What is the recommended treatment for a patient with hip bursitis, considering their medical history and potential underlying conditions such as arthritis?

Treatment for Hip Bursitis

Begin with conservative management including NSAIDs, physical therapy with stretching exercises, and activity modification; if symptoms persist after 2-4 weeks, proceed with image-guided corticosteroid injection into the inflamed bursa. 1

Initial Conservative Management (First-Line Treatment)

• Start with oral NSAIDs (such as naproxen 500 mg twice daily) when not contraindicated, as these provide anti-inflammatory effects for symptomatic relief 2, 3
• Implement relative rest and activity modification to reduce mechanical irritation of the bursa 1, 4
• Apply ice massage to the affected area to reduce inflammation 5
• Begin structured physical therapy focusing on stretching exercises for the lower back, sacroiliac joints, and iliotibial band 1, 4

The conservative approach should be maintained for at least 2 weeks before considering more invasive interventions 1. This timeframe allows adequate assessment of treatment response while avoiding premature escalation.

Physical Therapy and Exercise Protocol

• Prescribe strengthening exercises for hip girdle muscles and quadriceps to improve joint stability 6
• Include range of motion exercises to maintain hip mobility 6
• Implement a "small amounts often" pacing approach rather than intensive single sessions 6
• Consider adjunctive modalities including pulsed ultrasound therapy, interferential current, and electrical stimulation 4, 5, 7

Physical therapy should be supervised initially to ensure proper technique, though unsupervised home exercises can be incorporated once the patient demonstrates competency 2.

Corticosteroid Injection (Second-Line Treatment)

For patients whose symptoms persist despite 2-4 weeks of conservative therapy, proceed with corticosteroid injection 1:

• Use image guidance (ultrasound or fluoroscopy) to ensure accurate bursal placement, particularly given the deep anatomical location 2, 8
• Inject 24 mg betamethasone (or equivalent corticosteroid) combined with 1% lidocaine into the inflamed trochanteric bursa 1
• Reassess at 2-4 weeks post-injection to evaluate treatment response 8

The ACR conditionally recommends intra-articular corticosteroid injections for hip pathology when conservative measures fail 2, 8. While most evidence addresses intra-articular hip injections, the same principles apply to bursal injections given the similar anatomical considerations.

Special Considerations for Calcific Bursitis

• Attempt intensive conservative treatment first, even when calcifications are present on radiographs 5, 7
• Use high-dose pulsed ultrasound therapy as this modality has demonstrated resolution of calcifications in case reports 7
• Combine ultrasound with iontophoresis and physiotherapy for optimal results in calcific cases 7

Complete resolution of both symptoms and radiographic calcifications has been documented with non-invasive treatment, avoiding the need for surgical intervention 7.

Surgical Options (Third-Line Treatment)

Reserve surgical intervention for intractable symptoms that fail all conservative and injection therapies 1, 9:

• Endoscopic trochanteric bursectomy with iliotibial band release is the preferred minimally invasive approach 9
• Alternative procedures include open bursectomy or trochanteric reduction osteotomy for severe cases 1

Surgery should only be considered after exhaustive conservative management, typically requiring at least 3-6 months of failed non-operative treatment 9.

Critical Pitfalls to Avoid

• Do not attribute all lateral hip pain to bursitis without excluding other pathology—obtain radiographs to rule out hip osteoarthritis, stress fractures, or referred pain from lumbar spine pathology 2, 10
• Avoid blind injections of the hip region due to deep anatomical structures and adjacent neurovascular bundles; always use image guidance 2, 8
• Do not proceed with multiple simultaneous invasive procedures—attempt one modality at a time to assess individual efficacy 10
• Screen for underlying conditions such as inflammatory arthritis or metabolic disorders that may contribute to bursitis 2

Adjunctive Measures

• Recommend weight loss for overweight patients, as excess weight increases mechanical stress on the hip 2, 6
• Provide walking aids (cane on contralateral side) to reduce joint loading during acute flares 2, 6
• Optimize footwear to minimize biomechanical stress 6
• Address workplace modifications if occupational factors contribute to symptoms 2, 6