate Imaging Is Critical in This Case

• The combination of traumatic injury + weakness + lateral hip pain suggests possible tendon tear that may require surgical intervention 2, 6
• Gluteus medius tendon tears typically have good surgical outcomes when identified and treated appropriately 2
• Delaying definitive imaging may result in progression from partial to complete tear, worsening functional outcomes 1
• Early referral to orthopedics may improve patient outcomes if tear is identified 2

Treatment Algorithm Based on MRI Findings

If MRI shows tendinopathy without tear:

• Relative rest and activity modification to prevent further damage 4
• Physical therapy focusing on eccentric strengthening exercises and hip stabilizer strengthening 4, 7
• NSAIDs (naproxen 500mg twice daily) for acute pain relief and anti-inflammatory effect 4, 8
• Cryotherapy with repeated applications of melting ice water for acute pain relief 4
• Most patients (80%) with overuse tendinopathies fully recover within 3-6 months with conservative treatment 4

If conservative treatment fails after 4-6 weeks:

• Proceed with ultrasound-guided corticosteroid injection into the peritendinous region, which provides both diagnostic confirmation and therapeutic benefit 7
• Corticosteroids should be used with caution in tendon pathology 4

If MRI shows partial or complete tendon tear:

• Immediate orthopedic referral for surgical evaluation 2, 6
• Both open and endoscopic surgical options are available with good outcomes 6
• Surgery is indicated for chronic symptoms refractory to conservative therapy or acute complete tears 4, 6

Common Pitfalls to Avoid

• Do not dismiss this as simple "bursitis" and treat with NSAIDs alone—the weakness indicates likely tendon pathology requiring imaging 1, 3
• Do not delay MRI if symptoms persist or worsen—tendon tears require different management than tendinopathy 1, 2
• Do not use ultrasound as the primary diagnostic modality for suspected tendon tear—MRI is superior 1
• Do not forget to examine the lumbar spine—referred pain from spine pathology can mimic lateral hip pain 7, 5
• Recognize that most chronic tendon problems are degenerative ("tendinosis"), not inflammatory ("tendonitis")—this affects treatment approach 4, 9

Additional Diagnostic Considerations

• Consider iliopsoas pathology, femoroacetabular impingement, and labral pathology in the differential if pain is more anterior 7
• If diagnosis remains unclear after MRI, image-guided diagnostic injection can differentiate between bursal and intra-articular sources 7, 5
• Rule out lumbar spine pathology if hip examination findings are inconsistent with imaging 7, 5