Trochanteric Bursitis 

Updated: Apr 27, 2020
Author: Douglas D Dean, DO; Chief Editor: Ryan O Stephenson, DO 

Overview

Practice Essentials

Trochanteric bursitis is characterized by painful inflammation of the bursa located just superficial to the greater trochanter of the femur.[1, 2, 3, 4] Activities involving running and those involving the possibility of falls or physical contact, as well as lateral hip surgery and certain preexisting conditions, are potentially associated with trochanteric bursitis.

Patients typically complain of lateral hip pain, though the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh.[5]

Symptoms of trochanteric bursitis

The classic symptom of trochanteric bursitis is pain at the greater trochanteric region of the lateral hip. The pain may radiate down the lateral aspect of the ipsilateral thigh;[5] however, it should not radiate all the way into the foot. Onset may be either insidious or acute. The symptoms are made worse when the patient lies on the affected bursa (that is, when lying in the lateral decubitus position).

Hip movements (internal and external rotation), walking, running, weight-bearing, and other strenuous activities can exacerbate the symptoms. Patients may report that the pain limits their strength and makes their legs feel weak.

Diagnosis of trochanteric bursitis

The most classic physical finding in trochanteric bursitis, also known as greater trochanteric pain syndrome (GTPS), is point tenderness over the greater trochanter, which reproduces the presenting symptoms. Palpation may also reproduce pain that radiates down the lateral thigh. Additionally, it has been reported that tenderness to areas that are either superior or posterolateral to the trochanter can be identified.[6]

Lateral hip pain can often be elicited by carrying out passive external rotation of the hip without provoking such symptoms by internal rotation or performing end-range adduction.[7] In addition, the external rotation can be combined with passive hip abduction. Lateral hip pain can be reproduced with flexion of the hip followed by resisted hip abduction. Groin pain or referred knee pain provoked by passive internal rotation of the hip may indicate hip joint pathology (eg, osteoarthritis). Performing other specific musculoskeletal examinations, such as the Trendelenberg test and Ober test, can help to identify other structural derangements that may lead to lateral hip pain.[7, 8]

Plain radiography of the hip and femur may be performed to assess for possible fracture, underlying degenerative arthritis, or bony lesions, or for inflammation-related calcium deposition in the region of the greater trochanteric bursa (which may be associated with chronic trochanteric bursitis).

Bone scanning, computed tomography (CT) scanning, and magnetic resonance imaging (MRI) can be used to exclude underlying diseases.

Management of trochanteric bursitis

Treatment of trochanteric bursitis may include relative rest, application of ice, injection of corticosteroids and local anesthetics, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), and application of topical, sustained-release local anesthetic patches.[9, 10] Extracorporeal shock wave therapy (ESWT) is a good alternative to traditional nonoperative therapy.

A physical therapist can instruct the patient in a home exercise program, emphasizing stretching of the iliotibial band (ITB), the tensor fascia lata (TFL), the external hip rotators, the quadriceps, and the hip flexors. The use of phonophoresis and soft-tissue massage also may be helpful.[11]

Transcutaneous electrical nerve stimulation (TENS) can be considered in cases that prove resistant to the rehabilitation program, and surgical interventions can be useful in refractory cases.[11] When surgery is warranted, longitudinal release of the ITB combined with subgluteal bursectomy appears to be safe and effective for most patients.[12]

Pathophysiology

Acute or repetitive (cumulative) trauma may give rise to inflammation of the affected bursa. Acute trauma includes contusions from falls, contact sports, and other sources of impact.

