A 67-year-old man with hypertension, diabetes mellitus, and hyperlipidemia presents with three days of left hip and ankle pain, focal tenderness over the left greater trochanter, normal range of motion, and elevated blood pressure; what is the most likely diagnosis and appropriate next steps?

Greater Trochanteric Pain Syndrome (Trochanteric Bursitis)

The most likely diagnosis is greater trochanteric pain syndrome (GTPS), specifically trochanteric bursitis or gluteus medius/minimus tendinopathy, given the focal tenderness over the left greater trochanter with preserved range of motion. 1

Clinical Reasoning

This 67-year-old man presents with classic features of GTPS:

• Focal tenderness directly over the greater trochanter is the hallmark finding that distinguishes GTPS from other hip pathology 1, 2
• Normal range of motion effectively excludes intra-articular hip pathology such as osteoarthritis or femoroacetabular impingement 3
• Simultaneous hip and ankle pain is unusual but the trochanteric tenderness is the key localizing sign 2
• Age and comorbidities (diabetes, hypertension, hyperlipidemia) are typical for this condition, which affects 10-25% of the general population 4, 5

Important Differential Considerations to Exclude

L3 radiculopathy must be ruled out given the hip and leg pain distribution:

• L3 radiculopathy would present with dermatomal sensory loss along the medial aspect of the lower leg, which should be specifically tested 6, 7
• The absence of dermatomal sensory changes and focal trochanteric tenderness argue strongly against radiculopathy 6, 7
• Negative hip-specific tests (FABER, FADIR) would further exclude intra-articular pathology 3, 7

Peripheral arterial disease (PAD) should be considered given his cardiovascular risk factors:

• PAD typically causes exercise-induced pain relieved by rest (claudication), not continuous pain 3
• Document pedal pulses (dorsalis pedis, posterior tibial) on examination 3
• His pain pattern (continuous, not exercise-related) makes PAD less likely 3

Immediate Next Steps

1. Complete the Physical Examination

Perform these specific maneuvers:

• FABER test (Flexion, ABduction, External Rotation) and FADIR test (Flexion, ADduction, Internal Rotation) to exclude intra-articular hip pathology 3, 7
• Test for dermatomal sensory loss along the medial lower leg (L3 distribution) to exclude radiculopathy 6, 7
• Palpate pedal pulses bilaterally to assess for PAD 3
• Measure ankle-brachial index (ABI) if pedal pulses are diminished or absent 3

2. Obtain Plain Radiographs

Order AP pelvis and lateral hip radiographs to rule out other causes of hip pain including osteoarthritis, fracture, or structural abnormalities 1, 2

3. Address Elevated Blood Pressure

His blood pressure of 150/90 mmHg is elevated despite being on losartan 50 mg daily:

• Consider uptitrating losartan or adding a second antihypertensive agent
• Ensure medication compliance

Treatment Algorithm for GTPS

First-Line Conservative Management (Weeks 0-6)

Initiate all of the following simultaneously:

1. NSAIDs for pain control and anti-inflammatory effects 1, 8

   • However, use acetaminophen first (up to 4 grams daily) given his cardiovascular risk factors 1
   • If acetaminophen insufficient, use lowest effective dose of NSAIDs with a proton-pump inhibitor for GI protection 1

2. Physical therapy focusing on:

   • Eccentric strengthening of hip abductor muscles (gluteus medius/minimus) 1, 4
   • Stretching exercises for the iliotibial band 1, 4
   • Land-based exercises are preferred over aquatic therapy 1

3. Activity modification:

   • Avoid prolonged standing, stair climbing, and lying on the affected side 1, 4
   • Consider using a walking stick on the contralateral side to reduce loading 4

4. Cryotherapy:

   • Ice application for 10-minute periods through a wet towel for acute pain relief 1

Second-Line Treatment (If No Improvement at 6 Weeks)

Ultrasound-guided corticosteroid injection into the trochanteric bursa 1, 4

Critical safety considerations:

• All hip bursa injections MUST be performed under image guidance (ultrasound or fluoroscopy) to ensure accurate placement and avoid neurovascular injury 1
• Avoid injection within 3 months of any planned hip arthroplasty due to increased infection risk 1
• Peritrochanteric injection is preferred over intratendinous injection to avoid tendon damage 1
• Provides both diagnostic confirmation and therapeutic benefit 1, 4
• Improvement is typically short-lived with no sustained benefit at 2 years 1

Third-Line Treatment (If Failed Conservative Management at 3-6 Months)

Consider extracorporeal shock wave therapy as a safe, noninvasive option before surgery 1, 4

Surgical Referral

Refer to orthopedic surgery only after failure of 3-6 months of comprehensive conservative treatment 1, 4

Diagnostic Imaging Strategy

If symptoms persist despite initial treatment:

1. Ultrasound can detect trochanteric bursitis and evaluate gluteal tendons 1, 9

   • Note: Bursitis is present in only 20% of GTPS cases; most have gluteal tendinopathy (50%) or iliotibial band thickening (29%) 9

2. MRI provides comprehensive assessment of peritrochanteric structures if ultrasound is inconclusive 1, 2

Critical Pitfalls to Avoid

1. Do not assume "bursitis" is the primary pathology - most cases (80%) involve gluteal tendon pathology rather than true bursitis 8, 9

2. Do not miss L3 radiculopathy - always test for dermatomal sensory loss along the medial lower leg 6, 7

3. Do not perform blind (non-image-guided) hip injections - this violates safety guidelines and risks neurovascular injury 1

4. Do not overlook PAD in patients with multiple cardiovascular risk factors - document pedal pulses and consider ABI if diminished 3

5. In patients under 45 years with morning stiffness >30 minutes, consider axial spondyloarthropathy and obtain MRI of sacroiliac joints 1

6. Differentiate from hip osteoarthritis - OA causes groin pain with limited range of motion, unlike GTPS which has lateral pain with preserved motion 2, 8