Management of Greater Trochanteric Pain Syndrome in Breastfeeding Postpartum Women
Start with a structured physical therapy program focused on eccentric strengthening exercises for hip abductors, combined with iliotibial band stretching, as this provides superior long-term outcomes compared to other interventions and is safe during breastfeeding. 1, 2
Initial Conservative Management (First-Line Treatment)
Physical therapy should be initiated immediately and include the following specific components:
- Eccentric strengthening exercises targeting the gluteus medius and minimus muscles, which are particularly effective for tendon healing and pain reduction 1
- Iliotibial band stretching exercises to reduce lateral hip tension 1
- Activity modification to avoid prolonged sitting, stair climbing, and repetitive loading of the affected hip 1
- NSAIDs for pain relief (if compatible with breastfeeding; ibuprofen is generally considered safe) 3
This approach is safe for breastfeeding mothers and addresses the underlying tendinopathy without systemic medication concerns. Physical therapy alone achieved 60.5% symptom resolution at 15 months in one study 2.
Diagnostic Confirmation
If diagnosis is uncertain or symptoms persist beyond 4-6 weeks:
- Obtain plain radiographs first to exclude arthritis, bone tumors, or other structural pathology 1, 4
- MRI is the preferred imaging for soft tissue evaluation when radiographs are negative, as it can assess the gluteus medius/minimus tendons, trochanteric bursa, and peritrochanteric structures 5, 1
- Ultrasound is an acceptable alternative and can detect trochanteric bursitis while guiding therapeutic procedures 5, 1
Look for radiographic signs of >2 mm surface irregularities of the greater trochanter, which correlate with abductor tendon abnormalities 1, 4.
Second-Line Treatment for Persistent Symptoms (4-8 Weeks)
If physical therapy alone provides insufficient relief after 4-8 weeks:
Add ultrasound-guided corticosteroid injection to the physical therapy regimen:
- Ultrasound guidance is essential to ensure accurate peritendinous (not intratendinous) placement 1
- Inject into the trochanteric bursa using corticosteroid plus local anesthetic 1, 3
- Avoid intratendinous injection, as this may cause tendon damage 1
- Continue physical therapy concurrently, as the combination is more effective than injection alone 2
Corticosteroid injections are generally considered compatible with breastfeeding when used locally, though short-term pain relief (weeks to months) is typical rather than sustained benefit 1, 6.
Third-Line Treatment for Refractory Cases (3-6 Months)
If symptoms persist despite physical therapy and corticosteroid injection:
Consider focused extracorporeal shockwave therapy (f-ESWT):
- f-ESWT provides superior long-term outcomes compared to corticosteroid injection at 12 months, with significant improvements in pain (VAS 37.1 vs 55.0), function (HHS 69.7 vs 57.5), and quality of life 6
- ESWT demonstrated 68.3% improvement in pain scores compared to controls 2
- This is a non-invasive option that is safe during breastfeeding 6, 7
- Improvement in Trendelenburg test (hip abductor strength) was maintained at 12 months with ESWT but not with injection 6
Surgical Consideration
Reserve surgery only after 3-6 months of comprehensive conservative treatment failure including physical therapy, activity modification, NSAIDs, corticosteroid injection, and consideration of ESWT 1, 4.
Critical Pitfalls to Avoid
- Do not inject corticosteroid directly into the tendon substance, only peritendinous or into the bursa, as intratendinous injection causes tendon damage 1
- Recognize that bursitis and gluteus medius tendinosis frequently coexist and may be difficult to distinguish on imaging 5, 1
- Do not rely on corticosteroid injection alone—it must be combined with ongoing physical therapy for sustained benefit 2
- Ensure ultrasound guidance for all injections to improve accuracy and outcomes 1, 4