Other factors that may predispose to trochanteric bursitis include a leg-length discrepancy and lateral hip surgery.[13] Even if no true anatomic leg-length discrepancy is present, running on banked surfaces essentially produces a functional leg-length discrepancy because the contact surface of the downhill foot is lower. In addition, individuals with a broader greater trochanteric width in relation to their iliac crest width appear to be more likely to develop trochanteric bursitis.[14]

A retrospective case-control study by Canetti et al found that in cohort patients with surgical-stage greater trochanteric pain syndrome (GTPS [see the next paragraph]), the mean sacral slope was significantly lower than that in asymptomatic hip patients (33.1° vs 39.6°, respectively).[15]

The term greater trochanteric pain syndrome (GTPS) is now frequently substituted for the term trochanteric bursitis. Ongoing research using ultrasonography, MRI, and histologic analysis suggests that GTPS may be a better label for this condition, in that the regional pain and reproducible tenderness may be associated with myriad causes besides bursitis, such as tendinitis, tendinosis, tendinopathy, muscle tears, trigger points, ITB disorders, and general or localized pathology in surrounding tissues.[2, 16, 17, 18]

It is also worth noting that there are several other bursae in the vicinity of the trochanteric bursa (as noted in the image below) that may also present with pain. The subgluteus medius bursa lies between the gluteus medius tendon and the anterior-superior aspect of the lateral greater trochanter. The subgluteus minimus bursa lies between the gluteus medius tendon and the anterior facet of the greater trochanter. In addition, the subgluteus maximus bursa is more distally located between the distal attachment of the gluteus maximus and the femur.[19] Despite this, the older term, trochanteric bursitis, is still commonly used to describe most lateral hip pain.

Tr B = trochanteric bursa; G Med B = subgluteus me Tr B = trochanteric bursa; G Med B = subgluteus medius bursa; G Min B = subgluteus minimus bursa.

Etiology

Acute trauma (eg, from a fall or tackle) that causes the patient to land on the lateral hip region can result in trochanteric bursitis. More commonly, repetitive (cumulative) trauma is involved. Such trauma is caused by the repetitive contracture of the gluteus medius, the ITB, or both during running or walking.

Conditions that predispose patients to trochanteric bursitis include underlying lower leg gait disturbances, spinal disorders, and sacroiliac disturbances. Osteoarthritis of the hip may also be responsible, though this diagnosis generally manifests as groin or knee pain rather than lateral hip pain. Another predisposing factor is piriformis syndrome, because the piriformis muscle inserts on the greater trochanter.

Trochanteric bursitis can also develop as a complication of arthroscopic surgery of the hip (in an estimated 1.4% of cases).[20, 21, 22] At times, the bursitis develops spontaneously, without apparent precipitating factors.

A study by Fearon et al suggested that the pain of GTPS may be associated with an increased expression of substance P in the trochanteric bursa. The investigators found the presence of substance P in the trochanteric bursa to be significantly greater in patients with GTPS than in the controls, although the neuropeptide’s presence in tendons attaching to the greater trochanter did not differ significantly between the two groups.[23]

A study by Vap et al found a 7% prevalence of chronic trochanteric bursitis in patients with femoroacetabular impingement (FAI). The likelihood of chronic trochanteric bursitis in this group was 5.3 times greater in females than in males and 2.5 times greater in patients over age 30 years.[24]

Epidemiology

Trochanteric bursitis (ie, GTPS) is relatively common among physically active and sedentary patients. The prevalence of unilateral GTPS is 15.0% in women and 8.5% in men, and that of bilateral GTPS is 6.6% in women and 1.9% in men.[25] In a study by Lievense et al, the annual incidence of trochanteric pain in primary care was reported as being 1.8 per 1000 patients.[26]

Trochanteric bursitis can occur in adults of any age. Lievense et al found that trochanteric bursitis appeared to be much more common in females (80%) than in males.[26] No racial predilection has been reported.

Prognosis

No mortality is associated with trochanteric bursitis. Morbidity includes chronic pain, limping, and pain-related sleep disturbances that occur when the patient is lying on the affected side.[27]

Most patients with trochanteric bursitis respond very well to a combination of corticosteroid injection, physical therapy, and activity restriction. Some patients may require repetition of the corticosteroid injection.

