What is the current treatment for a patient with hip trochanteric bursitis?

Treatment of Hip Trochanteric Bursitis

The current treatment for hip trochanteric bursitis begins with conservative management including NSAIDs, physical therapy with eccentric hip abductor strengthening, and activity modification, followed by ultrasound-guided corticosteroid injection if symptoms persist after 4-6 weeks of conservative therapy. 1

First-Line Conservative Treatment (Initial 4-6 Weeks)

Pharmacological Management

• Start with acetaminophen (up to 4 grams daily) as first-line for mild-to-moderate pain, particularly in patients with cardiovascular disease or risk factors 1
• NSAIDs at the lowest effective dose should be added if acetaminophen is inadequate, providing both pain relief and anti-inflammatory effects 1
• Add proton-pump inhibitors in patients at risk for GI bleeding when NSAIDs are necessary 1

Physical Therapy (Critical Component)

• Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions 1
• Stretching exercises for the iliotibial band should be incorporated 1
• Land-based physical therapy is preferred over aquatic therapy 1
• Passive interventions (massage, ultrasound, heat) can supplement but should not substitute active physical therapy 1

Activity Modification

• Reduce repetitive loading of the lateral hip structures 1
• Cryotherapy with ice application for 10-minute periods through a wet towel can provide acute pain relief 1

Second-Line Treatment: Corticosteroid Injection

If conservative measures fail after 4-6 weeks, ultrasound-guided corticosteroid injection into the trochanteric bursa is indicated 1. This provides both diagnostic information and therapeutic benefit 1.

Injection Technique and Dosing

• Ultrasound guidance improves accuracy and is strongly recommended 1
• Dosing for bursal injection: 20-80 mg methylprednisolone (or equivalent) is appropriate for large joints/bursae 2
• The area should be prepared in a sterile manner, and a 20-24 gauge needle is inserted into the bursa after fluid aspiration confirms proper placement 2
• Peritendinous injections are preferred over intratendinous injections, as injections directly into tendon substance may have deleterious effects 1

Third-Line Treatment: Advanced Therapies

If symptoms persist despite comprehensive conservative treatment and corticosteroid injection:

• Extracorporeal shock wave therapy is a safe, noninvasive, and effective treatment for chronic tendinopathies providing pain relief 1
• Orthotics and bracing can reduce tension on affected tendons during healing 1
• Advanced physical therapy with continued eccentric strengthening should be maintained 1

Surgical Management

Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 3. Options include:

• Endoscopic trochanteric bursectomy with iliotibial band release 3
• Surgical repair of torn abductor tendons when MRI and clinical findings confirm tendon disruption and weakness 1

Critical Pitfalls and Caveats

Diagnostic Considerations

• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinopathy is difficult, and these conditions frequently coexist 1, 4
• Obtain radiographs first to rule out other causes of hip pain 1
• Consider ultrasound or MRI for persistent symptoms to assess peritrochanteric structures including abductor tendons 1
• In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis 1

Treatment Considerations

• Corticosteroid injections should be ultrasound-guided to ensure proper placement 1
• Treatment failures are most frequently the result of failure to enter the joint/bursal space 2
• Corticosteroid injections provide acute phase pain relief but don't alter long-term outcomes 1
• Avoid injecting sufficient material to cause blanching, as this may be followed by tissue slough 2

Special Populations

For patients with cardiovascular disease or risk factors, use a stepped-care approach: start with acetaminophen, aspirin, or tramadol before progressing to non-COX-2 selective NSAIDs 1.