Trochanteric bursitis. Treatment by corticosteroid injection

Musculoskeletal injection

Patients commonly present to primary care physicians with musculoskeletal symptoms. Clinicians certified in internal medicine must be knowledgeable about the diagnosis and management of musculoskeletal diseases, yet they often receive inadequate postgraduate training on this topic. The musculoskeletal problems most frequently encountered in our busy injection practice involve, in decreasing order, the knees, trochanteric bursae, and glenohumeral joints. This article reviews the clinical presentations of these problems. It also discusses musculoskeletal injections for these problems in terms of medications, indications, injection technique, and supporting evidence from the literature. Experience with joint injection and the pharmacological principles described in this article should allow primary care physicians to become comfortable and proficient with musculoskeletal injections.

Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

OBJECTIVE

To determine whether fluoroscopic guidance improves outcomes of injections for greater trochanteric pain syndrome.

DESIGN

Multicentre double blind randomised controlled study.

SETTING

Three academic and military treatment facilities in the United States and Germany.

PARTICIPANTS

65 patients with a clinical diagnosis of greater trochanteric pain syndrome.

INTERVENTIONS

Injections of corticosteroid and local anaesthetic into the trochanteric bursa, using fluoroscopy (n=32) or landmarks (that is, "blind" injections; n=33) for guidance.

PRIMARY OUTCOME MEASURES

0-10 numerical rating scale pain scores at rest and with activity at one month (positive categorical outcome predefined as >or=50% pain reduction either at rest or with activity, coupled with positive global perceived effect). Secondary outcome measures included Oswestry disability scores, SF-36 scores, reduction in drug use, and patients' satisfaction.

RESULTS

No differences in outcomes occurred favouring either the fluoroscopy or blind treatment groups. One month after injection the average pain scores were 2.7 at rest and 5.0 with activity in the fluoroscopy group compared with 2.2 and 4.0 in the blind injection group. Three months after the injection, 15 (47%) patients in the blind group and 13 (41%) in the fluoroscopy group continued to have a positive outcome.

CONCLUSION

Although using fluoroscopic guidance dramatically increases treatment costs for greater trochanteric pain syndrome, it does not necessarily improve outcomes.

TRIAL REGISTRATION

Clinical trials NCT00480675.

Trochanteric bursitis: refuting the myth of inflammation

BACKGROUND AND OBJECTIVES

Greater trochanteric (GT) bursitis is a common cause of hip pain. Previously, the etiology of the trochanteric pain syndrome was thought to be caused by inflammation of the subgluteus maximus bursa (i.e., bursitis). Recently, MRI and ultrasound studies have brought into serious doubt the idea that bursitis is the etiology for trochanteric pain. To our knowledge, no histologic study of GT bursitis has been reported to date. The purpose of this study is to evaluate the histopathology of patients with and without the clinical syndrome of GT bursitis to assess for the presence of bursal inflammation.

DESIGN AND METHODS

This is a prospective, case-controlled, blinded study of the histopathologic features of controls and patients with GT bursitis. We recruited patients who required total hip arthroplasty (THA) for rheumatoid or osteoarthritis. Inclusion criteria for the study consisted of the following: needing THA as standard of care; THA secondary to OA or RA; age greater than 18; and minimal risk for surgery by the American Heart Association Criteria. We excluded anyone who received a GT bursa injection 9 months before surgery. Eligible participants were then stratified as cases or controls using the 1985 clinical criteria for GT bursitis. The harvesting of the bursa required no modification of the surgical procedure. The specimens were then examined by 2 independent pathologists who were blinded as to the patients' clinical status.

RESULTS

Six bursal specimens were evaluated by 2 blinded surgical pathologists revealing primarily fibroadipose tissue with no signs of acute or chronic inflammation. There were 3 bursas in the control group and 2 specimens with clinical GT bursitis. No significant differences were found between the specimens of the 2 groups.

CONCLUSIONS

The results of this small prospective observational histologic study, along with recent MRI and ultrasound studies on the topic, strongly suggest that there is no etiologic role of bursal inflammation in the trochanteric pain syndrome.

Lateral hip pain: findings from magnetic resonance imaging and clinical examination

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVES

To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology.

BACKGROUND

LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem.

METHODS AND MEASURES

Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance imaging (MRI) studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined.

RESULTS

Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large.

CONCLUSIONS

The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MRI as a diagnostic reference standard. This factor, together with the imprecise point estimates of the likelihood ratios, means that no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology.