A retrospective study of 164 patients who presented with trochanteric pain found that at least 36% were still symptomatic after 1 year and 29% were still symptomatic after 5 years; thus, many patients developed chronic pain at this site.[26] Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold greater risk of persistent symptoms after 1 year than patients without OA. Patients treated with corticosteroid injection were 2.7 times less likely to have chronic pain at this site at 5 years than patients who were not treated in this manner.

A study by Robertson-Waters et al indicated that GTPS occurring after total hip arthroplasty is less responsive to surgery than is idiopathic GTPS, with postoperative satisfaction, Oxford Hip Scores, and visual analogue scale scores having been better for study patients in the idiopathic group.[28]

Patient Education

As with any medical condition, patients should be educated with regard to the nature of the condition, causative factors, and treatment plan. As with any therapy involving injection, patients should be educated to watch for any signs or symptoms of local infection at the injection site.

As with any corticosteroid injection, diabetic patients should be instructed that they may experience a transient increase in their blood glucose levels. All patients should be informed that symptoms usually do not begin to improve until a few days after the corticosteroid injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time during which the local anesthetic has worn off but the corticosteroids have not yet begun to have a therapeutic effect.

 

Presentation

History

The classic symptom is pain at the greater trochanteric region of the lateral hip. The pain may radiate down the lateral aspect of the ipsilateral thigh;[5] however, it should not radiate all the way into the foot. Onset may be either insidious or acute. The symptoms are made worse when the patient lies on the affected bursa (that is, when lying in the lateral decubitus position). The pain may awaken the patient at night.

Hip movements (internal and external rotation), walking, running, weight-bearing, and other strenuous activities can exacerbate the symptoms. Patients may report that the pain limits their strength and makes their legs feel weak.

Symptoms are often related to increased activity or exercise. With acute trauma, patients may recall specific details of the impact.

A cross-sectional study by Plinsinga et al indicated that, compared with healthy controls, patients with persistent, clinically diagnosed greater trochanteric pain syndrome (GTPS) tend to have significantly poorer quality of life, a reduced local pressure-pain threshold, poorer health status, impaired physical function, lower conditioned pain modulation, reduced hip abductor/extensor strength, greater levels of depression and anxiety, and a lower local cold-pain threshold. Moreover, they tend to spend less time engaged in vigorous physical activity. According to the investigators, depression, hip abductor strength, and time to complete stairs accounted for 26% of pain and disability in the study.[29]

Physical Examination

The most classic physical finding is point tenderness over the greater trochanter, which reproduces the presenting symptoms. Palpation may also reproduce pain that radiates down the lateral thigh. Additionally, it has been reported that tenderness to areas that are either superior or posterolateral to the trochanter can be identified.[6] Bursal swelling may be present, but this may be difficult to appreciate in many patients. With recent trauma, overlying skin changes of ecchymosis with abrasions may be apparent.

In obese patients, it may be difficult to locate the trochanter directly. Consider using the iliac crest as a landmark and assessing for the trochanter approximately 8 inches (20 cm) below the pelvic brim. Also consider palpating the region while passively circumducting the hip.

Lateral hip pain can often be elicited by carrying out passive external rotation of the hip without provoking such symptoms by internal rotation or performing end-range adduction.[7] In addition, the external rotation can be combined with passive hip abduction. Lateral hip pain can be reproduced with flexion of the hip followed by resisted hip abduction. Groin pain or referred knee pain provoked by passive internal rotation of the hip may indicate hip joint pathology (eg, osteoarthritis). Performing other specific musculoskeletal examinations, such as the Trendelenberg test and Ober test, can help to identify other structural derangements that may lead to lateral hip pain.[7, 8]

A study by Ganderton et al indicated that in women, the most diagnostically accurate clinical tests for greater trochanteric pain syndrome included palpation of the greater trochanter, resisted hip abduction, the resisted external derotation test, and the Patrick, or FABER (flexion, abduction, external rotation), test.[30]

To assess for sciatica or lumbosacral radiculopathy, perform a detailed neurologic examination of both lower extremities, including assessment of strength, reflexes, and sensation, as well as dural stretch maneuvers (eg, the straight leg raise).

