What is the first-line management of trochanteric bursitis?

Management of Trochanteric Bursitis

First-Line Treatment: Conservative Multimodal Approach

Start with NSAIDs, physical therapy focusing on hip abductor strengthening and iliotibial band stretching, and activity modification—this combination provides the foundation for successful management in most patients. 1, 2

Initial Pharmacologic Management

• NSAIDs are the first-line pharmacologic option for pain relief and anti-inflammatory effects 1, 2
• Acetaminophen (up to 4 grams daily) should be considered as an alternative first-line agent, particularly in patients with cardiovascular disease or GI bleeding risk 1, 2
• In patients with known cardiovascular disease, use a stepped-care approach: start with acetaminophen, aspirin, or tramadol before progressing to NSAIDs at the lowest effective dose 1
• Add proton-pump inhibitors when NSAIDs are necessary in patients at risk for GI bleeding 1

Physical Therapy and Activity Modification

• Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions and show superior long-term outcomes 1, 2
• Specific stretching exercises for the iliotibial band should be incorporated 1
• Land-based physical therapy is preferred over aquatic therapy 1, 2
• Activity modification to decrease repetitive loading of the affected bursa and tendon is essential 1, 2
• Passive interventions (massage, ultrasound, heat) can supplement but should not substitute active physical therapy 1
• Cryotherapy with ice application for 10-minute periods through a wet towel provides acute pain relief 1

Diagnostic Imaging Before Treatment

• Obtain plain radiographs first to rule out other causes of hip pain (fracture, arthritis, bone lesions) 3, 1, 2
• Ultrasound effectively detects trochanteric bursitis and can differentiate it from other soft tissue pathology, though distinguishing from gluteus medius tendinosis may be difficult 3, 1, 2
• MRI comprehensively assesses peritrochanteric structures including gluteus minimus/medius muscles, abductor tendons, and the trochanteric bursa when diagnosis remains unclear 3, 1, 2

Second-Line Treatment: Corticosteroid Injection

If symptoms persist after 6-8 weeks of conservative treatment, proceed to ultrasound-guided corticosteroid injection into the trochanteric bursa. 1, 2

Injection Technique and Safety

• All hip bursa 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
• Ultrasound guidance significantly improves injection accuracy compared to landmark-based techniques 1, 2
• Corticosteroid injection provides both diagnostic information and therapeutic benefit 1, 2
• Avoid corticosteroid injections within 3 months before a planned total hip arthroplasty due to increased risk of postoperative infection 1

Expected Outcomes and Limitations

• Improvement after corticosteroid injection is generally short-lived, with no sustained benefit at 2 years post-injection 1
• Compared with placebo, hip corticosteroid injections have a low incidence of adverse events at 6 months 1
• Repeated corticosteroid injections may have deleterious long-term effects on bone health and joint integrity, warranting cautious use 1

Third-Line Treatment: Advanced Conservative Options

If symptoms persist after corticosteroid injection, consider:

• Extracorporeal shock wave therapy is a safe, noninvasive, and effective treatment for chronic tendinopathies providing pain relief 1
• Continue advanced physical therapy with emphasis on eccentric strengthening exercises 1
• Orthotics and bracing to reduce tension on the affected tendon during healing 1

Surgical Intervention

Reserve surgery only after failure of 3-6 months of comprehensive conservative treatment. 1, 2, 4

• Endoscopic trochanteric bursectomy with iliotibial band release is the preferred minimally invasive technique for recalcitrant cases 4
• Surgical repair of torn abductor tendons is viable when MRI and clinical findings demonstrate tendon disruption with weakness 1

Critical Diagnostic Considerations and Pitfalls

Differential Diagnosis Challenges

• Trochanteric bursitis and gluteus medius/minimus tendinosis are difficult to distinguish and frequently coexist—both conditions may require treatment 1, 2
• In patients with hip prostheses, extracapsular disease from adverse reactions to metal debris can be misinterpreted as trochanteric bursitis 1, 2
• Extensive lumbar spine pathology may be the primary pain generator, as hip pain can be referred from lumbar spine disease 5

Red Flag: Inflammatory Arthropathy

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

Special Considerations for Calcific Trochanteric Bursitis

• Even extensive calcifications can resolve with intensive conservative treatment including high-dose pulsed ultrasound therapy, physiotherapy, and iontophoresis 6, 7
• Attempt non-invasive conservative treatment before considering surgical removal of calcifications 6, 7