Trochanteric bursitis. Treatment by corticosteroid injection

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

The effect of iliotibial band surgery at the hip: a systematic review

BACKGROUND

Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases.

PURPOSE

The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery.

METHODS

The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed.

RESULTS

A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery.

CONCLUSION

ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

Prognostic factors of trochanteric bursitis in surgical-staged patients: a prospective study

BACKGROUND

Trochanteric bursitis or greater trochanteric pain syndrome is a common disorder and frequent cause of lateral hip pain. It can lead to severe functional impairment with increase morbidity and poor quality of life.The purpose of the current study was to identify and evaluate relationship between health-related factors, as prognostic indicators, and clinical outcomes.

METHODS

A single-centre, prospective study was conducted and 60 patients (62 hips) were included with a minimum 12 months of follow-up. Clinical outcomes were evaluated using Hip Outcome Scale, Single Assessment Numeric Evaluation and Visual Analogue Scale. Radiological assessments and health-related factors were documented in an attempt to understand their validity as predictors of clinical outcomes. Complications and recurrence rates were also analyzed.

RESULTS

Univariate model revealed that an increased BMI (p = 0.001; OR = 1.05; 95% CI, 1.02-1.07); number of previous corticosteroid infiltrations (p = 0.001; OR = 1.28, 95% CI, 1.11-1.48); longer time from symptom onset to surgery (p = 0.001; OR = 1.19; 95% CI, 1.12-1.28); smoker status (p = 0.001; OR 11.2; 95% CI, 3.30-44.2); and the presence of prior lumbosacral fusion (LSF) (p = 0.001; OR 13.8; 95% CI, 2.96-101); were prognostic factors predisposing for poor clinical outcomes.Among prognostic health-related factors were medical comorbidities such as emotional distress (p < 0.001; OR 26.1; 95% CI, 5.71-192); fibromyalgia (p = 0.026; OR 3.56; 95% CI, 1.16-11.7); and hyporthyroidism (p = 0.005, OR = 6.55, 95% CI, 1.73-28.7).

CONCLUSIONS

Better overall physical function was predicted by lower number of corticosteroid infiltrations, shorter time span from symptom onset to surgery, non-smoker status and the absence of prior lumbosacral fusion. Obesity, smoking, the presence of emotional distress, fibromyalgia and hypothyroidism seem to increase the risk of poor clinical outcomes. A proper selection and/or correction of modifiable prognostic factors could reduce the incidence of endoscopic treatment failure and, as a consequence, improve patient outcomes and quality of life. However, future efforts should focus on experimental and randomised studies to fully determine these associations.

Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome? A 2 × 2 Factorial Randomized Clinical Trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a debilitating chronic condition, most prevalent in postmenopausal women. A positive association between high estrogen levels and tendon health may exist, and postmenopausal women have reduced estrogen. Menopausal hormone therapy (MHT) may reduce the incidence of tendon abnormality, particularly when combined with exercise.

PURPOSE

To determine the effect of MHT and exercise on tendon pain and function in postmenopausal women with GTPS.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Postmenopausal women (N = 132; n = 12, lost to follow-up) with GTPS were randomized into MHT and placebo transdermal cream groups combined with tendon-specific or sham exercise. All groups received education about avoiding gluteal tendon compression and load management throughout 12 weeks of intervention. The primary outcome was the Victorian Institute of Sport Assessment for gluteal tendinopathy (VISA-G), and secondary outcomes were measured at baseline and at 12 and 52 weeks. The Global Rating of Change was assessed at 12 and 52 weeks. A linear mixed-effects model was used to assess differences. Body mass index (BMI) was included as a covariate.

RESULTS

All participant groups improved over time (baseline vs 12 weeks, P < .001; baseline vs 52 weeks, P < .001). There was no difference among exercise groups measured by all outcomes (VISA-G: baseline, P = .97, mean difference [MD] = 0.10; 12 weeks, P = .49, MD = 2.15; 52 weeks, P = .32, MD = -3.08). There was a significant interaction effect between cream and BMI; therefore, the population was stratified by BMI levels (<25, <30, ≥30). The MHT groups (with exercise and education) had significantly better VISA-G outcomes (baseline, P = .04, MD = -11.20, 95% CI = -21.70 to -0.70; 12 weeks, P < .001, MD = -20.72, 95% CI = -31.22 to -10.22; 52 weeks, P = .002, MD = -16.71, 95% CI = -27.21 to -6.22) and secondary measure scores as compared with placebo at all time points when BMI was <25.

CONCLUSION

MHT or placebo combined with tendon-specific or sham exercise plus education reduced pain and increased function for this population. For women with a BMI <25, MHT with any exercise plus education was better than placebo. A targeted exercise or sham exercise strategy is effective when prescribed with education about avoiding gluteal tendon compression and load management.

REGISTRATION

ACTRN12614001157662 (Australian New Zealand Clinical Trials Registry).

Greater trochanteric pain syndrome: focused shockwave therapy versus an ultrasound guided injection: a randomised control trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a common problem with an incidence of 1.8-5.6 per 1000 population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential non-invasive management option for this difficult presentation.