Complications

Complications of trochanteric bursitis may include the following:

  • Progressive or persistent pain

  • Reduced mobility

  • Limited activity level

  • Limping (antalgic gait)

  • Sleep disturbance, which is especially problematic for a patient who usually sleeps in the side-lying position

Potential complications resulting specifically from focal corticosteroid injection include the following:

  • Bleeding, bruising, infection, and allergic reactions occurring after the injection

  • Necrotizing fasciitis – This has been observed from a single steroid injection of the greater trochanteric bursa[31]

  • Transient elevation of blood glucose levels occurring after corticosteroid injection in a diabetic patient

  • Cardiac arrhythmia occurring after intravascular injection of a local anesthetic

  • Subcutaneous skin atrophy occurring with more superficial administration of corticosteroids

  • Peripheral nerve dysfunction if the injection is administered very close to or within a major nerve

 

DDx

Diagnostic Considerations

In addition to the conditions listed in the differential diagnosis, other problems to be considered include soft-tissue metastases[32] and infectious diseases.

Differential Diagnoses

 

Workup

Approach Considerations

Generally, no laboratory studies are necessary for the diagnosis of trochanteric bursitis (greater trochanteric pain syndrome [GTPS]). On rare occasions, blood work may be needed to rule out infection or connective-tissue disease.

Occasionally, diagnostic injection of a local anesthetic into the trochanteric bursa may be helpful, particularly in an obese individual in whom the diagnosis is not yet certain.

Bursal inflammation is the classic histologic finding.

Plain Radiography, Bone Scintigraphy, CT, MRI, and US

Plain radiography of the hip and femur may be performed to assess for possible fracture, underlying degenerative arthritis, or bony lesions, or for inflammation-related calcium deposition in the region of the greater trochanteric bursa (which may be associated with chronic GTPS). Pelvic tilting caused by a leg-length discrepancy may be appreciated better with standing anteroposterior (AP) pelvis and hip films.

In the presence of significant trauma, always check the radiograph for evidence of fracture before proceeding with treatment. If it is thought that the pain may be secondary to metastatic cancer, consider performing a bone scan even if plain radiography has yielded negative findings.[32]

Bone scanning, computed tomography (CT) scanning, and magnetic resonance imaging (MRI) also can be used to exclude underlying diseases. A study by Fearon et al concluded that ultrasonography (US) appears to be clinically useful in the setting of GTPS by displaying degenerative changes, tendon tears, or bursal effusions, but is highly operator-dependent.[33] MRI and US can potentially be used to differentiate between gluteus medius tendinitis and trochanteric bursitis in patients with GTPS.[34]

A study by Blankenbaker et al concluded that on MRI examination, patients with trochanteric bursitis have peritrochanteric T2-signal abnormalities and a higher incidence of abductor tendinopathy; however, the report cautioned that MRI is a poor predictor of trochanteric bursitis, because these findings are not specific to this pathology.[35]

A narrative review of 10 studies of imaging modalities in the diagnosis of GTPS (7 of which employed MRI, 1 US, 1 plain radiography, and 1 bone scintigraphy) found that MRI consistently correlated best with clinical and intraoperative findings, with US and plain radiography also providing encouraging results.[36] The authors suggested that MRI should be the current investigation of choice for GTPS but noted that multicenter randomized, controlled trials would be required to confirm the validity of their conclusions.

 

Treatment

Approach Considerations

Treatment of trochanteric bursitis (greater trochanteric pain syndrome [GTPS]) may include relative rest, application of ice, injection of corticosteroids and local anesthetics, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), and application of topical, sustained-release local anesthetic patches.[9, 10] Extracorporeal shock wave therapy (ESWT) is a good alternative to traditional nonoperative therapy, and surgical interventions can be useful in refractory cases.[11]

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[37] ; usually, no other consultations are required.

