Is there a role for Platelet-Rich Plasma (PRP) therapy in treating patients with chronic hip trochanteric bursitis and gluteal tendon tendinosis/tendinitis who have failed conservative management?

PRP for Chronic Hip Trochanteric Bursitis and Gluteal Tendinopathy

For patients with chronic greater trochanteric pain syndrome (GTPS) and gluteal tendinopathy who have failed conservative management, a single ultrasound-guided leukocyte-rich platelet-rich plasma (LR-PRP) injection provides superior pain relief and functional improvement compared to corticosteroid injection, with benefits sustained at 2 years. 1, 2

Evidence Quality and Guideline Context

The recommendation for PRP in this specific condition diverges from broader osteoarthritis guidelines. The American College of Rheumatology/Arthritis Foundation strongly recommends against PRP for hip osteoarthritis due to lack of standardization and insufficient evidence 3. However, gluteal tendinopathy is a distinct pathology from hip osteoarthritis—it involves tendon degeneration rather than articular cartilage disease 3.

Clinical Algorithm for Treatment Selection

Step 1: Confirm Diagnosis

• Ultrasound or MRI confirmation of gluteus medius/minimus tendinopathy with intratendinous pathology 3, 1
• Exclude full-thickness tendon tears (these patients were excluded from successful trials) 1, 2
• Rule out hip osteoarthritis, which would change the treatment paradigm 3

Step 2: Document Failed Conservative Management

• Minimum 3-6 months of conservative therapy including relative rest, NSAIDs, and eccentric strengthening exercises 3
• Symptoms persisting >4 months predict better response to PRP 1
• Mean symptom duration in successful trials was >14-15 months 1, 2

Step 3: Choose Injection Therapy

For gluteal tendinopathy specifically:

• LR-PRP injection is superior to corticosteroid at 12 weeks and beyond 1, 2
• At 12 weeks: PRP group achieved mean modified Harris Hip Score (mHHS) of 74.05 vs. 67.13 for corticosteroid (p=0.048) 1
• At 24 weeks: PRP maintained superiority (77.60 vs. 65.72, p=0.0003) 2
• At 2 years: PRP group improved to mHHS of 82.59, while corticosteroid benefits were not maintained beyond 24 weeks 2

Step 4: Injection Technique

• Perform under ultrasound guidance 1, 2
• Inject intratendinously into gluteus medius/minimus tendons 1, 2
• Include trochanteric bursa if bursitis is present 4
• Single injection is sufficient (no evidence for multiple injections in this condition) 1, 2

Critical Distinctions from General Guidelines

Why gluteal tendinopathy differs from hip OA:

• The 2020 ACR/AF guidelines against PRP apply to intra-articular hip osteoarthritis, not periarticular tendinopathy 3
• Tendinopathy involves hypovascular tendon degeneration at the osteotendinous junction, not cartilage loss 3
• The pathophysiology of chronic tendinosis may be more responsive to growth factors in PRP than degenerative joint disease 3, 1

Expected Outcomes

Success rates at 12 weeks:

• 64.1% of PRP patients achieved mHHS ≥74 vs. 45.9% with corticosteroid 1
• 82% of PRP patients achieved minimal clinically important difference (MCID >8 points) vs. 56.7% with corticosteroid (p=0.016) 1

Long-term durability:

• PRP benefits continue improving through 2 years 2
• Corticosteroid benefits peak at 6 weeks and decline thereafter 2

Important Caveats

Patient selection matters:

• Evidence strongest for patients with symptoms >4 months 1
• Exclude patients with full-thickness gluteal tendon tears 1, 2
• Mean age in successful trials was 60 years with 9:1 female predominance 1, 2

Standardization concerns:

• Use leukocyte-rich PRP specifically (the formulation studied in positive trials) 1, 2
• The ACR's concern about PRP heterogeneity is valid—preparation methods vary widely 3, 5
• One recent trial using different PRP preparation showed no benefit over placebo, highlighting preparation variability 6

Crossover data supports efficacy:

• 27 patients who failed corticosteroid at 16-24 weeks crossed over to LR-PRP 2
• Their mHHS improved from 59.22 to 77.53 at 2 years post-crossover 2
• This provides additional evidence that PRP works when corticosteroid fails 2

Alternative if PRP Unavailable

If LR-PRP is not available or affordable, corticosteroid injection provides short-term benefit (6-12 weeks) but expect diminishing returns beyond 24 weeks 1, 2. Surgery should be reserved for patients who fail both injection therapies after 3-6 months 3.