METHOD

We ran a prospective, 2-arm, single-blinded, randomised control trial comparing focused shockwave therapy (f-ESWT) to an ultrasound guided corticosteroid injection. Primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris Hip Score (HHS) and Trendelenburg test for function; SF-36 for quality of life (QoL); and a Likert scale question for subjective assessment of symptom improvement.

RESULTS

104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image-guided injection. 11 patients were lost to follow-up. There were no significant differences in baseline scores between groups.At 3 months, pain, function and QoL scores had improved in both groups but were not statistically significant. The Trendelenburg test was significantly improved in the f-ESWT group with 80% patients being negative compared to 20% at baseline (p < 0.001).At 12 months, across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 37.1 versus 55.0 (p = 0.007, 95% confidence interval [CI], 6.3-30.8), HHS 69.7 versus 57.5 (p = 0.002, 95% CI, -20.0 to -4.6) and SF-36 52.4 versus 47.7 (p = 0.048, 95% CI, -9.31 to -0.04). The improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline (p < 0.001).

CONCLUSIONS

We have shown f-ESWT is an effective treatment for patients with GTPS. We would advocate f-ESWT as an effective non-invasive treatment modality for this challenging patient population.Trial Registration No. ISRCTN8338223.

Arthroscopic management of greater trochanter pain syndrome and abductor tears has demonstrated promising results in terms of improvement in pain scores and functional outcomes: a scoping review

PURPOSE

Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of 'greater trochanteric bursitis'. GTPS is common, particularly in women 50-79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature.

METHODS

A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS.

RESULTS

Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3-6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies.

CONCLUSION

Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future.

LEVEL OF EVIDENCE

IV.

COMPARISON BETWEEN CONCENTRATED BONE MARROW ASPIRATE AND CORTICOID IN GLUTEAL TENDINOPATHY

OBJECTIVE

To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies.

METHODS

48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections.

RESULTS

40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference.

CONCLUSION

BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up

BACKGROUND

A previously published trial showed that patients with chronic gluteal tendinopathy achieved greater clinical improvement at 12 weeks when treated with a single platelet-rich plasma (PRP) injection than those treated with a single corticosteroid injection (CSI).

PURPOSE

This follow-up study was conducted to determine whether there would be a sustained long-term difference in the modified Harris Hip Score (mHHS) at 2 years for a leucocyte-rich PRP (LR-PRP) injection in the treatment of chronic gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This trial included 80 patients randomized 1:1 to receive LR-PRP or CSI intratendinously under ultrasound guidance. Patients had a mean age of 60 years, a 9:1 ratio of women to men, a mean body mass index of 27, and a mean length of symptoms >15 months. No patients had full-thickness tears of the gluteal tendons. An open-labeled extension allowed patients to receive crossover treatment after 3 months. The main outcome measure was the mHHS.

RESULTS

The mean mHHS improved significantly at 12 weeks in the PRP group (74.05; SD, 13.92) as compared with the CSI group (67.13; SD, 16.04) ( P = .048). At 24 weeks, the LR-PRP group (77.60; SD, 11.88) improved further than the CSI group (65.72; SD, 15.28; P = .0003). Twenty-seven patients were deemed to have failed the CSI treatment at 16 to 24 weeks, with an exit score of 59.22 (SD, 11.54), and then had treatment with LR-PRP. The crossover group improved with the LR-PRP: from 59.22 (SD, 11.22) at baseline to 75.55 (SD, 16.05) at 12 weeks, 77.69 (SD, 15.30) at 24 weeks, and 77.53 (SD, 14.54) at 104 weeks. The LR-PRP group retained 38 of 39 patients to 52 weeks and continued to improve. Their baseline scores of 53.77 (SD, 12.08) improved to 82.59 (SD, 9.71) at 104 weeks ( P < .0001).

CONCLUSION

Among patients with chronic gluteal tendinopathy and a length of symptoms >15 months, a single intratendinous LR-PRP injection performed under ultrasound guidance results in greater improvement in pain and function than a single CSI. The improvement after LR-PRP injection is sustained at 2 years, whereas the improvement from a CSI is maximal at 6 weeks and not maintained beyond 24 weeks.

REGISTRATION

ACTRN12613000677707 (Australian New Zealand Clinical Trials identifier).

Glucocorticoid injections for greater trochanteric pain syndrome: a randomised double-blind placebo-controlled (GLUTEAL) trial

Small observational studies suggest that local glucocorticoid (GC) injection may be effective in the management of the greater trochanteric pain syndrome (GTPS). The objective was to perform the first randomised double-blind placebo-controlled trial to investigate the efficacy of local GC injection in the management of GTPS. The trial was conducted between November 2011 and May 2015. Inclusion criteria included lateral hip pain (LHP) for greater than 1 month, a LHP score of ≥ 4/10 and typical LHP reproduced by palpation of the greater trochanter. Participants were randomised in a 1:1 ratio to injection with a combination of local anaesthetic and GC (intervention) or injection with normal saline solution (placebo). The primary outcome of interest was the difference in pain intensity at 4 weeks post-injection between the two groups. Patients were followed for 6 months. A total of 46 patients were included. There were no significant differences between the two groups in terms of pain reduction at 1 month (p = 0.23). When including all measures in the first 4 weeks and using multilevel regression, there was a trend towards improvement in pain scores in favour of the intervention group (p = 0.08). There were no significant differences in pain scores between groups at 3 and 6 months. In the management of GTPS, local glucocorticoid injections are of no greater efficacy than injection of normal saline solution. Given the lack of long-term improvement and the potential for cortisone-related side effects, this intervention is of limited benefit.

