What is the treatment for trochanteric bursitis?

Treatment of Trochanteric Bursitis

First-Line Conservative Treatment

Begin with NSAIDs, physical therapy focusing on iliotibial band stretching and hip abductor strengthening, and activity modification to reduce pressure on the affected area. 1

Initial Conservative Measures

• NSAIDs provide both pain relief and anti-inflammatory effects and should be started immediately 1
• Physical therapy is essential and must include:
  • Stretching exercises specifically targeting the iliotibial band 1
  • Eccentric strengthening of hip abductor muscles (gluteus medius and minimus) 1
  • Supervised exercise programs are more effective than passive interventions 1
• Activity modification to decrease repetitive loading of the damaged tendon and bursa 1
• Cryotherapy (ice application for 10-minute periods through a wet towel) provides acute pain relief 1
• Land-based physical therapy is preferred over aquatic therapy 1

Important Diagnostic Consideration

Obtain plain radiographs first to rule out other causes of hip pain such as arthritis or bone tumors before proceeding with treatment 1, 2

Second-Line Treatment: Corticosteroid Injection

If symptoms persist after 4-6 weeks of conservative therapy, proceed with ultrasound-guided corticosteroid injection into the trochanteric bursa. 1

Injection Technique and Dosing

• Ultrasound guidance significantly improves injection accuracy and should always be used 1
• Dosage: 20-80 mg methylprednisolone (or equivalent such as 24 mg betamethasone) for large joints/bursal structures 3, 4
• Mix corticosteroid with 1% lidocaine for immediate pain relief 4
• Peribursal injection is preferred over intrabursal injection to avoid potential tissue damage 1
• The injection provides both diagnostic information and therapeutic benefit 1

Injection Protocol

• Prepare the area with appropriate antiseptic (70% alcohol) 3
• Use a 20-24 gauge needle 3
• Inject 20-60 mg of corticosteroid suspension into the bursal area 3
• Most patients require only a single injection (29.9% in one study), though 2-5 injections at 4-6 week intervals may be needed for refractory cases 5

Advanced Imaging When Needed

If symptoms persist despite initial conservative treatment, obtain ultrasound to detect bursitis and evaluate gluteal tendons. 1, 2

• Ultrasound is the preferred first-line imaging modality after radiographs due to cost-effectiveness and accuracy for superficial structures 2
• MRI should be reserved for cases where:
  • Ultrasound findings are equivocal 2
  • There is suspicion of abductor tendon tears or fatty atrophy 2
  • Comprehensive assessment of peritrochanteric structures is needed 1, 2

Refractory Cases: Additional Treatment Options

For patients failing 3-6 months of comprehensive conservative treatment including corticosteroid injections, consider extracorporeal shock wave therapy before surgical intervention. 1

Non-Surgical Options for Refractory Disease

• Extracorporeal shock wave therapy is safe, noninvasive, and effective for chronic tendinopathies 1
• Advanced physical therapy with continued eccentric strengthening exercises 1
• Orthotics and bracing to reduce tension on affected tendons 1

Surgical Management

Surgery should only be considered after failure of 3-6 months of comprehensive conservative treatment. 1

• Surgical options include iliotibial band release, trochanteric bursectomy, and surgical repair of torn abductor tendons 1, 6
• Endoscopic techniques allow for minimally invasive trochanteric bursectomy 6

Critical Pitfalls to Avoid

• Differentiation difficulty: Trochanteric bursitis and gluteus medius/minimus tendinosis frequently coexist and can be difficult to distinguish—treat both conditions simultaneously 1, 2
• Hip prosthesis patients: In patients with hip replacements, be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis 1
• Injection technique: Always use ultrasound guidance for corticosteroid injections to ensure proper placement 1
• Avoid intratendinous injection: Peritendinous injections are safer than intratendinous injections, which may have deleterious effects on tendon integrity 1
• Passive therapy limitations: Massage, ultrasound, and heat can supplement but should never substitute active physical therapy 1

Treatment Algorithm Summary

1. Obtain radiographs to rule out other pathology 1, 2
2. Start conservative treatment: NSAIDs + physical therapy (stretching and strengthening) + activity modification 1
3. If no improvement after 4-6 weeks: Add ultrasound-guided corticosteroid injection 1
4. If symptoms persist: Obtain ultrasound imaging to evaluate for coexisting tendinopathy 1, 2
5. After 3-6 months of failed conservative treatment: Consider extracorporeal shock wave therapy 1
6. Last resort: Surgical intervention for truly refractory cases 1