Trochanteric Bursitis Treatment & Management

Rehabilitation Program

Physical Therapy

Management of the patient during the acute phase can include icing of the affected regions for 20-30 minutes every 2-3 hours. The proper use of the various treatment modalities can be taught to patients during physical therapy sessions; subsequently, the patient can perform them independently. These modalities should be goal-directed as part of a comprehensive plan to facilitate active patient participation in the rehabilitation program.

The physical therapist can instruct the patient in a home exercise program, emphasizing stretching of the ITB and TFL and strengthening of the hip abductors, especially the gluteus medius. The use of phonophoresis and soft-tissue massage may also be helpful. Transcutaneous electrical nerve stimulation (TENS) can be considered in cases that prove resistant to the rehabilitation program.

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 and maintenance of this position for at least 10-20 seconds. This exercise can be repeated in various degrees of hip flexion, thus theoretically stretching the various ITB and TFL fibers. To avoid exacerbation of trochanteric bursitis (greater trochanteric pain syndrome, GTPS) and/or its symptoms, stretching should not be performed in a ballistic, jerking fashion. Instead, stretches should be performed in a controlled and sustained fashion.

Medical Issues/Complications

• Chronic pain
• Limited activity level
• Limping (antalgic gait)
• Sleep disturbance, which is especially problematic for patients who usually sleep on their sides

Surgical Intervention

Surgical intervention is generally not required for trochanteric bursitis (greater trochanteric pain syndrome, GTPS). Patients with this condition rarely need a bursectomy and partial resection of the greater trochanteric process.

Consultations

If the patient does not respond to appropriate treatments, or if the treating physician does not have the skill or supplies to perform corticosteroid injections, the patient may be referred to a musculoskeletal specialist. Usually, no other consultations are required.

Other Treatment

• Corticosteroid injection into the trochanteric bursa

  • A mixture of a corticosteroid and a local anesthetic (eg, 40-80 mg of long-acting methylprednisolone [eg, Depo-Medrol; Pharmacia & Upjohn Co, Kalamazoo, Mich] and 5 mL of 1% lidocaine) can be injected into the affected trochanteric bursa with a 22-gauge needle.
  • A 1.5-inch (3.8-cm) needle may be adequate for a slim patient. A heavier patient may require a 3.5-inch (8.9-cm) needle to reach the bursa.
  • The needle is advanced to the greater trochanter and then is withdrawn slightly so that it is located within the bursa before the injection is made.
  • 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.
  • Lievense et al found that, depending on the treatment setting, the rates of corticosteroid injections were 34% for primary care, 37% for specialist, and 34% for hospital, resulting in improvement rates between 60% 1-year follow-up and 66% at 5-year follow-up.^[5] Patients who had received a corticosteroid injection had a 2.7-fold higher chance of recovery after 5 years relative to those patients who had not received such an injection. Having had a corticosteroid injection was predictive for improvement within 5 years.^[5]
• Low-energy extracorporeal shock wave therapy

  • Recent studies have shown that shock wave therapy is an effective treatment for greater trochanteric pain syndrome, especially for those who have high signal on MRI scans.^{[10, 11]}
  • A recent study showed that shock wave therapy led to a significantly better result than home exercises and corticosteroid injections.^[12]

Rehabilitation Program

Physical Therapy

The physical therapy program should be advanced to include gradual resumption of sports-related activities.

Medical Issues/Complications

See Acute Phase, Medical Issues/Complications.

Other Treatment (Injection, manipulation, etc.)

Corticosteroid injections may be repeated, if necessary.

• Many authors and clinicians consider corticosteroid injections an important option within the comprehensive treatment plan for trochanteric bursitis (greater trochanteric pain syndrome, GTPS). A randomized, controlled clinical trial demonstrated that corticosteroid and lidocaine injection for trochanteric bursitis was an effective therapy with prolonged benefits.^[13]
• Trochanteric bursa injections are commonly performed without any radiographic guidance. However, some preliminary data suggest that radiologic confirmation (eg, with fluoroscopy) is necessary for accurate trochanteric bursa injections, especially in the following patients with^[14] :

  • Heavy body habitus or obesity
  • A history of repeated injections
  • A history of chronic inflammation
  • A history of previous surgery
  • Pain for long periods, with the development of peripheral sensitization, which may lead to the injection of medicine into tender areas rather than the areas involved in pain generation

For a diagnostic injection, local anesthetic without epinephrine (eg, 5 mL of 1-2% lidocaine) can be injected into the affected trochanteric bursa with a 22-gauge needle. A 1.5-inch (3.8-cm) needle may be adequate for a slim patient, but a heavier patient may require a 3.5-inch (8.9-cm) needle to reach the bursa. The needle is advanced to the greater trochanter (making contact with the bone as confirmation of depth and appropriate placement) and 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 pain relief, this is considered confirmation of trochanteric bursitis (greater trochanteric pain syndrome, GTPS) as the source of the pain.

• The injection of local anesthetic can be followed by the administration of steroids through the same needle; the syringe is then switched to one containing the corticosteroid. Injection of 40-80 mg of methylprednisolone acetate or triamcinolone acetonide should be adequate. This injection may be repeated after 4-6 weeks if pain relief has been less than 50%.
• In most cases (ie, the diagnosis of trochanteric bursitis (greater trochanteric pain syndrome, GTPS) seems straightforward from the clinical evaluation), a diagnostic injection (or local anesthetic injection) is not necessary before the corticosteroid injection. In these cases, the most straightforward approach is to perform the same needle approach as outlined above, followed by delivery of a mixture of a corticosteroid and a local anesthetic (eg, 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.

Relative rest includes restriction of activities, such as climbing stairs or getting in and out of chairs. Direct pressure on the affected site should also be avoided.

Evaluation and correction of any 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, US, TENS) should be considered in cases in which conventional therapy has failed in the patient (10-12 wk).

Rehabilitation Program

Physical Therapy

Ideally, by the time the patient is on maintenance therapy, he or she is independently performing a home exercise program to prevent recurrence of trochanteric bursitis (greater trochanteric pain syndrome, GTPS).