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups

PURPOSE

To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI.

METHODS

Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB.

RESULTS

The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores.

CONCLUSIONS

The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB.

LEVEL OF EVIDENCE

Level III, retrospective matched case control study.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection

BACKGROUND

Gluteus medius/minimus tendinopathy is a common cause of lateral hip pain or greater trochanteric pain syndrome.

HYPOTHESIS

There would be no difference in the modified Harris Hip Score (mHHS) between a single platelet-rich plasma (PRP) injection compared with a corticosteroid injection in the treatment of gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

There were 228 consecutive patients referred with gluteal tendinopathy who were screened to enroll 80 participants; 148 were excluded (refusal: n = 42; previous surgery or sciatica: n = 50; osteoarthritis, n = 17; full-thickness tendon tear, n = 17; other: n = 22). Participants were randomized (1:1) to receive either a blinded glucocorticoid or PRP injection intratendinously under ultrasound guidance. A pain and functional assessment was performed using the mHHS questionnaire at 0, 2, 6, and 12 weeks and the patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) at 12 weeks.

RESULTS

Participants had a mean age of 60 years, a ratio of female to male of 9:1, and mean duration of symptoms of >14 months. Pain and function measured by the mean mHHS showed no difference at 2 weeks (corticosteroid: 66.95 ± 15.14 vs PRP: 65.23 ± 11.60) or 6 weeks (corticosteroid: 69.51 ± 14.78 vs PRP: 68.79 ± 13.33). The mean mHHS was significantly improved at 12 weeks in the PRP group (74.05 ± 13.92) compared with the corticosteroid group (67.13 ± 16.04) ( P = .048). The proportion of participants who achieved an outcome score of ≥74 at 12 weeks was 17 of 37 (45.9%) in the corticosteroid group and 25 of 39 (64.1%) in the PRP group. The proportion of participants who achieved the MCID of more than 8 points at 12 weeks was 21 of 37 (56.7%) in the corticosteroid group and 32 of 39 (82%) in the PRP group ( P = .016).

CONCLUSION

Patients with chronic gluteal tendinopathy >4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. Registration: ACTRN12613000677707 (Australian New Zealand Clinical Trials Registry).

Greater trochanteric pain syndrome and gluteus medius and minimus tendinosis: nonsurgical treatment

Greater trochanteric pain syndrome (GTPS) affects 10–25% of people in developed countries. The underlying etiology for GTPS is most commonly the tendinosis or a tendon tear of the gluteus medius, minimus or both at the greater trochanter; the inflammation of the tendon is not a major feature. We critically evaluated conservative treatment, for which we reviewed 76 publications, grading them according to four levels of evidence. We identified a wide variety of conservative treatment options: home therapy (insoles, walking sticks/crutches, orthotic devices, stretching exercises and preventive measures); physiotherapy (massage and stretching exercises); infiltrations (corticosteroids and local anesthetics); image-guided infiltrations (fluoroscopy and ultrasound); shockwave therapy; platelet-rich plasma injection; and drug therapy. Severe complications associated with infiltrations are extremely rare, as are those associated with shockwave therapy. The most effective treatments were infiltrations with corticosteroids and shockwave therapy. We propose a graded treatment schedule for patients with GTPS.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part X: Sacroiliac Joint Syndrome

OBJECTIVE

To present an algorithm of sequential treatment options for managing sacroiliac joint (SIJ) pain in the setting of chronic low back pain (CLBP) in the older adult. This is the tenth part in a series, and includes an illustrative clinical case.

METHODS

The stepped care drug table and evaluation and treatment algorithm were created following a thorough literature review of approaches and subsequent analysis through a modified Delphi process. The principal investigator developed the initial draft, which was refined for content by an interdisciplinary panel of five experts. The refined materials were then assessed for the feasibility of implementation and validity of recommendations for older adults in a primary care setting by a panel of nine primary care providers. While not exclusive to Veteran's Health Administration (VHA) facilities, an emphasis was made to include resources and medications available to providers in the VHA.

RESULTS

The algorithm and drug table developed to systematically identify and address SIJ pain in the older adult is presented here. The process should begin with recognizing the presenting symptoms of CLBP stemming from the SI region, and supporting physical exam testing using the compression test and thigh thrust maneuver. Identification of the SIJ as a pain generator is followed by assessment and treatment of contributory factors. SIJ pain treatment should begin with education and self-management including exercise, and may escalate to include interventional procedures and/or referral to a pain rehabilitation program.

CONCLUSIONS

Pain originating from the SIJ is often under-recognized, but a structured and consistent approach can help identify older patients who would benefit from treatment of this contributor to CLBP.

KEY WORDS

Chronic Low Back Pain; Sacroiliac Joint Pain; Older Adults.

Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial

Study Design Prospective, randomized, partially blinded. Background Greater trochanteric pain syndrome (GTPS) is the current terminology for what was once called greater trochanteric or subgluteal bursitis. Cortisone (corticosteroid) injection into the lateral hip has traditionally been the accepted treatment for this condition; however, the effectiveness of injecting the bursa with steroids is increasingly being questioned. An equally effective treatment with fewer adverse side effects would be beneficial. Objective To investigate whether administration of dry needling (DN) is noninferior to cortisone injection in reducing lateral hip pain and improving function in patients with GTPS. Methods Forty-three participants (50 hips observed), all with GTPS, were randomly assigned to a group receiving cortisone injection or DN. Treatments were administered over 6 weeks, and clinical outcomes were collected at baseline and at 1, 3, and 6 weeks. The primary outcome measure was the numeric pain-rating scale (0-10). The secondary outcome measure was the Patient-Specific Functional Scale (0-10). Medication intake for pain was collected as a tertiary outcome. Results Baseline characteristics were similar between groups. A noninferiority test for a repeated-measures design for pain and averaged function scores at 6 weeks (with a noninferiority margin of 1.5 for both outcomes) indicated noninferiority of DN versus cortisone injection (both, P<.01). Medication usage (P = .74) was not different between groups at the same time point. No adverse side effects were reported. Conclusion Cortisone injections for GTPS did not provide greater pain relief or reduction in functional limitations than DN. Our data suggest that DN is a noninferior treatment alternative to cortisone injections in this patient population. Level of Evidence Therapy, level 1b. Registered December 2, 2015 at www.clinicaltrials.gov (NCT02639039). J Orthop Sports Phys Ther 2017;47(4):232-239. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6994.

Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study

QUESTION

What are the functional differences between people with greater trochanteric pain syndrome (GT), hip osteoarthritis (OA) or an asymptomatic population as measured by walking, Time Up and Go, single leg standing and strength?

DESIGN

Cross sectional study with blinded measurers.

PARTICIPANTS

38 participants with GT, 20 with end stage hip OA and 21 asymptomatic healthy control (AS) participants. All participants were women.

OUTCOME MEASURES

Pain (numeric rating scale), Walking speed (m/s), cadence (steps/min) and step length (m) measured via the 10m walk test and the Timed Up and Go; balance via single leg stance (s) duration; and hip abduction, adduction, medial and lateral rotation strength, standardized to body mass (BM) via the body mass average index (BMavg), measured via a wall mounted dynamometer.

RESULTS

The two symptomatic groups reported similar pain levels (p=0.226), more pain then the AS group (p<0.000). Compared to the AS participants, participants with GT or hip OA demonstrated lower walking speed (10mwt and TUG, p<0.001), lower cadence and shorter duration single leg stance on the affected leg (p<0.05). Participants with GT or hip OA also demonstrated bilaterally weaker hip abduction than the AS group (p≤0.005). Compared to AS and GT participants, participants with hip OA demonstrated adduction weakness on the affected side (p=0.008 and p=0.002 respectively).

CONCLUSION

There is a significant level of dysfunction and impairments associated with GT and hip OA. As activity limitations do not appear to be differentiated by structural impairments, we suggest that pain, rather than the underlying pathology may be the driving impairment that leads to walking and single leg standing dysfunction.

The outcome of endoscopy for recalcitrant greater trochanteric pain syndrome

INTRODUCTION

Greater trochanteric pain syndrome (GTPS), previously referred as trochanteric bursitis, is a debilitating condition characterised by chronic lateral hip pain. The syndrome is thought to relate to gluteal tendinopathy, with most cases responding to non-operative treatment. A number of open and endoscopic surgical techniques targeting the iliotibial band, trochanteric bursa and gluteal tendons have, however, been described for severe recalcitrant cases. We report the outcomes of one such endoscopic approach here.

MATERIALS AND METHODS

We retrospectively reviewed 49 patients (57 operations) who had undergone endoscopic longitudinal vertical iliotibial band release and trochanteric bursectomy. Inclusion criteria included diagnosed GTPS with a minimum of six months of non-operative treatment. Exclusion criteria included concomitant intra- or extra-articular hip pathology and previous hip surgery including total hip arthroplasty. Outcomes were assessed using the Visual Analogue Scale, Oxford hip Score and International Hip Outcome Tool (iHOT-33).

RESULTS

The series included 42 females and 7 males with a mean age of 65.0 years (26.7-88.6). Mean follow-up time was 20.7 months (5.3-41.2). Eight patients had full thickness gluteal tendon tears, of which 7 were repaired. Adjuvant PRP was injected intraoperatively in 38 of 57 operations (67.2 %). At follow-up, overall mean Visual Analogue Scale values had decreased from 7.8 to 2.8 (p < 0.001), Oxford hip Scores had increased from 20.4 to 37.3 (p < 0.001) and iHOT-33 scores had increased from 23.8 to 70.2 (p < 0.001). Of the 57 operations performed, patients reported feeling very satisfied with the surgical outcome in 28 operations (49.1 %), satisfied in 17 operations (29.8 %) and less than satisfied in 12 operations (21.1 %).

