What is the best course of treatment for a 35-year-old female with outer hip pain, specifically trochanteric bursitis, that worsens with weight-bearing activities such as walking and standing on one leg with hips directly over feet?

Treatment of Lateral Hip Pain (Greater Trochanteric Pain Syndrome)

Initial Conservative Management

Begin with a combination of NSAIDs, activity modification, and targeted physical therapy focusing on hip abductor strengthening and iliotibial band stretching. 1

First-Line Pharmacologic Treatment

• Prescribe oral NSAIDs when not contraindicated, as they represent the primary pharmacologic intervention for symptomatic hip pain 2
• Consider acetaminophen as an alternative if NSAIDs are contraindicated 2
• Avoid chronic opioid therapy, as guidelines recommend against their use for chronic hip pain management 3

Physical Therapy Protocol

• Initiate stretching exercises focused on the lower back, sacroiliac joints, and iliotibial band 1
• Progress to hip abductor strengthening exercises to address the underlying biomechanical dysfunction that contributes to trochanteric bursitis 1
• Continue conservative therapy for 4-6 weeks before escalating treatment 1

Activity Modification

• Reduce weight-bearing activities that exacerbate symptoms, particularly prolonged standing on one leg and extended walking 1
• Implement rest periods during the acute inflammatory phase 1

Second-Line Treatment: Corticosteroid Injection

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

Injection Technique and Dosing

• Inject 24 mg betamethasone (or equivalent corticosteroid) combined with 1% lidocaine into the inflamed bursa 1
• Consider injecting all four peri-trochanteric bursae rather than a single focal injection, as trochanteric area pain typically involves a quartet of bursal inflammation (subgluteus maximus, subgluteus medius, subgluteus minimus, and subiliotibial band bursae) 5
• Use ultrasound or fluoroscopic guidance to ensure accurate placement 5

Expected Outcomes

• Two-thirds of patients achieve excellent response with one or two corticosteroid injections 4
• The remaining one-third show improvement, though may not achieve complete resolution 4
• Approximately 25% of patients experience relapse within 2 years and may require repeat injection 4

Diagnostic Imaging Considerations

When to Order Advanced Imaging

• If symptoms persist despite conservative therapy and injection, or if numbness develops, obtain MRI of the hip without IV contrast to exclude alternative diagnoses 6
• MRI can detect occult fractures, labral tears, muscle/tendon tears, and nerve compression that may mimic trochanteric bursitis 6
• Plain radiographs are not sensitive for trochanteric bursitis but should be obtained initially to exclude arthritis, fractures, or bone tumors 6

Imaging Findings

• STIR sequence MRI demonstrates abnormal increased signal in the trochanteric bursae when inflamed 7
• Three-phase bone scan may show focal increased tracer activity in the trochanteric regions on blood pool images only 7

Surgical Management for Refractory Cases

Reserve surgical intervention for the rare subset of patients with intractable symptoms despite exhaustive conservative management including multiple injections. 1, 8

Surgical Options

• Endoscopic trochanteric bursectomy with iliotibial band release represents the preferred minimally invasive approach 8
• Alternative procedures include open iliotibial band release, subgluteal bursectomy, and trochanteric reduction osteotomy 1
• Recent advances in hip arthroscopy allow for improved minimally invasive techniques to address recalcitrant trochanteric bursitis 8

Critical Pitfalls to Avoid

• Do not proceed directly to injection without attempting conservative therapy first, as many patients respond to NSAIDs and physical therapy alone 1
• Do not inject only one bursa, as the syndrome typically involves multiple peri-trochanteric bursae requiring comprehensive treatment 5
• Do not delay MRI if symptoms worsen or new neurologic symptoms develop, as this may indicate alternative pathology requiring different management 6
• Do not use peripheral nerve blocks of the obturator nerve, as this is considered experimental/investigational with insufficient evidence 6

Treatment Algorithm Summary

1. Weeks 0-6: NSAIDs + activity modification + physical therapy (stretching and strengthening) 1, 2
2. Week 6+: If persistent symptoms, add corticosteroid injection (all four peri-trochanteric bursae) 1, 4, 5
3. Week 12+: If still symptomatic, obtain MRI hip without contrast to exclude alternative diagnoses 6
4. Refractory cases: Consider surgical consultation for endoscopic bursectomy with iliotibial band release 8