eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Trochanteric Bursitis: Treatment & Medication
Updated: Oct 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
While only limited controlled studies have proven the usefulness of physical therapy (PT) for this condition, a specific and goal-directed PT program often seems quite reasonable. PT can be incorporated to teach the patient a home exercise program, emphasizing stretching of the ITB, tensor fascia lata (TFL), external hip rotators, quadriceps, and hip flexors. The use of phonophoresis and soft-tissue massage also may be helpful. (See images below and Images 2-3.)
This photo demonstrates one method of stretching the iliotibial band (ITB) in the standing position. One foot is crossed over the other, and the patient leans away from the side being stretched. The exercise is performed by letting the side to be stretched lean in toward the wall. The patient should feel the stretch at the lateral aspect of the hip that is closest to the wall. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.
This photo demonstrates one method of stretching the iliotibial band (ITB) in the supine position. The foot that is ipsilateral to the stretch is crossed over the contralateral knee. Next, the thigh that is ipsilateral to the stretch is pulled across the midline (adduction). The patient should feel the stretch at the lateral aspect of the hip, in the area shown by the dark line. Stretching should be done in a controlled, sustained manner, never in a ballistic manner with sudden, jerking movements.
Stretching of the ITB and TFL can be achieved with a program that incorporates passive adduction of the knee of the affected limb across the midline as far as possible, with this position being held for at least 10-20 seconds. The stretch can be repeated in various degrees of hip flexion, thus theoretically stretching various fibers within the ITB and TFL. To avoid exacerbation, stretching should not be performed in a ballistic, jerking fashion. Instead, stretches should be carried out in a controlled, sustained fashion.
Transcutaneous electrical nerve stimulation (TENS) can be considered in resistant cases.
Medical Issues/Complications
- Chronic pain
- Limited activity level
- Limping (antalgic gait)
- Sleep disturbance, which is especially problematic for a patient who usually sleeps in the side-lying position
Surgical Intervention
Generally, no surgical intervention is required for cases of trochanteric bursitis, because most patients respond well to nonsurgical treatment. However, longitudinal release of the ITB combined with subgluteal bursectomy appears to be a safe and effective treatment for patients with symptoms that are refractory to conservative management.16 Only rarely does a patient with trochanteric bursitis need a bursectomy and partial resection of the greater trochanteric process.17,18,19
Consultations
The patient may be referred to a physiatrist or other musculoskeletal specialist.20
Other Treatment
Treatment may include relative rest, ice, injection, and nonsteroidal anti-inflammatory drugs (NSAIDs).21,22
- Corticosteroid injection into the trochanteric bursa23,24,25
- Many authors and clinicians consider injections to be an important option within the comprehensive treatment plan. A randomized, controlled clinical trial has shown that corticosteroid and lidocaine injection for trochanteric bursitis is an effective therapy with a prolonged benefit.26
- Trochanteric bursa injections are commonly performed without radiographic guidance. However, some preliminary data suggest that radiological confirmation (for example, with fluoroscopy) is necessary for accurate trochanteric bursa injections, especially in patients who are obese, have a history of trauma, suffer from chronic inflammation, or have had previous surgery, as well as when repeated injections are necessary. Such confirmation may also be needed in patients with chronic pain who therefore have developed peripheral sensitization, which may lead to the injection of medicine into tender areas rather than into areas involved in pain generation.27
- The procedure for diagnostic injection is to use local anesthetic without epinephrine (for example, 5 mL of 1-2% lidocaine), which is injected into the affected trochanteric bursa using a 22-gauge needle. A 1.5-in (3.8-cm) needle may be adequate for a slimmer patient, but a heavier patient may require a 3.5-in (8.9-cm) needle to reach the bursa. The needle is advanced to the greater trochanter (with contact with the bone being made in order to confirm depth and appropriate placement) and is then withdrawn slightly so that it is located within the bursa. The local anesthetic can then be injected directly into the bursa. If the patient receives appropriate relief, this would be considered confirmation of trochanteric bursitis as the etiology of the pain.
- This injection of local anesthetic can then be followed by the administration of steroids (by using the needle that is already in place and switching to a syringe containing the corticosteroid). Injection of 40-80 mg of methylprednisolone acetate or triamcinolone acetonide should be adequate. This injection may be repeated at 4-6 weeks if pain relief has been less than 50%.
