Physical Medicine and Rehabilitation for Trochanteric Bursitis Treatment & Management

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.^[16] (See images below.)

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.

• 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

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.^[17] Only rarely does a patient with trochanteric bursitis need a bursectomy and partial resection of the greater trochanteric process.^{[18, 19, 20]}

The patient may be referred to a physiatrist or other musculoskeletal specialist.^[21]

Treatment may include relative rest, ice, injection, and nonsteroidal anti-inflammatory drugs (NSAIDs).^{[22, 23]}

• Corticosteroid injection into the trochanteric bursa^{[24, 25, 26, 27]}

  • 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.^[28]
  • 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.^[29]
  • 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).