What is the appropriate diagnosis and treatment for a patient over 50 years old with trochanteric area tenderness, no history of trauma, and potential risk factors for osteoporosis?

Trochanteric Area Tenderness Without Trauma in Patients Over 50

In a patient over 50 years old with trochanteric area tenderness and no trauma history, you must first rule out an occult intertrochanteric or subtrochanteric fracture with plain radiographs (AP pelvis and lateral hip), then evaluate for greater trochanteric pain syndrome (GTPS) if imaging is negative. 1, 2

Initial Diagnostic Approach

Immediate Imaging to Exclude Fracture

• Obtain plain radiographs (AP pelvis and lateral hip) as the first diagnostic step to exclude occult fragility fracture, particularly in patients over 50 with osteoporosis risk factors 1, 2
• Look specifically for intertrochanteric or subtrochanteric fracture lines, cortical disruption, or subtle trabecular changes 2
• If plain films are negative but clinical suspicion remains high (severe pain with weight-bearing, inability to ambulate, point tenderness over bone rather than soft tissue), proceed to MRI to detect occult fracture 1

Clinical Examination Findings

• Point tenderness posterolateral to the greater trochanter suggests GTPS, while tenderness directly over bone with inability to bear weight suggests fracture 3, 4
• Test for pain with resisted hip abduction (positive in GTPS due to gluteus medius/minimus involvement) 4, 5
• Assess gait pattern and weight-bearing tolerance—pain with weight-bearing suggests hardware failure, nonunion, or fracture rather than GTPS 6
• Examine for coexisting conditions: low back pain, iliotibial band tenderness, obesity, and osteoarthritis of the hip (all associated with GTPS) 3

Management Algorithm

If Fracture is Identified

• For stable intertrochanteric fractures, use a sliding hip screw; for unstable fractures, use a cephalomedullary nail 2
• Initiate immediate osteoporosis evaluation including DEXA scan, vitamin D level, calcium level, and parathyroid hormone level 2, 6
• Refer to orthopedic surgery urgently for operative management 2

If No Fracture (GTPS Diagnosis)

• Begin conservative management with physical therapy focusing on hip abductor strengthening, regular acetaminophen, and avoid NSAIDs in elderly patients due to acute kidney injury and gastrointestinal complications 6
• Consider corticosteroid injection into the trochanteric bursa or lateral hip if symptoms persist beyond 4-6 weeks of conservative therapy 3, 7
• Use opioids cautiously if needed, as elderly patients are vulnerable to accumulation, over-sedation, and respiratory depression; avoid codeine due to constipation and postoperative cognitive dysfunction 6

Osteoporosis Evaluation (Critical in All Patients Over 50)

Systematic Fracture Risk Assessment

• Every patient over 50 with trochanteric tenderness requires systematic evaluation for subsequent fracture risk, including clinical risk factors (prior fractures, falls, low body weight, family history of hip fracture, smoking, alcohol use ≥3 units/day) 1, 6, 8
• Order DEXA scan of spine and hip to measure bone mineral density 1
• Calculate 10-year absolute fracture risk using FRAX tool with BMD results 1, 8
• Assess for secondary causes of osteoporosis: thyroid disease, hyperparathyroidism, hypogonadism, malnutrition 1

Pharmacological Treatment Indications

• Initiate bisphosphonates or denosumab for patients with T-score ≤-2.5, history of vertebral or hip fracture, or high 10-year fracture risk (≥20%) to reduce vertebral and hip fractures 8
• Ensure adequate calcium (1000-1200 mg) and vitamin D (600-800 IU) supplementation 1, 8
• Consider anabolic medications (teriparatide, abaloparatide, romosozumab) for very high-risk individuals with recent vertebral fractures or hip fracture with T-score ≤-2.5 8

Common Pitfalls to Avoid

• Do not dismiss trochanteric tenderness as simple bursitis without imaging in patients over 50—occult fractures are common and devastating if missed 1, 2
• Do not use NSAIDs as first-line analgesia in elderly patients due to renal and gastrointestinal toxicity 6
• Do not fail to initiate osteoporosis evaluation and treatment—this represents a critical opportunity for secondary fracture prevention 1, 6, 8
• Recognize that most GTPS cases are self-limited with conservative measures providing resolution within 6-12 weeks 3, 7