What are the treatment options for hip trochanteric bursitis and gluteal tendon (medius and minimus) tendinosis/tendinitis?

Treatment of Hip Trochanteric Bursitis and Gluteal Tendon Tendinosis/Tendinitis

Start with conservative therapy including NSAIDs, physical therapy with eccentric hip abductor strengthening, and activity modification; if symptoms persist beyond 6 weeks, proceed to ultrasound-guided corticosteroid injection into the trochanteric bursa. 1

Initial Diagnostic Approach

• Obtain plain radiographs first to exclude other causes of hip pain such as arthritis, fractures, or bone tumors before proceeding with treatment 2
• Recognize that trochanteric bursitis and gluteus medius/minimus tendinosis frequently coexist and can be difficult to differentiate clinically 1, 3
• Consider ultrasound or MRI if diagnosis remains unclear after radiographs, as ultrasound can effectively detect both bursitis and evaluate gluteal tendons 2, 1

First-Line Conservative Treatment (0-6 Weeks)

Pharmacological Management

• Begin with NSAIDs for pain relief and anti-inflammatory effects 1
• For patients with cardiovascular disease or risk factors, consider acetaminophen (up to 4 grams daily) as first-line before NSAIDs 1
• Add proton-pump inhibitors in patients at risk for GI bleeding when NSAIDs are necessary 1

Physical Therapy Protocol

• Implement supervised exercise programs focusing on eccentric strengthening of hip abductor muscles (gluteus medius and minimus), which are more effective than passive interventions 1
• Include stretching exercises for the iliotibial band and lower back 4
• Apply cryotherapy (ice for 10-minute periods through a wet towel) for acute pain relief 1
• Prioritize land-based physical therapy over aquatic therapy 1

Activity Modification

• Reduce repetitive loading activities that aggravate lateral hip pain 1
• Avoid activities that increase pressure on the affected area 1

Second-Line Treatment (After 6 Weeks of Failed Conservative Therapy)

Corticosteroid Injection

• Inject 24 mg betamethasone with 1% lidocaine (or equivalent) into the trochanteric bursa under ultrasound guidance 1, 4
• Ultrasound guidance improves accuracy and ensures proper placement 1
• Use peritendinous rather than intratendinous injections to avoid deleterious effects on tendon substance 1
• This provides both diagnostic information and therapeutic benefit 1

Alternative Non-Invasive Option

• Consider extracorporeal shock wave therapy as a safe, noninvasive, and effective treatment for chronic tendinopathies after failed initial management 1, 5
• Systematic review evidence shows low-energy shock wave therapy superior to other nonoperative modalities 5

Refractory Cases (After 3-6 Months of Comprehensive Conservative Treatment)

Surgical Intervention

• Reserve surgery only after failure of 3-6 months of comprehensive conservative treatment 1
• Surgical options include:
  • Endoscopic trochanteric bursectomy with iliotibial band release 6
  • Surgical repair of torn abductor tendons when MRI confirms tendon disruption and clinical weakness is present 1
  • Other options: longitudinal iliotibial band release, Z-plasty, or trochanteric reduction osteotomy 4, 5
• Surgical efficacy ranges from good to excellent outcomes in refractory cases based on VAS and Harris Hip Scores 5

Critical Clinical Pitfalls to Avoid

• Do not assume isolated bursitis—gluteus medius/minimus tendinosis coexists in most cases and may be the primary pathology 1, 7
• Avoid blind corticosteroid injections—always use ultrasound guidance to ensure proper bursal placement and avoid intratendinous injection 1
• In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis 1
• Do not rely solely on passive interventions (massage, ultrasound, heat)—these should only supplement active physical therapy 1
• Avoid premature surgical referral—most patients respond to conservative measures, with symptom resolution rates of 49-100% with appropriate nonoperative treatment 5

Treatment Algorithm Summary

1. Weeks 0-6: NSAIDs + eccentric strengthening physical therapy + activity modification + cryotherapy
2. Week 6+ (if persistent): Add ultrasound-guided corticosteroid injection OR extracorporeal shock wave therapy
3. Months 3-6+ (if refractory): Consider surgical intervention (bursectomy, iliotibial band release, or tendon repair)

This stepped approach ensures appropriate escalation while recognizing that trochanteric bursitis is self-limiting in the majority of patients 5, 7.