Special considerations for particular patient subgroups include the following:

  • Pregnant women – Although a focal corticosteroid injection can be performed during pregnancy, avoid giving oral NSAIDs to pregnant patients, especially in the third trimester

  • Pediatric population – If the patient is a minor, obtain informed consent from the parent or legal guardian before proceeding with any injection

  • Geriatric population – Exercise caution when administering oral NSAIDs to elderly patients

Evaluation and correction of underlying gait abnormalities are important and may be addressed with assistive devices (eg, canes, walkers, orthotics, shoe lifts, and knee braces). Use of deep-heating modalities (eg, ultrasonography and transcutaneous electrical nerve stimulation [TENS]) should be considered in resistant cases (ie, those in which pain persists for 10-12 weeks or longer).

If conventional treatment of GTPS fails to provide therapeutic benefit, reexamination of the patient for piriformis syndrome should be considered, because the piriformis muscle inserts on the greater trochanteric bursa. In such cases, piriformis syndrome treatment may resolve the GTPS.

Surgical Intervention

Generally, no surgical intervention is required for cases of trochanteric bursitis, because most patients respond well to nonsurgical treatment. However, surgery may be indicated if symptoms prove refractory to conservative management.

When surgery is warranted for refractory GTPS symptoms, longitudinal release of the ITB combined with subgluteal bursectomy appears to be safe and effective for most patients.[12] Only rarely does a patient with trochanteric bursitis need a bursectomy and partial resection of the greater trochanteric process.[38, 39, 40]

A study by Domínguez et al indicated that endoscopic surgery can yield good to excellent results in GTPS. The report involved 23 patients who underwent endoscopic treatment for the condition, with significant improvement in pain—as measured with the visual analogue scale, Western Ontario and McMaster Universities Arthritis Index, Modified Harris Hip Score, and Hip Outcome Score—found at 3-, 6-, and 12-month follow-up.[41]

A study by Coulomb et al indicated that for GTPS caused by gluteal tendinopathy with partial thickness tear, endoscopic debridement without tear repair produces modest clinical benefits in patients who are refractory to conservative treatment. The study, which included 17 patients, found the average visual analogue scale scores for pain preoperatively and at postoperative follow-up (average follow-up 37.6 mo) to be 7.2 and 3.3, respectively. Additionally, Harris Hip Scores were 53.5 and 79.8, respectively. While seven patients achieved resumption of sports activities, five had a poor outcome at follow-up.[42]

Activity

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.

Athletes with trochanteric bursitis should refrain from participating in their sport but may be expected to return to play without restrictions when the following goals have been achieved:

  • Resolution of symptoms

  • Resolution of any positive physical examination findings (eg, limping or tenderness to palpation)

  • Adequate performance of sports-specific practice drills, without recurrence of symptoms or physical examination findings

Prevention

All patients should be advised to avoid lying on the affected side, if possible. For patients who participate in sports, prevention may include emphasis on following an appropriate training schedule and avoiding constant unidirectional activities on banked surfaces. For example, if running must be done on a banked surface, the athlete ideally should spend half the time running one way on the embankment and the rest of the time running the other way so as not to overload the tissues on one side of the body.

Athletes who participate in contact sports (eg, hockey) should be educated regarding the appropriate use and size of protective padding. Athletes in endurance sports should be educated regarding the importance of ITB stretching and hip abductor strengthening.

Long-Term Monitoring

The patient should be instructed to return for reevaluation within approximately 1 month, at which time the clinician should assess the degree of therapeutic response to the corticosteroid injection and to any other interventions that have been initiated (eg, physical therapy).

If there is significant progression of the symptoms or if there are any local signs of infection at the injection site, the patient should be instructed to contact the physician sooner than 1 month after the injection.

Physical Therapy

Although only a limited number of controlled studies have supported the usefulness of physical therapy for treating GTPS, a specific and goal-directed physical therapy program often seems a reasonable option.