CONCLUSIONS

While the majority of patients with GTPS will improve with non-operative management, endoscopic iliotibial band release, trochanteric bursectomy and gluteal tendon repair is a safe and effective treatment for severe recalcitrant cases.

Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is common, resulting in significant pain and disability. There is no condition specific outcome score to evaluate the degree of severity of disability associated with GTPS in patients with this condition.

OBJECTIVE

To develop a reliable and valid outcome measurement capable of evaluating the severity of disability associated with GTPS.

METHODS

A phenomenological framework using in-depth semi structured interviews of patients and medical experts, and focus groups of physiotherapists was used in the item generation. Item and format clarification was undertaken via piloting. Multivariate analysis provided the basis for item reduction. The resultant VISA-G was tested for reliability with the inter class co-efficient (ICC), internal consistency (Cronbach's Alpha), and construct validity (correlation co-efficient) on 52 naïve participants with GTPS and 31 asymptomatic participants.

RESULTS

The resultant outcome measurement tool is consistent in style with existing tendinopathy outcome measurement tools, namely the suite of VISA scores. The VISA-G was found to be have a test-retest reliability of ICC2,1 (95% CI) of 0.827 (0.638-0.923). Internal consistency was high with a Cronbach's Alpha of 0.809. Construct validity was demonstrated: the VISA-G measures different constructs than tools previously used in assessing GTPS, the Harris Hip Score and the Oswestry Disability Index (Spearman Rho:0.020 and 0.0205 respectively). The VISA-G did not demonstrate any floor or ceiling effect in symptomatic participants.

CONCLUSION

The VISA-G is a reliable and valid score for measuring the severity of disability associated GTPS.

Trochanteric bursitis: the last great misnomer

Trochanteric bursitis has been used as a general term to describe pain around the greater trochanteric region of the hip. We hypothesised that trochanteric bursitis may not however have an inflammatory component and that accordingly, bursal inflammation has no role in lateral hip pain. This study was designed to test this hypothesis. Patients undergoing primary total hip replacement were enrolled in this prospective, case-controlled, blinded study. Twenty-five patients who met the criteria for diagnosis of trochanteric bursitis (group A) were matched with a control group of 25 patients (group B). Trochanteric bursal samples were harvested from all patients intraoperatively and sent for histological analysis for the presence of inflammation. The intraoperative appearance of the abductor tendon insertion was also noted. None of the samples showed any evidence of acute or chronic inflammatory changes. Intraoperatively, five patients (20%) in group A were noted to have thinning of the gluteus medius tendon but no macroscopic tendon tears were detected in any bursal samples. This study suggests that there is no inflammatory component to so-called trochanteric bursitis, which accordingly casts doubt on both the terminology and the existence of this condition as a separate clinical entity. Clinicians should search for an alternative cause of symptoms in such cases.

Evaluation and management of greater trochanter pain syndrome

Greater trochanteric pain syndrome is an enigmatic but common cause of lateral hip symptoms in middle-aged active women. The most common manifestation of this syndrome is a degenerative tendinopathy of the hip abductors similar to the intrinsic changes seen with rotator cuff pathology in the shoulder. There are no definitive tests to isolate the underlying pathology and palpation is a non-specific means by which to differentiate the source of the pain generator. The physical examination must comprehensively evaluate for a cluster of potential impairments and contributing factors that will need to be addressed to effectively manage the likely functional limitations and activity challenges the syndrome presents to the patient. Compressive forces through increased tension in the iliotibial band should be avoided. Intervention strategies should include education regarding postural avoidance, activity modifications, improvement of lumbopelvic control, and a patient approach to resolving hip joint restrictions and restoring the tensile capabilities of the deep rotators and abductors of the hip. A number of reliable and validated hip-specific self-report outcome tools are available to baseline a patient's status and monitor their progress. Further investigations to identify the epidemiological risk factors, establish effective treatment strategies, and predict prognosis are warranted.

Greater trochanter pain syndrome: a descriptive MR imaging study

OBJECTIVE

Greater trochanter pain syndrome (GTPS) is a diverse clinical entity caused by a variety of underlying conditions. We sought to explore the impact of (1) hip morphology, namely the center-edge angle (CEa) and femoral neck-shaft (NSa) angle, (2) hip abductor tendon degeneration, (3) the dimensions of peritrochanteric edema and (4) bursitis, on the presence of GTPS, using MR imaging.

MATERIALS AND METHODS

The presence of pain was prospectively assessed blindly by the senior author. CEa and NSa were blindly measured in 174 hip MR examinations, after completion of the clinical evaluation by another evaluator. The existence and dimensions of T2 hyperintensity of the peritrochanteric soft tissues, the existence and dimensions of bursae, as well as degeneration and tearing of gluteus tendons were also recorded.

RESULTS

Out of 174 examinations, 91 displayed peritrochanteric edema (group A) and 34 bursitis, all with peritrochanteric edema (group B). A number of 78 patients from both A and B groups, showed gluteus medius tendon degeneration and one tendon tear. CEa of groups A and B were 6° higher than those of normals (group C, P=0.0038). The mean age of normals was 16.6 years less than in group A and 19.8 years less than in group B (P<0.0001). Bursitis was associated with pain with a negative predictive value of 97% (P=0.0003).

