What is the preferred treatment for hip bursitis, hip bursa injection with corticosteroid (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)) or oral medications like ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) or naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID))?

Hip Bursitis Treatment: Corticosteroid Injection vs Oral NSAIDs

For hip bursitis (trochanteric bursitis), begin with oral NSAIDs and conservative measures, but proceed to corticosteroid injection when oral medications provide inadequate relief, as injection provides superior and more rapid symptom resolution in this condition.

Initial Management Approach

Start with conservative therapy for all patients with hip bursitis 1, 2:

• Oral NSAIDs (ibuprofen 800 mg three times daily or naproxen 500 mg twice daily) combined with rest and stretching exercises focused on the lower back and sacroiliac joints 1, 3
• Continue this regimen for 2-4 weeks before escalating treatment 1, 2
• Add acetaminophen up to 4 g/day as adjunctive therapy if NSAIDs alone are insufficient 4, 5

When to Proceed to Injection

Corticosteroid injection is indicated when:

• Symptoms persist despite 2-4 weeks of adequate oral NSAID therapy at appropriate doses 1, 2
• Pain significantly limits function or quality of life 2
• Patient requires more rapid symptom resolution 1, 6

Injection Technique and Efficacy

The evidence strongly favors corticosteroid injection for persistent hip bursitis:

• One or two local corticosteroid injections (24 mg betamethasone with 1% lidocaine or equivalent) provide excellent response in two-thirds of patients and improvement in the remaining cases 1, 6
• The syndrome responds so readily to injection that it "should always be considered in hip pain syndromes, as it is so easily relieved" 6
• Only one-fourth of patients relapse within 2 years after successful injection 6
• Use ultrasound or fluoroscopic guidance when available to ensure accurate delivery 7, 4

Important Distinctions: Hip Bursitis vs Hip Osteoarthritis

Critical caveat: The guidelines citing strong recommendations for oral NSAIDs over injection apply specifically to hip osteoarthritis, not hip bursitis 7. For hip OA, oral NSAIDs are the mainstay of pharmacologic management and are strongly recommended as initial oral medication 7. However, for hip bursitis (trochanteric bursitis), the pathophysiology and treatment response differ significantly 1, 2, 6.

Treatment Algorithm for Hip Bursitis

1. Weeks 0-4: Oral NSAIDs (ibuprofen 800 mg TID or naproxen 500 mg BID) plus rest, ice, and stretching exercises 1, 2

2. If inadequate response: Add acetaminophen 1000 mg every 6-8 hours 4

3. If still inadequate at 2-4 weeks: Proceed to corticosteroid injection (betamethasone 24 mg with lidocaine 1%) into the inflamed bursa 1, 6

4. If symptoms recur: Consider repeat injection (up to 2 injections total) 6

5. Refractory cases only: Surgical options (iliotibial band release, subgluteal bursectomy) are reserved for rare cases of intractable symptoms 1, 2

Safety Considerations

• Infection risk: While septic bursitis after injection is theoretically possible, it is rarely reported and should not deter appropriate use 8
• NSAID monitoring: Monitor for gastrointestinal, cardiovascular, and renal adverse effects with prolonged oral NSAID use 7
• Avoid retrocalcaneal bursa injection: Unlike trochanteric bursitis, steroid injection into the retrocalcaneal bursa may adversely affect Achilles tendon biomechanics 2

Alternative Consideration

Dry needling has been shown to be noninferior to cortisone injection for greater trochanteric pain syndrome, with no adverse effects reported, and may be considered as an alternative when available 9.