What is the plan of care for a patient diagnosed with trochanteric bursitis?

Plan of Care for Trochanteric Bursitis

Begin with non-pharmacological interventions (physical therapy with eccentric hip abductor strengthening and activity modification) combined with NSAIDs, escalating to ultrasound-guided corticosteroid injection only if conservative measures fail after an adequate trial. 1, 2

Initial Diagnostic Workup

• Obtain plain radiographs first to exclude other causes of hip pain such as fractures, arthritis, or bone lesions 1, 2
• Use ultrasound for confirmation when diagnosis is uncertain, as it effectively detects trochanteric bursitis, though distinguishing from gluteus medius tendinosis can be challenging since both conditions frequently coexist 1, 2
• Reserve MRI for persistent symptoms or when comprehensive assessment of peritrochanteric structures (gluteus minimus/medius muscles, abductor tendons, bursa) is needed after negative or indeterminate radiographs 1, 2
• In patients with hip prostheses, maintain high suspicion for adverse reactions to metal debris (ARMD) that could mimic trochanteric bursitis 1, 2

First-Line Treatment: Conservative Management

Non-Pharmacological Interventions (Primary)

• Initiate supervised physical therapy focusing on eccentric strengthening of hip abductor muscles, which demonstrates superior long-term outcomes compared to passive interventions 1, 2
• Prescribe land-based physical therapy over aquatic therapy, as it shows better efficacy with moderate-quality evidence 1, 2
• Implement stretching exercises for the iliotibial band and lower back/sacroiliac joints 1, 3
• Modify activities to decrease repetitive loading of the damaged tendon and bursa 1, 2
• Apply cryotherapy (ice for 10-minute periods through wet towel) for acute pain relief 1
• Use passive interventions (massage, ultrasound, heat) only as supplements, not substitutes for active physical therapy 1

Pharmacological Management

• Start with NSAIDs for pain relief and anti-inflammatory effects as recommended first-line pharmacotherapy 1, 2
• Consider acetaminophen as first-line for mild-to-moderate pain, particularly in patients with cardiovascular disease or risk factors, not exceeding 4 grams daily 2, 4
• In patients with known cardiovascular disease or ischemic heart disease risk factors, use a stepped-care approach: start with acetaminophen, aspirin, or tramadol before progressing to non-COX-2 selective NSAIDs at the lowest effective dose 4
• For acute bursitis or tendonitis with naproxen, initiate 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial daily dose not exceeding 1250 mg 5
• Add proton-pump inhibitors in patients at risk for GI bleeding when NSAIDs are necessary 4

Second-Line Treatment: Corticosteroid Injection

• Proceed to corticosteroid injection into the trochanteric bursa when symptoms persist despite 4-6 weeks of comprehensive conservative treatment 1, 2
• Always use ultrasound guidance to improve injection accuracy and ensure proper placement 1, 2
• Inject peritendinously rather than intratendinously, as direct tendon substance injections may have deleterious effects 1
• Use betamethasone 24 mg with 1% lidocaine (or equivalent) into the inflamed bursa 3
• Expect symptom resolution in 49-100% of patients with corticosteroid injection as primary treatment 6

Third-Line Treatment: Advanced Interventions

For Refractory Cases After Failed Initial Management

• Consider extracorporeal shock wave therapy (SWT) as a safe, noninvasive, and effective treatment for chronic cases, which demonstrates superiority over other nonoperative modalities in comparative studies 1, 6
• Continue advanced physical therapy with eccentric strengthening exercises while maintaining relative rest from pain-provoking activities 1
• Use orthotics and bracing to reduce tension on the affected tendon during healing 1

Surgical Management

• Reserve surgery only after failure of 3-6 months of comprehensive conservative treatment 1, 2
• Surgical options include: iliotibial band release, trochanteric bursectomy, Z-plasty, osteotomy, or repair of gluteus medius tears if MRI confirms tendon disruption with clinical weakness 1, 3, 6
• All surgical techniques demonstrate superiority to corticosteroid therapy and physical therapy according to VAS and Harris Hip Scores in comparative studies 6

Critical Pitfalls to Avoid

• Do not perform local injections around Achilles, patellar, or quadriceps tendons due to rupture risk 2
• Avoid high-impact aerobic training involving rapid load application across joint structures 2
• Recognize that trochanteric bursitis and gluteus medius/minimus tendinosis frequently coexist and may be difficult to differentiate clinically 1, 2
• In elderly patients using NSAIDs, use the lowest effective dose as unbound plasma fraction increases with age despite unchanged total plasma concentration 5
• Do not use naproxen in patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 5