What is the treatment for trochanteric (greater trochanter) bursitis?

From the Guidelines

Trochanteric bursitis can be effectively treated with a combination of conservative measures and medications, with corticosteroid injections into the bursa providing significant relief for several months, as suggested by Robbins et al 1. Initial treatment should focus on rest, ice application to the affected hip for 15-20 minutes several times daily, and avoiding activities that aggravate the pain. Over-the-counter NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily) can reduce inflammation and pain. Physical therapy is crucial, incorporating stretching exercises for the iliotibial band and strengthening exercises for hip abductors. A physical therapist may also use techniques like ultrasound or massage. Weight loss is recommended for overweight patients as excess weight increases pressure on the hip. Proper footwear and avoiding sleeping on the affected side can also help. Most cases resolve within weeks to months with these approaches. If symptoms persist beyond 6-12 months despite conservative treatment, surgical intervention might be considered, though this is rarely necessary. Some key points to consider in the treatment of trochanteric bursitis include:

• The use of ultrasound (US) to detect trochanteric bursitis, as it can detect fluid collections and guide injections 1.
• The importance of differentiating between bursitis and gluteus medius tendinosis, as the two may coexist 1.
• The role of MRI in evaluating surrounding soft tissue entities, such as iliopsoas or subiliacus bursitis, athletic pubalgia, and abductor tendinosis or tears 1. It is essential to prioritize the most recent and highest quality study, which in this case is 1, to guide treatment decisions and ensure the best possible outcomes for patients with trochanteric bursitis.

From the FDA Drug Label

Intra-Articular The intra-articular or soft tissue administration of triamcinolone acetonide injectable suspension is indicated as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, synovitis of osteoarthritis. Management of Pain, Primary Dysmenorrhea, and Acute Tendonitis and Bursitis Because the sodium salt of naproxen is more rapidly absorbed, naproxen sodium is recommended for the management of acute painful conditions when prompt onset of pain relief is desired.

The treatment for trochanteric bursitis may include:

• Intra-articular injection of triamcinolone acetonide injectable suspension as adjunctive therapy for short-term administration 2
• Oral administration of naproxen, with a recommended starting dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required 3 Key points:
• The dose and frequency of naproxen should be adjusted to suit an individual patient's needs.
• Caution is advised when high doses are required, and some adjustment of dosage may be required in elderly patients.

From the Research

Treatment Options for Trochanteric Bursitis

• Conservative measures are often the first line of treatment, including rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and stretching exercises focused on the lower back and sacroiliac joints 4
• Corticosteroid injections, such as 24 mg betamethasone and 1% lidocaine, can be effective for patients whose symptoms persist despite conservative therapy 4
• Low-energy shock-wave therapy (SWT) has been found to be superior to other nonoperative modalities in some studies 5
• Surgical options, such as iliotibial band release, subgluteal bursectomy, and trochanteric reduction osteotomy, may be necessary in rare cases of intractable symptoms 4, 5

Efficacy of Treatment Options

• A systematic review found that traditional nonoperative treatment helped most patients, while SWT was a good alternative, and surgery was effective in refractory cases 5
• A network meta-analysis found that platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group at 1 to 3 months follow-up 6
• Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months 6

Specific Treatment Approaches

• Conservative treatment, including pulsed ultrasound, ice massage, interferential current, and chiropractic lumbopelvic manipulation, can be effective in managing calcific trochanteric bursitis 7
• A trial of conservative measures is warranted for trochanteric bursitis, even when calcinosis is present, before more invasive therapies are considered 7