CONCLUSION

Acetabular morphology is associated with GTPS and the absence of bursitis was proved to be clinically relevant. Peritrochanteric edema alone was not associated with local pain.

Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control study

Musculoskeletal injury causes pain and when chronic can affect mental health, employment and quality of life. This study examined work participation, function and quality of life in people with greater trochanteric pain syndrome (GTPS, n=42), severe hip osteoarthritis (OA, n=20) and an asymptomatic group (ASC, n=23). No differences were found between the symptomatic groups on key measures, both were more affected than the ASC group, they had lower quality of life score (p<0.001), Harris Hip Score (p<0.001) and higher Oswestry Disability Index (p<0.001). Participants with GTPS were the least likely to be in fulltime work (prob. GTPS=0.29; OA=0.52; and ASC=0.68). GTPS appears to confer levels of disability and quality of life similar to levels associated with end stage hip OA.

Greater trochanteric pain syndrome: does imaging-identified pathology influence the outcome of interventions?

AIM

To assess the outcomes for patients seen in a rheumatology service presenting with features of the greater trochanteric pain syndrome (GTPS) and the impact of imaging results on the outcomes of treatment.

METHODS

Retrospective audit, using a phone interview was performed to establish links between results of imaging undertaken in the diagnostic work-up of patients with lateral hip pain and clinical outcomes for these patients. Patient perceptions of the effectiveness of interventions were also assessed.

RESULTS

Forty-five patients were included (82% female, mean age 69.6 years). Sixty-nine percent underwent radiological work-up, including plain X-rays (55%), computed tomography scans (64%), magnetic resonance imaging (48%) and ultrasound (90%). Coexistent trochanteric bursitis (TB) and gluteal tendinopathy were the most commonly elucidated pathologies accounting for the symptomatic presentation of 40% of patients. Forty-one patients underwent some form of intervention, most commonly injection of local anesthetic and corticosteroid (LACS) into the region of the TB (87%), two-thirds of which were undertaken under radiological guidance. Pain reduction was maximal following the third injection, with a significantly better response to unguided interventions and levels of symptomatic relief following the first injection being a good indicator of the probability of complete remission. Radiological demonstration of isolated TB correlated with a greater reduction in lateral hip symptoms following LACS TB injections both in the immediate post-injection phase and in the long-term.

CONCLUSION

The results of this audit suggest that the management of GTPS has reasonable patient outcomes; however, a prospective study with greater patient numbers is needed to confirm these results.

Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: greater trochanter bursa versus subgluteus medius bursa

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of corticosteroid injections into the greater trochanteric bursa as opposed to the subgluteus medius bursa in patients with greater trochanteric pain syndrome.

MATERIALS AND METHODS

We retrospectively reviewed 183 injections (149 performed in women, 34 performed in men; age range 23-90 years; median, 53 years) performed for treatment of greater trochanteric pain syndrome. A 10-cm visual analog scale survey was used to assess pain level before the procedure and 14 days after the procedure. A 3-mL corticosteroid solution was injected into either the greater trochanteric bursa or the subgluteus medius bursa under direct ultrasound guidance. Procedure images were retrospectively reviewed to determine the site of injection. Diagnostic images obtained at the time of the procedure were also reviewed for findings of tendinopathy, bursitis, and enthesopathy. Statistical analysis of differences in pain reduction was performed, as was analysis for association between pain relief and demographic variables of age, sex, previous injections, and ultrasound findings.

RESULTS

Sixty-five injections met the inclusion criteria; 56 performed in women and nine performed in men (age range, 30-82 years; median, 53 years). Forty-one injections were into the greater trochanteric bursa and 24 into the subgluteus medius bursa. There was a statistically significant difference in pain reduction between greater trochanteric bursa and subgluteus medius bursa injections with a median pain reduction of 3 as opposed to 0 (p < 0.01). There was no statistically significant association between pain relief and demographic variables or ultrasound findings.

CONCLUSION

Corticosteroid injections into the greater trochanteric bursa may be more effective than injections into the subgluteus medius bursa for treatment of greater trochanteric pain syndrome.

Trochanteric area pain, the result of a quartet of bursal inflammation

Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients’ use of the term “hip” can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of “hip” pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.

Management of the greater trochanteric pain syndrome: a systematic review

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter.

SOURCE OF DATA

We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected.

AREAS OF AGREEMENT

Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months.

AREAS OF CONTROVERSY

Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS.

GROWING POINTS

Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS.

CONCLUSION

The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

The relationship of femoral neck shaft angle and adiposity to greater trochanteric pain syndrome in women. A case control morphology and anthropometric study

Objective

To evaluate if pelvic or hip width predisposed women to developing greater trochanteric pain syndrome (GTPS).

Design

Prospective case control study.

Participants

Four groups were included in the study: those gluteal tendon reconstructions (n=31, GTR), those with conservatively managed GTPS (n=29), those with hip osteoarthritis (n=20, OA) and 22 asymptomatic participants (ASC).

