What is the recommended treatment for greater trochanteric bursitis?

Treatment of Greater Trochanteric Bursitis

Start with NSAIDs, physical therapy focusing on iliotibial band stretching and hip abductor strengthening, and activity modification; if symptoms persist after 4-6 weeks, proceed to ultrasound-guided corticosteroid injection. 1

Initial Diagnostic Workup

Before initiating treatment, obtain plain radiographs to exclude fractures, arthritis, or bone tumors that may mimic trochanteric bursitis. 1, 2 This is critical because the condition frequently coexists with gluteus medius/minimus tendinopathy, making clinical diagnosis challenging. 1, 3

First-Line Conservative Treatment (4-6 Weeks)

Pharmacologic Management

• NSAIDs are the cornerstone of initial pharmacologic therapy for their anti-inflammatory and analgesic effects. 1
• For patients with cardiovascular disease or risk factors, use a stepped approach: start with acetaminophen (maximum 4 grams daily), then progress to NSAIDs at the lowest effective dose if needed. 1
• Naproxen is FDA-approved specifically for bursitis, with dosing of 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (maximum 1250 mg first day, then 1000 mg daily thereafter). 4
• Add proton-pump inhibitors when prescribing NSAIDs to patients at risk for GI bleeding. 1

Physical Therapy Protocol

• Supervised exercise programs emphasizing eccentric strengthening of hip abductor muscles are superior to passive interventions. 1
• Stretching exercises should target the iliotibial band specifically. 1
• Land-based therapy is preferred over aquatic therapy. 1
• Passive modalities (massage, ultrasound, heat) may supplement but should not replace active exercise. 1

Activity Modification

• Reduce repetitive loading activities that aggravate lateral hip structures. 1, 3
• Cryotherapy with ice applied for 10-minute periods through a wet towel provides acute pain relief. 1

Second-Line Treatment: Corticosteroid Injection

If conservative measures fail after 4-6 weeks, proceed to corticosteroid injection. 5, 6

Injection Technique

• Ultrasound guidance significantly improves injection accuracy and should be used routinely. 1, 2
• Inject corticosteroid into the trochanteric bursa (not intratendinous, as this may damage tendons). 1
• The injection provides both diagnostic confirmation and therapeutic benefit. 1
• Success rates range from 49% to 100% with corticosteroid injection as primary treatment. 6

Important Caveat

In patients with hip prostheses, be cautious not to misinterpret adverse reactions to metal debris (ARMD) as trochanteric bursitis, as this requires different management. 1, 2

Third-Line Treatment: Advanced Modalities

If symptoms persist despite injection:

• Extracorporeal shock wave therapy is safe, noninvasive, and effective for chronic cases, with level II evidence showing superiority over other nonoperative modalities. 1, 6
• Consider repeat ultrasound or MRI to reassess for coexisting gluteal tendon tears, which may require different management. 1, 2

Surgical Intervention

Surgery should only be considered after 3-6 months of failed comprehensive conservative treatment. 1 Surgical options include iliotibial band release, bursectomy, or repair of torn abductor tendons if MRI confirms tendon disruption. 1, 6 All surgical techniques show superior outcomes compared to conservative therapy in refractory cases based on visual analog scale and Harris Hip Scores. 6

Common Pitfalls

• Do not rely on imaging alone—diagnosis requires correlation with clinical symptoms and physical examination findings. 2
• Trochanteric bursitis and gluteus medius/minimus tendinopathy frequently coexist, making differentiation difficult even with advanced imaging. 1, 3, 2
• Avoid intratendinous corticosteroid injection, as this may cause tendon damage; use peritendinous injection instead. 1
• Most cases are self-limited and respond to conservative measures within weeks to months. 6, 7