Management of Greater Trochanteric Bursitis with Morning Stiffness
For a patient with greater trochanteric bursitis experiencing morning stiffness lasting 30 minutes, the most appropriate initial management combines NSAIDs (preferably naproxen) with targeted physical therapy focusing on hip abductor strengthening and iliotibial band stretching. 1, 2
Critical Diagnostic Consideration
The presence of morning stiffness lasting more than 30 minutes in this clinical context raises an important red flag. While this patient presents with greater trochanteric bursitis, morning stiffness exceeding 30 minutes—particularly in patients under 45 years—should trigger consideration of axial spondyloarthropathy, which requires MRI evaluation and rheumatology referral. 3 This is especially important because inflammatory arthropathies can coexist with mechanical hip problems.
However, assuming the primary diagnosis is isolated greater trochanteric bursitis, proceed with the following algorithm:
First-Line Treatment Approach
Pharmacological Management
NSAIDs are the recommended first-line pharmacological treatment for pain relief and anti-inflammatory effects. 1, 2
Naproxen is specifically preferred over other NSAIDs due to its efficacy and safety profile, with demonstrated effectiveness in reducing morning stiffness in musculoskeletal conditions. 4
Naproxen has been shown to decrease morning stiffness and pain at rest in inflammatory conditions affecting the hip region. 4
For patients with cardiovascular disease or risk factors, consider acetaminophen first (not exceeding 4 grams daily) before progressing to NSAIDs. 2
Add proton-pump inhibitors in patients at risk for gastrointestinal bleeding when NSAIDs are necessary. 2
Non-Pharmacological Management
Physical therapy with targeted exercises for hip abductor muscles shows superior long-term outcomes compared to other interventions and should be initiated immediately. 1
Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions. 2
Stretching exercises for the iliotibial band should be incorporated into the physical therapy regimen. 2
Activity modification to decrease repetitive loading of the damaged tendon and bursa is essential. 1
Land-based physical therapy is preferred over aquatic therapy. 1
Important Clinical Pearls
Differentiation between trochanteric bursitis and gluteus medius/minimus tendinopathy is difficult, and these conditions frequently coexist. 1, 2 The morning stiffness pattern may suggest concurrent tendinopathy rather than isolated bursitis.
Obtain radiographs first to rule out other causes of hip pain, including hip osteoarthritis or structural abnormalities. 1, 2
Ultrasound can effectively detect trochanteric bursitis and evaluate gluteal tendons if symptoms persist beyond initial conservative management. 1, 2
Second-Line Treatment (If Initial Management Fails After 4-6 Weeks)
Ultrasound-guided corticosteroid injection into the trochanteric bursa provides both diagnostic information and therapeutic benefit. 1, 2
Ultrasound guidance significantly improves injection accuracy compared to landmark-based techniques. 1, 2
Peritendinous injections are preferred over intratendinous injections to avoid potential tendon damage. 2
Common Pitfalls to Avoid
Do not dismiss prolonged morning stiffness (>30 minutes) as simply part of bursitis—this warrants evaluation for inflammatory arthropathy, particularly in younger patients. 3
Avoid high-impact aerobic activities during the acute phase, as rapid load application can worsen symptoms. 1
In patients with hip prostheses, be cautious of misinterpreting adverse reactions to metal debris as trochanteric bursitis. 1, 2
Do not inject directly into the Achilles, patellar, or quadriceps tendons due to rupture risk, though this is less relevant for trochanteric injections. 1