Because greater trochanteric pain syndrome (GTPS) shares pain patterns with other musculoskeletal conditions, the diagnosis may not be made for several years. Patients may experience considerable pain and not see improvement in spite of having received several therapies. However, many advances in the evaluation and management of hip pathology have taken place in recent years, resulting in improved outcomes.
Painful hip conditions are being seen in increasing frequency in all age groups, usually in women after the fourth decade. Treatment often is directed toward conservative measures, with physical therapy and NSAIDs and, when appropriate, therapeutic injections into the trochanteric bursa. Pain not relieved by conservative means or not improved by injection of local anesthetic and corticosteroids should prompt the physician to the possibility of an incorrect diagnosis and a more thorough investigation into the source of pain. Pathologies often can be managed successfully with arthroscopic and open surgical approaches based on the patient's specific condition.
This 2-part article describes the diagnosis and management of hip pathology in GTPS. In the first part ("Evaluating hip pathology in trochanteric pain syndrome," The Journal of Musculoskeletal Medicine, September 2008, page 428), we focused on patient evaluation and the differential diagnosis. This second part discusses approaches to disease management and prevention.
Management of hip pathology centers on conservative treatment. NSAIDs may be of benefit in reducing pain. Icing the joint can provide some degree of relief. Physical therapy—in the form of strengthening of the hip abductors, adductors, and internal and external rotators; back extensors; and abdominals (the core)—is combined with stretching of the iliotibial band (ITB) and hip external rotators. The goal of stretching out the tissues is to relieve tension in the structures surrounding the greater trochanter and, as such, reduce friction. Local diathermy, iontophoresis, and pulsed ultrasonographic therapy for calcific tendinitis also have been successful in the management of trochanteric bursitis.1 Although pulsed ultrasonography has been used with success, there is concern about disruption to the tendon insertion during therapy.
Successful relief of trochanteric compartment pain has been achieved with local anesthetic and corticosteroid injections.2-5 Significant relief may be achieved with 1 or 2 injections.
The purpose of injection for trochanteric pain typically is to deposit the medication into the largest bursa between the overlying ITB and the underlying gluteus maximus tendons and the converging fibers of the gluteus medius and fascia along the lateral aspect of the trochanter. Specific injections into the smaller gluteal bursae have not been described.
Correct placement of the injection into the region also should take into account the possibility of direct injection into a tendon and the potential that this creates for tendon rupture because of intratendinous corticosteroid deposition. Pain not relieved by no more than 2 properly placed injections, significant weakness on testing, or a lack of success with physical therapy should raise suspicion of underlying pathology that requires more aggressive management or, more significantly, an incorrect diagnosis.