Morphology of the bursae associated with the greater trochanter of the femur

BACKGROUND

Abnormalities of the bursae in the vicinity of the greater trochanter have been implicated in the pathogenesis of lateral hip pain. The purpose of the present study was to investigate the detailed morphology of the bursae associated with the greater trochanter of the femur.

METHODS

The bursae deep to the tendons of each of the gluteal muscles were examined in eighteen embalmed human hips with use of macrodissection and histological techniques. The specimens were obtained from eight female and seven male donors who had had a mean age of seventy-eight years at the time of death.

RESULTS

A total of 106 bursae were identified in ten different locations, with an average of six bursae per hip. As many as four bursae were present beneath the gluteus maximus muscle and the fascia lata, including those normally thought of as the "trochanteric" bursae and the gluteofemoral bursa. Two bursae typically were found beneath the tendon of the gluteus medius muscle: the anterior subgluteus medius bursa and the piriformis (posterior subgluteus medius) bursa. In the majority of cases, a single bursa was located deep to the gluteus minimus tendon, although two different bursae were identified: the subgluteus minimus bursa and the secondary subgluteus minimus bursa. All of these bursae demonstrated a synovial lining, which was predominantly areolar in type.

CONCLUSIONS

The present study revealed that numerous bursae are intimately associated with the greater trochanter and that at least two bursae are associated with each of the gluteal tendons.

Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice

BACKGROUND

Regional pain in the hip in adults is a common cause of a general practitioner visit. A considerable part of patients suffer from (greater) trochanteric pain syndrome or trochanteric bursitis. Local corticosteroid injections is one of the treatment options. Although clear evidence is lacking, small observational studies suggest that this treatment is effective in the short-term follow-up. So far, there are no randomised controlled trials available evaluating the efficacy of injection therapy. This study will investigate the efficacy of local corticosteroid injections in the trochanter syndrome in the general practice, using a randomised controlled trial design. The cost effectiveness of the corticosteroid injection therapy will also be assessed. Secondly, the role of co-morbidity in relation to the efficacy of local corticosteroid injections will be investigated.

METHODS/DESIGN

This study is a pragmatic, open label randomised trial. A total of 150 patients (age 18-80 years) visiting the general practitioner with complaints suggestive of trochanteric pain syndrome will be allocated to receive local corticosteroid injections or to receive usual care. Usual care consists of analgesics as needed. The randomisation is stratified for yes or no co-morbidity of low back pain, osteoarthritis of the hip, or both. The treatment will be evaluated by means of questionnaires at several time points within one year, with the 3 month and 1 year evaluation of pain and recovery as primary outcome. Analyses of primary and secondary outcomes will be made according to the intention-to-treat principle. Direct and indirect costs will be assessed by questionnaires. The cost effectiveness will be estimated using the following ratio: CE ratio = (cost of injection therapy minus cost of usual care)/(effect of injection therapy minus effect of usual care).

DISCUSSION

This study design is appropriate to estimate effectiveness and cost-effectiveness of the injection therapy. We choose to use a pragmatic study design and are thus not able to study specific effects of the injection with corticosteroids. A distinction between placebo effect of the injection and specific effects of the corticosteroids is therefore not possible.

Arthroscopic bursectomy with concomitant iliotibial band release for the treatment of recalcitrant trochanteric bursitis

Trochanteric bursitis with lateral hip pain is a commonly encountered orthopaedic condition. Although most patients respond to corticosteroid injections, rest, physical therapy (PT), stretching, and anti-inflammatory medications, those with recalcitrant symptoms may require operative intervention. Studies have explored the use of the arthroscope in the treatment of these patients. However, these reports have not addressed the underlying pathology in this chronic condition. We believe that the iliotibial band must be addressed and is the main cause of pain, inflammation, and trochanteric impingement leading to the development of bursitis. We report a new technique for arthroscopic trochanteric bursectomy with iliotibial band release. Our technique involves 2 incisions--one 4 cm proximal to the greater trochanter along the anterior border of the iliotibial band, and the other 4 cm distal and along the posterior border. The 30 degrees arthroscope is introduced through the inferior portal, and a cannula is introduced through the superior portal. A 5.5-mm arthroscopic shaver is inserted through the superior cannula to clear off the surface of the iliotibial band, so that it may be adequately visualized. A hooked electrocautery probe is then used to longitudinally incise the iliotibial band until it no longer rubs, causing impingement over the greater trochanter.