Methods

Anterior-posterior pelvic x-rays were evaluated for femoral neck shaft angle; acetabular index, and width at the lateral acetabulum, and the superior and lateral aspects of the greater trochanter. Body mass index, and waist, hip and greater trochanter girth were measured. Data were analysed using a one-way analysis of variance (ANOVA; posthoc Scheffe analysis), then multivariate analysis.

Results

The GTR group had a lower femoral neck shaft angle than the other groups (p=0.007). The OR (95% CI) of having a neck shaft angle of less than 134°, relative to the ASC group: GTR=3.33 (1.26 to 8.85); GTPS=1.4 (0.52 to 3.75); OA=0.85 (0.28 to 2.61). The OR of GTR relative to GTPS was 2.4 (1.01 to 5.6). No group difference was found for acetabular or greater trochanter width. Greater trochanter girth produced the only anthropometric group difference (mean (95% CI) in cm) GTR=103.8 (100.3 to 107.3), GTPS=105.9 (100.2 to 111.6), OA=100.3 (97.7 to 103.9), ASC=99.1 (94.7 to 103.5), (ANOVA: p=0.036). Multivariate analysis confirmed adiposity is associated with GTPS.

Conclusion

A lower neck shaft angle is a risk factor for, and adiposity is associated with, GTPS in women.

Efficacy of treatment of trochanteric bursitis: a systematic review

OBJECTIVE

Trochanteric bursitis (TB) is a self-limiting disorder in the majority of patients and typically responds to conservative measures. However, multiple courses of nonoperative treatment or surgical intervention may be necessary in refractory cases. The purpose of this systematic review was to evaluate the efficacy of the treatment of TB.

DATA SOURCES

A literature search in the PubMed, MEDLINE, CINAHL, and ISI Web of Knowledge databases was performed for all English language studies up to April 2010. Terms combined in a Boolean search were greater trochanteric pain syndrome, trochanteric bursitis, trochanteric, bursitis, surgery, therapy, drug therapy, physical therapy, rehabilitation, injection, Z-plasty, Z-lengthening, aspiration, bursectomy, bursoscopy, osteotomy, and tendon repair.

STUDY SELECTION

All studies directly involving the treatment of TB were reviewed by 2 authors and selected for further analysis. Expert opinion and review articles were excluded, as well as case series with fewer than 5 patients. Twenty-four articles were identified. According to the system described by Wright et al, 2 studies, each with multiple arms, qualified as level I evidence, 1 as level II, 1 as level III, and the rest as level IV. More than 950 cases were included.

DATA EXTRACTION

The authors extracted data regarding the type of intervention, level of evidence, mean age of patients, patient gender, number of hips in the study, symptom duration before the study, mean number of injections before the study, prior hip surgeries, patient satisfaction, length of follow-up, baseline scores, and follow-up scores for the visual analog scale (VAS) and Harris Hip Scores (HHS).

DATA SYNTHESIS

Symptom resolution and the ability to return to activity ranged from 49% to 100% with corticosteroid injection as the primary treatment modality with and without multimodal conservative therapy. Two comparative studies (levels II and III) found low-energy shock-wave therapy (SWT) to be superior to other nonoperative modalities. Multiple surgical options for persistent TB have been reported, including bursectomy (n = 2), longitudinal release of the iliotibial band (n = 2), proximal or distal Z-plasty (n = 4), osteotomy (n = 1), and repair of gluteus medius tears (n = 4).

CONCLUSIONS

Efficacy among surgical techniques varied depending on the clinical outcome measure, but all were superior to corticosteroid therapy and physical therapy according to the VAS and HHS in both comparison studies and between studies. This systematic review found that traditional nonoperative treatment helped most patients, SWT was a good alternative, and surgery was effective in refractory cases.

Soft tissue pathology around the hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Four common types of bursitis: diagnosis and management

Bursitis is a common cause of musculoskeletal pain and often prompts orthopaedic consultation. Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology. Common types of bursitis include prepatellar, olecranon, trochanteric, and retrocalcaneal. Most patients respond to nonsurgical management, including ice, activity modification, and nonsteroidal anti-inflammatory drugs. In cases of septic bursitis, oral antibiotics may be administered. Local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis; however, steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon. Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis.

Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care

PURPOSE

We undertook a study to evaluate the effectiveness of corticosteroid injections in primary care patients with greater trochanteric pain syndrome (GTPS).

METHODS

We evaluated the effect of corticosteroid injections compared with expectant treatment (usual care) in a pragmatic, multicenter, open-label, randomized clinical trial in the Netherlands. Patients (aged 18 to 80 years) with GTPS visiting 81 participating primary care physicians were randomly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). Primary outcomes of pain severity (numerical rating scale 0 to 10) and recovery (yes or no total or major recovery) were evaluated at 3-month and 12-month follow-up visits. Adverse events were collected at 6 weeks.

RESULTS

At the 3-month follow-up visit, 34% of the patients in the usual care group had recovered compared with 55% in the injection group (adjusted OR = 2.38; 95% CI, 1.14-5.00, number needed to treat = 5). Pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 (95% CI, 0.31-2.05) and in pain with activity of 1.30 (95% CI, 0.32-2.29). At the 12-month follow-up, 60% of the patients in the usual care group had recovered compared with 61% in the injection group (OR = 1.05; 95% CI, 0.50-2.27). Pain severity at rest and on activity decreased in both groups and the 12-month follow-up showed no significant differences, with adjusted differences of 0.14 (95% CI, -0.75 to 1.04) for pain at rest and 0.45 (95% CI, -0.55 to 1.46) for pain with activity. Aside from a short period with superficial pain at the site of the injection, no differences in adverse events were found.

