In a patient with trochanteric or iliopsoas bursitis who still has pain after several weeks of activity modification, nonsteroidal anti-inflammatory drugs, physical therapy, and stretching, when should a hip bursa injection be performed and what is the recommended image‑guided technique and medication mixture?

Hip Bursa Injection: Timing and Technique

For patients with trochanteric or iliopsoas bursitis who have failed 4-6 weeks of conservative treatment (activity modification, NSAIDs, physical therapy, and stretching), proceed with image-guided corticosteroid injection using ultrasound or fluoroscopic guidance, injecting a mixture of corticosteroid (such as betamethasone 12-24 mg or methylprednisolone) combined with local anesthetic (such as 4 mL of 1% lidocaine). 1, 2, 3

Timing of Injection

When to Proceed with Injection

• Inject after 4-6 weeks of failed conservative management, which should include activity modification, NSAIDs, physical therapy focusing on stretching and strengthening of hip stabilizers 1, 2
• For trochanteric bursitis specifically, the American College of Radiology recommends corticosteroid injection when initial conservative measures fail 2
• For iliopsoas bursitis, the American College of Radiology similarly recommends proceeding with injection after 4-6 weeks of unsuccessful initial treatment 1
• Do not delay injection unnecessarily, as prolonged symptoms without intervention may lead to progression of pathology and worse functional outcomes 4

Critical Timing Consideration

• Avoid corticosteroid injection within 3 months before planned joint replacement surgery due to potential infection risk 5

Image Guidance Requirements

Mandatory Image Guidance for Hip Injections

• All hip bursa injections must be image-guided due to joint depth and proximity to vascular and neural structures 5, 2
• The VA/DoD guidelines explicitly state that hip injections require image guidance to ensure safety, unlike knee injections which do not 5

Preferred Imaging Modality

• Ultrasound guidance is the preferred method as it improves accuracy, allows real-time visualization, and can evaluate the iliopsoas tendon dynamically 1, 2
• Fluoroscopy is an acceptable alternative, with studies showing that blind injections contact the greater trochanter in only 78% of cases and achieve proper bursal spread in only 45% on first attempt 6
• Ultrasound guidance ensures proper placement and confirms that injectate reaches the area of pathology 2, 6

Injection Technique and Medication

For Trochanteric Bursitis

• Target: Trochanteric bursa at the lateral edge of the greater trochanter 2, 6
• Medication mixture: Corticosteroid (betamethasone 12-24 mg preferred based on dose-response data) mixed with 4 mL of 1% lidocaine 3
• Higher doses of betamethasone (24 mg vs 6 mg) show significantly better pain relief (p < 0.0123) 3
• Injection approach: Peritendinous rather than intratendinous to avoid deleterious effects on tendon substance 2

For Iliopsoas Bursitis

• Target: Iliopsoas bursa or peritendinous region 1, 7
• Medication mixture: Local anesthetic combined with corticosteroid 7
• All reviewed studies used local anesthetics, with 83% also adding corticosteroid 7
• Dual benefit: Provides both diagnostic confirmation and therapeutic benefit 1, 7

Expected Outcomes

Efficacy Data

• Trochanteric bursitis: 77.1% of patients report improvement at 1 week, 68.8% at 6 weeks, and 61.3% maintain improvement at 26 weeks 3
• Iliopsoas injections: Numeric Rating Scale improves from mean 7.33 pre-injection to 2.47 post-injection, and Harris Hip Score improves from 58.49 to 89.91 7
• Effects are time-limited without long-term improvement at 2-year follow-up, similar to knee injections 5

Progression to Surgery

• Only 28.9% of patients with iliopsoas pathology progress to surgery after injection, with psoas tenotomy being the most common procedure (38.3% of surgical cases) 7
• Surgery should only be considered after failure of 3-6 months of comprehensive conservative treatment including injection 2, 8

Critical Pitfalls to Avoid

Diagnostic Pitfalls

• Do not assume isolated bursitis: Trochanteric bursitis frequently coexists with gluteus medius/minimus tendinosis, and these can be difficult to differentiate 4, 2
• Rule out competing diagnoses: Examine the lumbar spine, as referred pain can mimic hip bursitis 4, 2
• Obtain plain radiographs first to exclude osseous pathology, arthritis, or structural abnormalities before proceeding with injection 1, 4, 2
• Red flag: In patients younger than 45 years with morning stiffness lasting more than 30 minutes, consider axial spondyloarthropathy and obtain MRI of sacroiliac joints 2

Technical Pitfalls

• Never inject blindly: Blind injections achieve proper bursal spread in only 45% of first attempts 6
• Avoid intratendinous injection: Inject peritendinous rather than directly into tendon substance to prevent tendon damage 2
• In patients with hip prostheses: Be cautious of misinterpreting adverse reactions to metal debris (ARMD) as trochanteric bursitis 2

Safety Considerations

• No complications were reported in systematic reviews of iliopsoas injections 7
• Few adverse events occur with hip corticosteroid injections compared to placebo at 6 months 5
• However, providers must consider potential long-term negative effects on bone health and joint structure with repeat injections 5