Management of the patient during the acute phase can include icing of the affected regions for 20-30 minutes every 2-3 hours. 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 iliotibial band (ITB), the tensor fascia lata (TFL), the external hip rotators, the quadriceps, and the hip flexors. The use of phonophoresis and soft-tissue massage also may be helpful.[11] TENS can be considered in cases that prove resistant to the rehabilitation program.

Stretching of the ITB (see the images below) and the 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, maintaining 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 or its symptoms, stretching should be performed not in a ballistic, jerking fashion but in a controlled, sustained fashion.

Photo demonstrates method of stretching iliotibial Photo demonstrates method of stretching iliotibial band (ITB) in standing position. One foot is crossed over other, and patient leans away from side being stretched. Exercise is performed by allowing side that will be stretched to lean in toward wall. Patient should feel stretch at lateral aspect of hip that is closest to wall. Stretching should be done in controlled, sustained manner, never a ballistic manner with sudden jerking movements.
Photo demonstrates method of stretching iliotibial Photo demonstrates method of stretching iliotibial band (ITB) in supine position. Foot ipsilateral to stretch is crossed over contralateral knee. Next, thigh ipsilateral to stretch is pulled across midline (adduction). Patient should feel stretch at lateral aspect of hip, in area shown by dark line. Stretching should be done in controlled, sustained manner, never in ballistic manner with sudden jerking movements.

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

Corticosteroid Injection

Many authors and clinicians consider corticosteroid injections to be an important option within the comprehensive treatment plan for GTPS.[43, 44, 45, 46, 47] A randomized, controlled clinical trial found corticosteroid and lidocaine injection for trochanteric bursitis to be an effective therapy that provided a prolonged benefit.[48] (Note, however, that corticosteroids should never be injected into a site that appears to be infected.)

Although trochanteric bursa injections are commonly performed without any radiographic guidance, there are some preliminary data to suggest that radiologic confirmation (eg, with fluoroscopy) is necessary to ensure the accuracy of the injections, especially in patients with any of the following[49] :

  • 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

The procedure for a diagnostic injection is to give a local anesthetic without epinephrine (eg, 5 mL of 1-2% lidocaine). This is injected into the affected trochanteric bursa via a 22-gauge needle. In a slimmer patient, a 1.5-in. (3.8-cm) needle may be adequate, but in a heavier patient, a 3.5-in. (8.9-cm) needle may be required to reach the bursa.

The needle is advanced to the greater trochanter, and contact with the bone is made in order to confirm correct insertion depth and appropriate placement. Once contact is made, the needle is withdrawn slightly so that the tip is located within the bursa. The local anesthetic is then injected directly into the bursa. Relief of pain after injection would be considered confirmation of trochanteric bursitis as the etiology of the pain.

Injection of local anesthetic can then be followed by injection of a corticosteroid. This is easily accomplished by using the needle that is already in place and switching to a new syringe containing the corticosteroid. Injection of 40-80 mg of methylprednisolone acetate or triamcinolone acetonide should be adequate. If pain relief is insufficient (ie, less than 50%), the injection may be repeated at 4-6 weeks.

In cases where the diagnosis of trochanteric bursitis seems straightforward on the basis of the clinical evaluation, it is not necessary to perform a diagnostic local anesthetic injection before the corticosteroid injection. In such cases, the most straightforward approach is to position the needle as described (see above) and then to deliver a mixture of a corticosteroid and a local anesthetic (eg, 40-80 mg of long-acting methylprednisolone with 5 mL of 1% lidocaine).

Lievense et al 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. The chance of recovery at 5 years was 2.7-fold greater in patients who received a corticosteroid injection than in those who did not.[26]

Accordingly, the investigators concluded that corticosteroid injections were predictive of 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.[26]

In a multicenter, open-label, randomized clinical trial from the Netherlands that evaluated the corticosteroid injections against expectant treatment (usual care) in primary care patients with GTPS, a clinically relevant effect was shown at 3 months for recovery and for pain at rest and with activity: the recovery rate was 34% in the usual care group and 55% in the injection group.[46] However, at 12 months, the differences in outcome were no longer present: the recovery rate was 60% in the usual care group and 61% in the injection group.