Lateral trochanteric pain following primary total hip arthroplasty

The purpose of this study was to evaluate the incidence of lateral trochanteric pain (LTP) following primary total hip arthroplasty (THA) and identify risk factors. From 1993 to 1998, 543 primary THAs were performed for osteoarthritis. Lateral trochanteric pain was identified in 24 (4.4%) of 543 patients. The incidence of LTP with the posterior approach was 1.2% (1/82), and the incidence with the direct lateral approach was 4.9% (23/461). Leg length discrepancy, femoral offset, and heterotopic ossification were not correlated with LTP. No patient required operative treatment. Lateral trochanteric pain after primary THA was significantly more common in females (P < .04) and in patients who had a direct lateral approach (P < .01). Lateral trochanteric pain in this series was effectively treated with nonoperative modalities.

Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study

BACKGROUND

Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy.

METHODS

The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread.

RESULTS

The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients.

CONCLUSIONS

Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Evidence-Based Soft Tissue Rheumatology

Trochanteric bursitis is a term used to name a syndrome that features pain and tenderness over the greater trochanter. Present evidence suggests that in the majority of cases, symptoms result from pathology of the gluteus medius or minimus muscles rather than a bursa. Lower limb length discrepancy, iliotibial band contracture, hip osteoarthritis and lumbar spondylosis are often mentioned, but no proved as predisposing factors. After a lumbar spine or hip and other local pathology have been considered and clinically excluded, the clinical features of the syndrome, ie lateral location of pain plus characteristic trochanteric tenderness are usually sufficient to reach a diagnosis. Most patients with trochanteric bursitis can be successfully treated with a NSAID, physiotherapy plus a local corticosteroid injection. The few refractory cases are often treated surgically. Disappointingly, none of the therapeutic interventions used in trochanteric bursitis have been validly assessed.

MR imaging of sports-related hip disorders

Hip arthroscopy is being used increasingly for the diagnosis and treatment of hip disorders. MR imaging performed with appropriate technical considerations may aid not only in preoperative planning but in the appropriate selection of patients, which tends to lead to better postoperative results. Although the painful hip is imaged most commonly by radiography, MR imaging is considered the next imaging test of choice for evaluation of most common hip abnormalities in athletes, including labral injuries, ligament injuries, osteochondral injuries, fractures, bursitis, and musculotendinous injuries. MR arthrography can be a particularly useful technique for dedicated assessment of hip joint internal derangements.

MRI in greater trochanter pain syndrome

The greater trochanter pain syndrome refers to pain on the lateral aspect of the hip joint. This is frequently attributed to trochanteric bursitis and distension of the subgluteal bursae. Associated tears of the tendons of gluteus medius and minimus have been described and may result from repetitive frictional trauma to these tendons and their associated bursae secondary to impingement beneath the tensor fascia lata. Occasionally tendinous damage may result from acute local direct trauma or a hyperadductive strain injury. We describe MRI in two patients with chronic lateral hip pain.

The role of arthroscopic bursectomy in the treatment of trochanteric bursitis

The use of arthroscopy to treat recalcitrant trochanteric bursitis is reported and its role in treating this common clinical entity is discussed. During a 7-year period, 27 patients underwent this procedure. All patients complained of recurrent lateral hip pain despite at least 2 localized injections with corticosteroids. Minimum follow-up was 1 year, and the cases of 22 patients were reviewed after 5 years. Twenty-three of the 27 patients had good or excellent results immediately following the procedure and experienced no complications. At 1 year, only 1 patient had experienced symptom recurrence, and at 5 years, only 2 patients had had recurrence. All patients except 1 were satisfied with their outcome. Arthroscopically performed trochanteric bursectomy is a minimally invasive technique that appears to be both safe and effective for treating recalcitrant pain syndromes.

Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists

BACKGROUND CONTEXT

Greater trochanteric pain syndrome (GTPS) is a regional syndrome characterized by pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh that may mimic the symptoms of lumbar nerve root compression. Despite these known features, the diagnosis of GTPS is often missed, and documentation of its prevalence in an orthopedic spine specialty practice is lacking.

PURPOSE

To determine the prevalence of the GTPS in patients referred to a tertiary care orthopedic spine referral center for the evaluation of low back pain, and to describe the demographic and clinical characteristics of patients with this syndrome.

STUDY DESIGN/SETTING

Retrospective analysis.

PATIENT SAMPLE

A total of 247 consecutive patients referred for low back pain from August 1998 through December 2000.

OUTCOME MEASURES

Clinical response to injection, demographic characteristics, physical examination findings, prevalence of GTPS and preexisting diagnostic evaluations.

