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 [38] ; usually, no other consultations are required.
Special considerations for particular patient subgroups include the following:
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Pregnant women – Although a focal corticosteroid injection can be performed during pregnancy, avoid giving oral NSAIDs to pregnant patients, especially in the third trimester
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Pediatric population – If the patient is a minor, obtain informed consent from the parent or legal guardian before proceeding with any injection
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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. [39, 40, 41]
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. [42]
Similarly, a literature review by Crutchfield et al indicated that in patients with trochanteric bursitis, refractory lateral hip pain can safely and effectively be treated with either arthroscopic or open procedures involving trochanteric bursectomy. Hip scores such as the Harris Hip Score and Hip Outcome Score consistently and significantly improved for both approaches, as did functional and pain metrics such as the 36-Item Short Form Survey score and visual analogue scale score. No significant differences between arthroscopic surgery and open procedures were seen with regard to pain, total complications, complication severity, and total failures. [43]
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. [44]
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:
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Resolution of symptoms
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Resolution of any positive physical examination findings (eg, limping or tenderness to palpation)
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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 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 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. [45, 46, 47, 48, 49] A randomized, controlled clinical trial found corticosteroid and lidocaine injection for trochanteric bursitis to be an effective therapy that provided a prolonged benefit. [50] (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 [51] :
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Heavy body habitus or obesity
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A history of repeated injections
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A history of chronic inflammation
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A history of previous surgery
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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. [48] 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. [52]
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. [53]
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, 54]
A study by Rompe et al showed that ESWT yielded significantly better results than home exercises or corticosteroid injections. [55]
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Tr B = trochanteric bursa; G Med B = subgluteus medius bursa; G Min B = subgluteus minimus bursa.
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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.
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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.
Tables
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. |
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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. |
