eMedicine Specialties > Sports Medicine > Hip
Trochanteric Bursitis: Treatment & Medication
Updated: Sep 28, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
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 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. 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.3 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.3
Recovery Phase
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. A randomized, controlled clinical trial demonstrated that corticosteroid and lidocaine injection for trochanteric bursitis was an effective therapy with prolonged benefits.5
- 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 with6 :
- 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 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 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).
Maintenance Phase
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.
Medication
Medications are used primarily to decrease the pain and inflammation of trochanteric bursitis; thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and focal corticosteroid injections that are used in conjunction with the rehabilitation plan.
Nonsteroidal anti-inflammatory drugs
Oral NSAIDs can help decrease pain and inflammation. Various oral NSAIDs can be used, and none holds a clear distinction as the drug of choice. The choice of 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 patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many OTC low-dose preparations are available.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
May increase sodium and fluid retention and may raise BP when used with ACE-inhibitors and diuretics; may increase risk of bleeding (eg, GI), especially among individuals ingesting alcohol or aspirin and among those administered corticosteroids, heparin, or warfarin
Documented hypersensitivity; aspirin/NSAID-induced asthma; caution with history of GI bleed, hypertension, CHF, and elderly patients
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
To minimize the risks of adverse effects, avoid concurrent administration of multiple NSAIDs; special caution is needed for patients on anticoagulants or systemic corticosteroids and for patients with a bleeding disorder or significant alcohol use; most NSAIDs are considered class D (unsafe) during the third trimester of pregnancy due to the potential risk of affecting closure of the fetal ductus arteriosus and thus should be avoided in this time period.
Corticosteroid preparations for focal injection
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 to choose from. Commonly, the corticosteroid is mixed with one of several local anesthetic agents before injection.
Methylprednisolone (Depo-Medrol)
Corticosteroids such as methylprednisolone are used commonly for local injections into bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI side effects and other risks of systemic medications.
Adult
40 mg (1 mL) of methylprednisolone is a typical dose used for injection at many sites and often mixed with few mL of local anesthetic such as 1% lidocaine.
Pediatric
Not established
Local corticosteroid injections are not known to have the same degree of medication interactions as those seen with oral or other systemic administration of corticosteroids
Documented hypersensitivity; skin infection at the site of injection
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution when performing injections in any patient on anticoagulant therapy or with a history of bleeding disorders because of the risk of hemorrhage or local bruising; never inject corticosteroids through an infected area of skin; a patient with diabetes 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 |
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References
Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. Jan 2003;406:84-8. [Medline].
Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92. [Medline].
Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. Mar 2005;55(512):199-204. [Medline]. [Full Text].
Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. Eur Radiol. Jul 2007;17(7):1772-83. [Medline].
Shbeeb MI, O'Duffy JD, Michet CJ Jr, O'Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol. Dec 1996;23(12):2104-6. [Medline].
Cohen SP, Narvaez JC, Lebovits AH, Stojanovic MP. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth. Jan 2005;94(1):100-6. [Medline]. [Full Text].
Hofmeister E, Engelhardt S. Necrotizing fasciitis as complication of injection into greater trochanteric bursa. Am J Orthop. May 2001;30(5):426-7. [Medline].
Brinker MR, Miller MD. The adult hip. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:269-85.
Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Publishing; 2000:11-2.
Lennard TA. Fundamentals of procedural care. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
McGee DJ. Hip. Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1992:333-71.
Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
Snider RK. Hip and thigh. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:264-303.
Snider RK. Injection and corticosteroids. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:37-9.
Steinberg JG, Seybold EA. Hip and pelvis. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:171-203.
Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:783-812.
Further Reading
Keywords
external snapping hip syndrome, lateral snapping hip syndrome, extra-articular snapping hip syndrome, greater trochanteric bursitis, greater trochanteric pain syndrome, GTPS, hip pain, thigh pain
