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. [33]
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. [34] MRI and US can potentially be used to differentiate between gluteus medius tendinitis and trochanteric bursitis in patients with GTPS. [35]
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. [36]
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. [37] 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.
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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. |
