What is the best management plan for an adult patient with enthesopathy along the greater trochanters, possibly with a history of repetitive strain or overuse injuries to the hip or lower limb, and underlying conditions such as osteoarthritis?

Management of Greater Trochanteric Enthesopathy

Begin with a structured 6-12 week conservative treatment program combining exercise therapy, weight reduction if BMI >25, and NSAIDs or acetaminophen, followed by ultrasound-guided corticosteroid injection into the greater trochanteric bursa (not subgluteus medius bursa) if conservative measures fail, reserving endoscopic iliotibial band release only for patients who remain refractory after exhausting all non-surgical options. 1, 2

Core First-Line Conservative Management (Weeks 0-12)

Non-Pharmacological Foundation:

• Initiate a structured exercise program focusing on local hip muscle strengthening (gluteus medius/minimus) and general aerobic fitness, as this forms the cornerstone of treatment for all peritrochanteric pathology 1
• Prescribe weight loss interventions if BMI ≥25 kg/m², as even 5-10% body weight reduction significantly reduces mechanical stress on the greater trochanter enthesis 1
• Recommend iliotibial band stretching exercises to address the mechanical component of greater trochanteric pain syndrome 3
• Apply local heat or cold applications for symptomatic relief during acute flares 1
• Consider assistive devices such as a walking stick to offload the affected hip during ambulation 1

Pharmacological Options:

• Start with acetaminophen up to 4,000 mg/day in divided doses as the safest first-line oral analgesic 1
• Add oral NSAIDs at the lowest effective dose for the shortest duration if acetaminophen provides insufficient relief, with mandatory gastroprotection (proton pump inhibitor) in patients with gastrointestinal risk factors 1
• Avoid opioid analgesics as they are not recommended for musculoskeletal conditions like enthesopathy 1

Second-Line Intervention: Ultrasound-Guided Corticosteroid Injection

If conservative measures fail after 6-12 weeks, proceed with ultrasound-guided corticosteroid injection specifically targeting the greater trochanteric bursa (not the subgluteus medius bursa), as this provides significantly superior pain reduction with a median improvement of 3 points on a 10-point scale versus 0 points for subgluteus medius bursa injections 1, 2

Critical Technical Point:

• Injection placement is crucial—the greater trochanteric bursa injection demonstrates statistically significant superiority (p < 0.01) over subgluteus medius bursa injection 2
• Expect short-term pain relief (first 3-6 months), but recognize that the effect typically does not persist long-term 4
• Ultrasound guidance is essential to ensure accurate needle placement and confirm the presence of bursitis, tendinopathy, or enthesopathy 2

Third-Line Minimally Invasive Option

For patients who fail corticosteroid injection and remain symptomatic, consider percutaneous ultrasound-guided tenotomy (TENEX®) of the iliotibial band before proceeding to open surgery, as this demonstrates 70% pain relief at one year with median pain reduction from 9/10 to 5/10 (p < 0.001) 5

Surgical Management (Reserved for Refractory Cases)

Reserve endoscopic iliotibial band release and bursectomy only for patients who have failed all conservative measures including physical therapy, weight loss, NSAIDs, corticosteroid injections, and potentially percutaneous tenotomy 3, 6, 4

Surgical outcomes:

• Endoscopic release demonstrates significant pain reduction and functional improvement in 91% of patients (10 of 11) at median 28-month follow-up 3
• All validated outcome scores (VAS, WOMAC, mHHS, HOS) show statistically significant improvement (p < 0.001) at 3,6, and 12 months postoperatively 6
• However, the complication and re-intervention rate should not be underestimated, making this truly a last-resort option 4

Common Pitfalls to Avoid

Do not inject the subgluteus medius bursa—this is a critical technical error that results in treatment failure, as the greater trochanteric bursa is the correct target 2

Do not rush to surgery—the evidence consistently shows that most cases respond to conservative management, and surgery carries non-negligible complication rates 4

Do not use hyaluronic acid injections—these are specifically not recommended for hip pathology including peritrochanteric conditions 1

Do not prescribe glucosamine or chondroitin supplements—these lack evidence for enthesopathy and are not recommended 1

Special Considerations for Underlying Osteoarthritis

If the patient has concomitant hip osteoarthritis contributing to symptoms, ensure the treatment plan addresses both the enthesopathy and the intra-articular pathology, as the case example demonstrates that greater trochanteric tenderness should be distinguished from intra-articular hip pain through careful physical examination (pain with palpation of greater trochanter versus pain with hip rotation) 1

Consider total hip arthroplasty if severe hip osteoarthritis is the primary driver of disability, as this provides definitive treatment when conservative measures fail and radiographic evidence shows severe degenerative joint disease 1