- In most cases, in which the diagnosis of trochanteric bursitis seems straightforward from the clinical evaluation, a diagnostic injection (or local anesthetic injection) is not necessary prior to the corticosteroid injection. In these cases, the most straightforward approach is to perform the same needle approach outlined above, followed by the delivery of a mixture of a corticosteroid and a local anesthetic (such as 40-80 mg of long-acting methylprednisolone [eg, Depo-Medrol] and 5 mL of 1% lidocaine).
- Further specifics of the injection procedure and potential complications are beyond the scope of this text. Interested clinicians are encouraged to read other appropriate sources.
- In their study, Lievense and colleagues found that, depending on the treatment setting (primary care vs hospital vs specialist), injection rates were 34%, 34%, and 37%, respectively, resulting in improvement rates of 60-66% at follow-up visits 1 year and 5 years later. In patients who received a corticosteroid injection, the chance of recovery at 5 years was 2.7-fold higher than it was for patients who had not received an injection. Thus, the report indicated that corticosteroid injections are predictive for improvement at 5 years, with the injection being associated with a lower likelihood of chronic pain development at the site at which it was administered.8
- Relative rest includes restriction of activities, such as climbing stairs or getting in and out of chairs. Direct pressure on the affected site also should be avoided.
- Evaluation and correction of underlying gait abnormalities are important and may be addressed with assistive devices (eg, cane, walker, orthotics, shoe lift, knee brace).
- Use of deep-heating modalities (eg, ultrasound, TENS) should be considered in resistant cases (10-12 wk).
Medication
For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral NSAIDs and focal corticosteroid injections; these are employed in conjunction with the rest of the rehabilitation plan.
Nonsteroidal anti-inflammatory drugs
Oral NSAIDs can help to decrease pain and inflammation and may be used for several weeks. Various oral NSAIDs can be used. The choice of an NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
DOC for mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg PO tid/qid
>12 years: Administer as in adults
May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity
Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; to minimize risks of side effects, patient should avoid taking multiple NSAIDs concurrently; caution in patients taking anticoagulants or systemic corticosteroids, as well as with bleeding disorders or significant alcohol use; caution in congestive heart failure, hypertension, and decreased renal and hepatic function
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with a small body size, in elderly patients, and in persons with renal or liver disease. Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults
May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg PO; not to exceed 10 mg/kg/d
Probenecid may increase toxicity of NSAIDs; co-administration with ibuprofen may decrease effects of loop diuretics; co-administration with anticoagulants may prolong PT (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug
Flurbiprofen (Ansaid)
May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
May decrease effects of loop diuretics with co-administration; co-administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug
Corticosteroids
In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. When corticosteroid injections are used, there are a variety of corticosteroid preparations from which to choose. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Again, there are various local anesthetic agents from which to choose.
Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, Adlone)
Used commonly for local injections of bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.
Adult
40 mg (1 mL), intralesionally, is common for many sites, often mixed with few mL of local anesthetic, such as 1% lidocaine
Pediatric
Not established
Local corticosteroid injections are not known to produce the same degree of medication interaction as that resulting from oral or other systemic administration of corticosteroids
Documented hypersensitivity; skin infection at the site of injection; use caution when performing injections in any patient on anticoagulants or with a history of bleeding disorders, because of the risk of hemorrhage or local bruising
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Never inject corticosteroids through an area of infected skin; diabetic patients may sometimes experience a transient elevation of blood glucose level after a local corticosteroid injection
More on Trochanteric Bursitis |
| Overview: Trochanteric Bursitis |
| Differential Diagnoses & Workup: Trochanteric Bursitis |
 Treatment & Medication: Trochanteric Bursitis |
| Follow-up: Trochanteric Bursitis |
| Multimedia: Trochanteric Bursitis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Further Reading
Related eMedicine topics:
Bursitis [Emergency Medicine]
Bursitis [Orthopedic Surgery]
Snapping Hip Syndrome
The Approach to the Painful Joint
Clinical trials:
Steroid Injection for the Treatment of Greater Trochanteric Pain Syndrome
Keywords
trochanteric bursitis, bursitis, trochanter, bursitis hip, greater trochanteric bursitis, bursitis injection, trochanteric injection, greater trochanteric pain syndrome, extra-articular snapping hip syndrome, external snapping hip syndrome, painful inflammation of the bursa, lateral hip pain, repetitive contracture of gluteus medius, repetitive contracture of the iliotibial band