METHODS

The diagnosis of GTPS was made based on history and physical examination and was confirmed by response to anesthetic corticosteroid injection. Demographic and clinical characteristics of the study group were evaluated. Follow-up data were available at a mean of 8 weeks postinjection (range, 2 to 48 weeks).

RESULTS

The prevalence of GTPS was 20.2% (51 of 252). Mean age (54 years) was the same for patients with (range, 25 to 85 years) and without (range, 17 to 85 years) GTPS. Significantly more women than men had GTPS (p<.03). Of the 51 patients diagnosed with GTPS at initial presentation, 54.9% (28 of 51) had already obtained a magnetic resonance imaging examination (although only 15.7%, ie, 8 of 51, demonstrated objective neurologic findings) and 62.7% (32 of 51) had previously been evaluated by an orthopedist or neurosurgeon; one patient had undergone two lumbar decompressions without clinical improvement before our evaluation.

CONCLUSIONS

GTPS accounts for a substantial proportion of patients referred to our center for evaluation of low back pain. Both primary care physicians and specialty surgeons may miss this diagnosis, most common in middle-aged women. Accurate recognition of this problem earlier in the evaluation of patients with low back, buttock or lateral thigh symptoms may dramatically reduce costly patient referrals and diagnostic tests and may prevent unwarranted surgery.

Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome

OBJECTIVE

This study examined patients with greater trochanteric pain syndrome (GTPS) to determine the prevalence of gluteus medius pathology by utilizing magnetic resonance imaging (MRI), and to evaluate the presence of Trendelenburg's sign, pain on resisted hip abduction, and pain on resisted hip internal rotation as predictors of a gluteus medius tear in this group of patients.

METHODS

Twenty-four subjects with clinical features consistent with GTPS were recruited. A standard physical assessment was performed at study entry, including assessment of the 3 specific physical signs. Following this initial assessment, MRI of the affected hip was performed. A 1.5T whole body MRI system was utilized, with T1 and T2 fast spin-echo sequences performed in the coronal and axial planes. All MR images were reviewed in random order by a single radiologist. In 12 patients, the 3 physical signs were assessed at study entry and at 2 months by the same observer and the intraobserver reliability for each of the signs was calculated.

RESULTS

All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg's sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg's sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).

CONCLUSION

The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg's sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg's sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.

Trochanteric bursitis (greater trochanter pain syndrome)

Trochanteric bursitis, a common regional pain syndrome, is characterized by chronic, intermittent aching pain over the lateral aspect of the hip. The incidence of trochanteric bursitis peaks between the fourth and sixth decades of life, but cases have been reported in all age-groups. The diagnosis may be elusive, especially if symptoms are atypical. This condition can be associated with pain and limitation of function. Treatment includes physical therapy measures, analgesics, and local glucocorticoid injection. In this article, we review the pathogenesis, common initial symptoms, diagnostic approach, and treatment options for trochanteric bursitis.

Greater trochanteric pain syndrome (trochanteric bursitis) in low back pain

The greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is a regional pain syndrome characterized by typical local tenderness over the trochanteric region. Recently this syndrome was found in hospital-referred, chronic low back pain (LBP) patients. To confirm the correlation between GTPS and LBP in different patient settings and to present quantitative data about associated clinical features, we prospectively evaluated consecutive LBP patients from a general practice (n = 40), an occupational health service (n = 124) and a rheumatology outpatient clinic (n = 40). GTPS was found in 25, 18 and 45% of patients, respectively and was associated with female sex and duration of LBP. Associated clinical features were radiating pain and paraesthesiae in the legs, tenderness of the ilio-tibial tract and aggravation of pain during standing for a short time, descending stairs, lying on the affected side and crossing legs. These observations demonstrate that GTPS is common in LBP and is easy to recognize on clinical grounds.

Avascular necrosis of the femoral head presenting as trochanteric bursitis

Five patients are described with avascular necrosis of the femoral head who presented with ipsilateral trochanteric bursitis, in the absence of clearcut hip joint disease. Avascular necrosis was indicated by magnetic resonance imaging. It is suggested that clinical trochanteric bursitis, especially when refractory to local corticosteroid treatment, may be the initial sign of hip disease. In the patient with risk factor(s) for avascular necrosis that diagnosis should be considered and evaluated with appropriate studies, such as magnetic resonance imaging, to prevent weight bearing at an early stage and permit possible surgical decompression in the hope of postponing or obviating the need for total hip replacement.