A study by Habib et al on the impact of local corticosteroid injection for GTPS on the hypothalamic-pituitary-adrenal axis found transient secondary adrenal insufficiency in four (19%) of the study’s 21 patients. The injection contained 80 mg of methylprednisolone acetate, with the insufficiency seen only at postinjection weeks 1 and 2.[50]

A retrospective study by Park et al indicated that in GTPS patients treated with ultrasonographically guided injections of corticosteroids and local anesthetics, the presence of knee osteoarthritis, lumbar facet joint pain, or sacroiliac joint pain may reduce the therapy’s effectiveness.[51]

Extracorporeal Shock Wave Therapy

Studies by Furia et al and Vannet et al demonstrated that low-energy extracorporeal shock wave therapy (ESWT) is an effective treatment for GTPS, especially for those who have high signals on MRI.[10, 52]

A study by Rompe et al showed that ESWT yielded significantly better results than home exercises or corticosteroid injections.[53]

 

Medication

Medication Summary

 

Table. (Open Table in a new window)

For trochanteric bursitis (greater trochanteric pain syndrome [GTPS]), medications are used primarily to decrease pain and inflammation. The most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and focal corticosteroid injections; these are employed in conjunction with the rest of the rehabilitation plan.

 

Although an off-label use, another option is symptomatic treatment with a topical, sustained-release local anesthetic patch, such as the Lidoderm (lidocaine transdermal) patch, especially when there is an associated sleep disturbance due to the patient lying on the side affected by GTPS.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

Oral NSAIDs can help to decrease pain and inflammation and may be given for several weeks. Various oral agents can be used. The choice of an NSAID is largely a matter of convenience (eg, how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Ibuprofen (Motrin, Advil, Addaprin, Ibu, Caldolor)

Ibuprofen inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclo-oxygenase (COX), thus inhibiting prostaglandin synthesis.

Ketoprofen

Ketoprofen is used for the relief of mild to moderate pain and inflammation. Administer small dosages initially to patients with small body size, elderly patients, and those with renal or liver disease.

When administering this medication, doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Naproxen (Naprosyn, Naprelan, Anaprox, Aleve)

Naproxen relieves mild to moderately severe pain and inhibits inflammatory reactions. It probably does so by decreasing the activity of the enzyme cyclo-oxygenase, thus inhibiting prostaglandin synthesis.

Flurbiprofen

Flurbiprofen may inhibit the cyclo-oxygenase enzyme, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Indomethacin (Indocin)

Indomethacin inhibits prostaglandin synthesis. It is rapidly absorbed, and metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.

Corticosteroids

Class Summary

In contrast to the widespread systemic distribution of an orally administered 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. Various corticosteroid preparations are available from which to choose. Commonly, the corticosteroid is mixed with a local anesthetic before injection. Again, there are various local anesthetic agents from which to choose.

Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, A-Methapred)

Corticosteroids such as methylprednisolone are used commonly for local injections of bursae or joints, to provide a local anti-inflammatory effect while minimizing some of the gastrointestinal and other risks of systemic medications.

Dexamethasone (Baycadron)

Dexamethasone has many pharmacologic benefits, but it also has significant adverse effects. It stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, tumor necrosis factor-alpha [TNF-alpha], interleukin-6 [IL-6], IL-2, and interferon-gamma [IFN-gamma]). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas.

Dexamethasone suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. It breaks down granulocyte aggregates and improves pulmonary microcirculation.

Dexamethasone is readily absorbed via the gastrointestinal tract and is metabolized in the liver. Inactive metabolites are excreted via the kidneys. The drug lacks the salt-retaining property of hydrocortisone.

Patients can be switched from an IV to a PO regimen in a 1:1 ratio.

Triamcinolone (Aristospan Intralesional, Kenalog)

Triamcinolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes (PMNs) and reversing capillary permeability. All corticosteroids can reduce symptoms.