CONCLUSION

In this first randomized controlled trial assessing the effectiveness of corticosteroid injections vs usual care in GTPS, a clinically relevant effect was shown at a 3-month follow-up visit for recovery and for pain at rest and with activity. At a 12-month follow-up visit, the differences in outcome were no longer present.

Greater trochanteric pain syndrome

Originally defined as "tenderness to palpation over the greater trochanter with the patient in the side-lying position," greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans.

Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study

BACKGROUND

Greater trochanteric pain syndrome can be severely debilitating. Ideal imaging modalities are not established, treatments are not reliably evaluated, and the underlying pathology is not well understood.

QUESTIONS/PURPOSES

Using surgical and histopathology findings as a gold standard, we therefore determined the positive predictive value of preoperative ultrasound assessment for greater trochanteric pain syndrome recalcitrant to nonoperative management. In addition, we report the outcomes of gluteal tendon reconstructive surgery using validated clinical and functional outcome tools and evaluate the contribution of the tendon and bursa to greater trochanteric pain syndrome.

PATIENTS AND METHODS

We reviewed 24 patients who had combined gluteal tendon reconstruction and bursectomy. Preoperative ultrasound imaging was compared with surgical findings. In the absence of a greater trochanteric pain syndrome specific outcome tool, surgical outcomes for pain and function were assessed via a 100-mm visual analog scale, the modified Harris hip score, and the Oswestry Disability Index. Strength also was measured. The tendon and bursa tissue collected at surgery was histopathologically reviewed.

RESULTS

In our small study, ultrasound had a high positive predictive value for gluteal tendon tears (positive predictive value = 1.0). Patients reported high levels of pain relief and function after surgery; tendon and bursa showed pathologic changes.

CONCLUSIONS

Ultrasound appears to be clinically useful in greater trochanteric pain syndrome; reconstructive surgery seems to relieve pain and the histopathologic findings show tendinopathy and bursa pathology coexist in greater trochanteric pain syndrome.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment

We examined the efficacy of corticosteroid injection as treatment for postarthroplasty trochanteric bursitis and the risk factors for failure of nonoperative treatment. There were 32 (4.6%) cases of postsurgical trochanteric bursitis in 689 primary total hip arthroplasties. Of the 25 hips with follow-up, 11 (45%) required multiple injections. Symptoms resolved in 20 (80%) but persisted in 5. We found no statistically significant differences between patients who did and did not develop trochanteric bursitis, or between those who did and did not respond to treatment. There was a trend toward younger age and greater limb-length discrepancy in nonresponders. In conclusion, (1) corticosteroid injection(s) for postoperative trochanteric bursitis is effective; and (2) nonoperative management may be more likely to fail in young patients and those with leg-length discrepancy.

Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome

BACKGROUND

There are no controlled studies testing the efficacy of various nonoperative strategies for treatment of greater trochanter pain syndrome. Hypothesis The null hypothesis was that local corticosteroid injection, home training, and repetitive low-energy shock wave therapy produce equivalent outcomes 4 months from baseline.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

Two hundred twenty-nine patients with refractory unilateral greater trochanter pain syndrome were assigned sequentially to a home training program, a single local corticosteroid injection (25 mg prednisolone), or a repetitive low-energy radial shock wave treatment. Subjects underwent outcome assessments at baseline and at 1, 4, and 15 months. Primary outcome measures were degree of recovery, measured on a 6-point Likert scale (subjects with rating completely recovered or much improved were rated as treatment success), and severity of pain over the past week (0-10 points) at 4-month follow-up.

RESULTS

One month from baseline, results after corticosteroid injection (success rate, 75%; pain rating, 2.2 points) were significantly better than those after home training (7%; 5.9 points) or shock wave therapy (13%; 5.6 points). Regarding treatment success at 4 months, radial shock wave therapy led to significantly better results (68%; 3.1 points) than did home training (41%; 5.2 points) and corticosteroid injection (51%; 4.5 points). The null hypothesis was rejected. Fifteen months from baseline, radial shock wave therapy (74%; 2.4 points) and home training (80%; 2.7 points) were significantly more successful than was corticosteroid injection (48%; 5.3 points).

CONCLUSION

The role of corticosteroid injection for greater trochanter pain syndrome needs to be reconsidered. Subjects should be properly informed about the advantages and disadvantages of the treatment options, including the economic burden. The significant short-term superiority of a single corticosteroid injection over home training and shock wave therapy declined after 1 month. Both corticosteroid injection and home training were significantly less successful than was shock wave therapy at 4-month follow-up. Corticosteroid injection was significantly less successful than was home training or shock wave therapy at 15-month follow-up.

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.

Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome

BACKGROUND

Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.

HYPOTHESIS

Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm(2); total energy flux density, 360 mJ/mm(2)). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.

RESULTS

Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for greater trochanteric pain syndrome.