Treatment Plan for Left Hip Bursitis
Begin with conservative management including NSAIDs, rest, and physical therapy focused on stretching exercises; if symptoms persist after conservative measures, proceed with image-guided corticosteroid injection into the bursa. 1, 2, 3
Initial Conservative Management (First-Line Treatment)
- Start with NSAIDs at the lowest effective dose as the primary pharmacologic intervention for pain control 1, 2
- Implement rest and activity modification to reduce mechanical irritation of the bursa 3, 4, 5
- Prescribe stretching exercises specifically targeting the lower back, sacroiliac joints, and iliotibial band 3
- Apply ice to the affected area to reduce inflammation 4, 5
- Consider weight reduction if the patient is obese or overweight, as this addresses a key risk factor 1
Important caveat: In patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1, 2
When Conservative Treatment Fails
- Proceed with image-guided (ultrasound or fluoroscopy) corticosteroid injection into the trochanteric bursa if symptoms persist despite 2-4 weeks of conservative therapy 1, 2, 3
- The recommended injection consists of betamethasone 24 mg (or equivalent corticosteroid) combined with 1% lidocaine 3
- Ultrasound can effectively detect trochanteric bursitis and guide injection placement 1
Critical distinction: Differentiation between bursitis and gluteus medius tendinosis may be difficult on imaging, and the two conditions may coexist, which affects treatment planning 1
Medications to Avoid
- Do not use opioid analgesics as they are inferior to NSAIDs for musculoskeletal pain and cause significantly more side effects 2
- Reserve opioids only for patients in whom NSAIDs are contraindicated, ineffective, or poorly tolerated 1, 2
- Avoid intrabursal corticosteroid injection as initial therapy; use only after conservative measures fail 2, 4
Diagnostic Imaging Approach
- Obtain plain radiographs first to exclude other pathology such as calcific bursitis, fracture, or arthritis 1
- Use ultrasound for targeted evaluation of the trochanteric bursa, abductor tendons, and to guide injections 1
- Consider MRI without IV contrast if there is diagnostic uncertainty or concern for gluteus medius/minimus tendon pathology 1
Common pitfall: Extracapsular disease can be misinterpreted as trochanteric bursitis on imaging, so careful clinical correlation is essential 1
Surgical Intervention (Rare Cases)
- Reserve surgery for intractable symptoms that fail all conservative measures and injections 3, 5, 6
- Surgical options include endoscopic trochanteric bursectomy, iliotibial band release, or subgluteal bursectomy 3, 5, 6
- Arthroscopic techniques are preferred over open procedures for minimally invasive management 6
Special Considerations
- Rule out septic bursitis if there are signs of infection (erythema, warmth, fever); this requires bursal aspiration with Gram stain and culture 4
- Address underlying inflammatory conditions (gout, rheumatoid arthritis) if present, as these require disease-specific treatment 4, 5
- Monitor elderly patients and those with comorbidities closely for NSAID-related adverse effects, particularly gastrointestinal complications 2