Local anesthetics

Class Summary

Analgesics may aid in decreasing the severity of pain.

Lidocaine (Lidoderm)

Lidocaine decreases the permeability of neuronal membranes to sodium ions, thus inhibiting depolarization and blocking the transmission of nerve impulses.

Capsaicin (Aleveer, Qutenza, Salonpas Gel-Patch)

Capsaicin is a natural chemical derived from plants of the Solanaceae family. It penetrates deep for the temporary relief of minor aches and pains of muscles and joints associated with inflammatory reactions. Capsaicin may render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons.

 

Questions & Answers

Overview

What is trochanteric bursitis, and what are its associated conditions?

How is pain due to trochanteric bursitis characterized?

How are musculoskeletal exams used in the evaluation of trochanteric bursitis?

What is the role of imaging studies in the workup of trochanteric bursitis?

How is trochanteric bursitis treated?

What is the pathogenesis of trochanteric bursitis?

What is greater trochanteric pain syndrome (GTPS)?

What other types of bursa-related pain occur in the area affected by trochanteric bursitis?

What causes trochanteric bursitis?

Which conditions predispose patients to trochanteric bursitis?

Which neuropeptide is elevated in patients with trochanteric bursitis?

What is the relationship between trochanteric bursitis and femoroacetabular impingement (FAI)?

What is the epidemiology of trochanteric bursitis?

What is the mortality and morbidity of trochanteric bursitis?

How does trochanteric bursitis progress?

What information should be provided to patients with trochanteric bursitis?

Presentation

What is the classic symptom of trochanteric bursitis, and how is greater trochanteric pain syndrome apparently associated with quality of life, health status, and conditioned pain modulation?

What is the classic physical finding in trochanteric bursitis?

How is pain evaluated in the physical exam for trochanteric bursitis?

What are the complications of trochanteric bursitis?

What are the potential complications of corticosteroid injection in the treatment of trochanteric bursitis?

DDX

What are the diagnostic considerations in trochanteric bursitis?

What are the differential diagnoses for Trochanteric Bursitis?

Workup

What are the approach considerations in the workup of trochanteric bursitis?

What is the role of plain radiography in the workup of trochanteric bursitis?

What is the role of bone scanning, CT scanning, and MRI in the workup of trochanteric bursitis?

How effective is MRI in the diagnosis of trochanteric bursitis?

Treatment

What is the treatment for trochanteric bursitis?

When are special considerations warranted in the treatment of trochanteric bursitis?

What are the treatment options for trochanteric bursitis?

Is endoscopic surgery an effective treatment approach for trochanteric bursitis?

When is surgery indicated in the treatment of trochanteric bursitis?

Is endoscopic debridement an effective treatment for trochanteric bursitis?

What activity restrictions are indicated in the treatment of trochanteric bursitis?

What are the criteria for return to play in athletes with trochanteric bursitis?

What are preventive measures for patients treated for trochanteric bursitis?

What can athletes with who participate in contact sports do to prevent recurrence of trochanteric bursitis?

What long-term monitoring is indicated in the treatment of trochanteric bursitis?

What is the role of physical therapy in the treatment of trochanteric bursitis?

What are the benefits of a home exercise program in patients with trochanteric bursitis?

How effective are corticosteroid injections as treatment for trochanteric bursitis?

When is fluoroscopy guidance indicated for corticosteroid injections in the treatment of trochanteric bursitis?

How is a corticosteroid injection for the treatment of trochanteric bursitis performed?

How effective are corticosteroid injections as treatment for trochanteric bursitis?

How effective is extracorporeal shock wave therapy as treatment for trochanteric bursitis?

Medications

Which medications in the drug class Local anesthetics are used in the treatment of Trochanteric Bursitis?

Which medications in the drug class Corticosteroids are used in the treatment of Trochanteric Bursitis?

Which medications in the drug class Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are used in the treatment of Trochanteric Bursitis?