What is the initial treatment for greater trochanteric pain syndrome?

Initial Treatment for Greater Trochanteric Pain Syndrome

Begin with physical therapy focused on eccentric strengthening of hip abductor muscles combined with NSAIDs for pain control, as this approach provides superior long-term outcomes compared to other interventions. 1, 2

Diagnostic Workup Before Treatment

• Obtain plain radiographs first to exclude alternative causes such as arthritis, fractures, or bone tumors 1, 2, 3
• Consider ultrasound if diagnosis remains unclear, as it effectively detects trochanteric bursitis and evaluates gluteal tendons, though distinguishing from gluteus medius tendinosis can be challenging 1, 2
• Reserve MRI for cases with negative or equivocal radiographs when tendon, muscle, or ligament injury is suspected 1, 3

First-Line Treatment Algorithm

Non-Pharmacological Management (Primary Treatment)

Physical therapy with targeted hip abductor exercises is the cornerstone of initial management and shows the best long-term results. 1, 4

• Implement supervised exercise programs emphasizing eccentric strengthening of hip abductor muscles, which are more effective than passive interventions 2
• Prescribe land-based physical therapy over aquatic therapy 1, 2
• Modify activities to decrease repetitive loading of the damaged tendon and bursa 1, 2
• Apply ice for 10-minute periods through a wet towel for acute pain relief 2

Pharmacological Management (Adjunctive Treatment)

• Prescribe NSAIDs for pain relief and anti-inflammatory effects 1, 2
• Consider acetaminophen as first-line for mild to moderate pain, not exceeding 4 grams daily 1

Second-Line Treatment (If First-Line Fails)

Ultrasound-guided corticosteroid injection into the trochanteric bursa provides both diagnostic confirmation and therapeutic benefit when combined with ongoing physical therapy. 1, 2, 3

• Use ultrasound guidance to improve injection accuracy 1, 2, 3
• Recognize that corticosteroid injections provide short-term pain relief (first few months) but do not alter long-term outcomes 4, 5
• Combine injections with continued physical therapy for sustained benefit rather than using injections alone 4

Critical Clinical Pitfalls

• Coexisting conditions: Trochanteric bursitis and gluteus medius/minimus tendinosis frequently coexist and can be difficult to differentiate clinically 1, 2, 3
• Hip prosthesis patients: In patients with hip replacements, adverse reactions to metal debris can mimic trochanteric bursitis and must be excluded 1, 2
• Injection technique: Avoid intratendinous injections; use peritendinous approach to prevent tendon damage 3
• Avoid high-impact activities: High-impact aerobic training rapidly loads joint structures and should be avoided during treatment 1

When to Consider Advanced Treatment

• Reserve surgical intervention only after 3-6 months of comprehensive conservative treatment failure 1, 2, 3
• Consider extracorporeal shock wave therapy for chronic cases unresponsive to physical therapy and NSAIDs 2, 4

Expected Outcomes

• Physical therapy shows 60.5% symptom resolution at 15 months, though improvements may not be immediate 4
• Most patients respond well to conservative management without requiring surgery 6, 7
• Up to one-third of patients may fail initial therapy and require escalation of treatment 8