What is the proper technique, medication regimen, contraindications, and post‑procedure instructions for a trochanteric hip injection in an older adult with greater trochanteric pain syndrome?

Trochanteric Hip Injection Technique and Protocol

All trochanteric hip injections must be performed under image guidance (ultrasound or fluoroscopy) to ensure accurate needle placement and avoid injury to nearby vascular and neural structures. 1

Mandatory Imaging Guidance

• Image guidance is explicitly required for all hip bursa injections (unlike knee injections which may be performed without imaging), as blind injections contact the greater trochanter in only 78% of cases and achieve proper bursal spread in only 45% on first attempt. 1, 2
• Ultrasound guidance is the preferred modality as it allows real-time visualization of the bursa, improves injection accuracy, and can simultaneously assess for gluteal tendon pathology. 1, 3
• Without fluoroscopic or ultrasound guidance, 55% of injections fail to reach the target bursa on first attempt, with 10% of patients requiring four or more needle placements. 2

Medication Regimen

• Inject a combination of local anesthetic (lidocaine) plus corticosteroid into the trochanteric bursa. 1, 4
• The corticosteroid provides both diagnostic confirmation (if pain improves with the lidocaine component) and therapeutic benefit, though pain relief is generally short-lived with no sustained benefit at 2 years post-injection. 1
• Peritendinous injections are strongly preferred over intratendinous injections, as injections directly into the tendon substance may have deleterious effects on tendon integrity. 1, 4

Critical Contraindications and Timing

• Corticosteroid injections must be avoided within 3 months before a planned total hip arthroplasty due to increased risk of postoperative infection. 1
• In patients with hip prostheses, exercise extreme caution as extracapsular disease from adverse reactions to metal debris (ARMD) can be misinterpreted as trochanteric bursitis. 1, 4
• Repeated corticosteroid injections may have deleterious long-term effects on bone health and joint integrity, warranting cautious use and limiting frequency. 1

Pre-Injection Diagnostic Workup

• Obtain plain radiographs first to rule out alternative causes of hip pain including arthritis, bone tumors, periprosthetic fractures, or avulsions of the greater trochanter. 1, 4, 3
• Radiographs showing >2 mm surface irregularities of the greater trochanter are associated with abductor tendon abnormalities, though this finding has only 64% sensitivity and 26% specificity for greater trochanteric pain syndrome. 5, 4
• Consider MRI if symptoms persist or if there is concern for gluteal tendon tears, as MRI can comprehensively assess the gluteus minimus and medius muscles, abductor tendons, and trochanteric bursa. 1, 3
• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis is often difficult on imaging, and the two conditions frequently coexist. 1, 4, 3

Injection Technique Specifics

• After achieving bone contact with the needle, confirm positioning on the lateral edge of the greater trochanter using imaging. 2
• Under fluoroscopy, inject 1 ml of radiopaque contrast to confirm bursal spread before administering the therapeutic injectate. 2
• Older patients are more likely to require multiple needle placements than younger patients, so anticipate technical difficulty in elderly populations. 2

Post-Procedure Instructions

• Initiate or continue physical therapy focusing on eccentric strengthening exercises of hip abductor muscles, as supervised exercise programs are more effective than passive interventions. 1, 4
• Modify activities to reduce repetitive loading of the affected hip, particularly avoiding pivoting movements, acceleration activities, and sports requiring rapid directional changes. 4
• Avoid prolonged sitting, stair climbing, and forceful hip adduction under load during the acute recovery phase. 4
• Apply cryotherapy (ice for 10-minute periods through a wet towel) for acute pain relief in the first 48-72 hours post-injection. 1
• Land-based physical therapy is preferred over aquatic therapy interventions. 1

Red Flag: Rule Out Inflammatory Arthropathy

• In patients younger than 45 years with morning stiffness lasting more than 30 minutes, obtain MRI of the sacroiliac joints and refer to rheumatology to evaluate for axial spondyloarthropathy. 1

Expected Outcomes and Follow-Up

• Corticosteroid injections are associated with a low incidence of adverse events at 6 months compared with placebo. 1
• Pain relief is typically short-lived; most patients show no sustained benefit at 2 years post-injection. 1
• If symptoms persist after 3-6 months of comprehensive conservative treatment (including injection, physical therapy, NSAIDs, and activity modification), consider surgical consultation. 1, 4
• The majority of patients with greater trochanteric pain syndrome respond well to conservative management without requiring surgery. 6, 7