Trochanteric bursitis
Greater trochanteric pain syndrome

Ultrasound guided trochanteric bursa steroid injection

What is hip trochanteric bursitis (greater trochanteric pain syndrome)?

Trochanteric bursitis injection is a common indication for ultrasound-guided steroid injections in our practice. The condition is characterized by a pain sensation on the outside of the hip. The pain is usually located next to a bony prominence at the outer aspect of the hip (called the greater trochanter), hence the condition's name.

Relevant anatomy

The greater trochanter is a bony prominence at the side of the hip. It is part of the femur (the long thigh bone) and attaches to two important tendons, the gluteus medius and gluteus minimus. These muscles play an important role in hip joint stability. There is a third gluteal muscle (called the gluteus maximus). This is the largest of the three and lies on top of the other two muscles. The trochanteric bursa lies between the gluteus medius and minimus tendons and the gluteus maximus muscle. A bursa is a thin fluid-containing sac usually seen adjacent to a bone to provide cushioning effect and protection. We have a few of these within our body (like in the shoulder and the hip).

Trochanteric pain syndrome is common in up to 25% of the population. It results from inflammation of the gluteal tendons at their attachment to the greater trochanter, a condition called "gluteal tendinosis". Often, there is associated inflammation of the overlying trochanteric bursa, termed "trochanteric bursitis". Ultrasound assessment is very useful in assessing the anatomical structures in this area, including the gluteal tendons and the trochanteric bursa, to decide about the best management options.

The diagram demonstrates the normal anatomy of the gluteal muscles from the back

Risk factors for developing trochanteric bursitis include:

- Age and Gender: the condition is more common in women above the age of 40.

-Gluteal muscle weakness – The gluteus medius and minimus muscles are referred to as the "hip abductors" and play an important role in hip joint stability and movement. Weakness of these muscles results in altered biomechanics and increases the stress on the hip joint and the adjacent tendons.

- Incorrect prolonged postures – for example, prolonged hip hitching.

-Increased body weight/high Body Mass Index (BMI).

- Direct injury to the outside of the hip.

What are the cause of trochanteric pain syndrome?

The anatomical structures that can be involved in Trochanteric pain syndrome include:

The gluteal tendons- Evidence shows that gluteal tendons inflammation is the most likely cause of pain in this area. The tendons can get inflamed and irritated if they are exposed to increased stress. This is referred to as gluteal tendonitis. Repeated tendon inflammation will interfere with tendon healing and recovery, resulting in a thickened and unhealthy tendon. This is referred to as gluteal tendinopathy. In more advanced cases, there could be a tear to the gluteal tendon attachment. An ultrasound will be very useful in establishing the diagnosis and assessing the integrity of the gluteal tendons.
The bursa- Associated inflammation and thickening of the overlying trochanteric bursa can also be seen in this condition. This is referred to as "trochanteric bursitis". For many years, this was thought to be the primary cause of this condition. However, newer evidence shows that bursitis is most likely to happen secondary to the inflammation of the gluteal tendons, which is most likely the primary cause.

How do you know if you have greater trochanteric pain syndrome?

The main symptoms of trochanteric bursitis are:

Pain at the outside of the hip. The pain is usually gradual and felt intermittently at the beginning. As the condition progresses, the pain will become more frequent.
There could be a history of direct trauma to the area.
The pain can be more severe after prolonged activities (like running), lying down on the affected side, and crossing the legs.
The pain can affect your posture and balance on the affected leg.

What other hip conditions can mimic hip bursitis?

Other conditions that can be mistaken for hip bursitis include:

Greater trochanteric pain syndrome vs hip osteoarthritis

In hip osteoarthritis, the pain is usually felt at the front of the hip or in the groin region. In contrast, in hip (trochanteric) bursitis, the pain is felt at the outside of the hip and can extend down the thigh. The hip bursitis pain usually gets worse when lying on the affected side. To find out more, please see our article about Hip osteoarthritis.

Greater trochanteric pain syndrome vs Femoracetabular impingement

In femoracetabular impingement, the pain is usually felt at the front of the hip or in the groin region. The condition tends to affect the younger population, and it is usually seen secondary to variation in the hip anatomy. The pain is usually worse on hip flexion (bringing the knee towards the chest). In contrast, in hip (trochanteric) bursitis, the pain is felt at the outside of the hip and can extend down the thigh. The hip bursitis pain usually gets worse when lying on the affected side. To find out more, please see our article Femoracetabular impingement.

How to diagnose trochanteric pain syndrome?

Usually, the condition is suspected clinically, but imaging is required to confirm the diagnosis and assess the severity of the condition. Ultrasound is an excellent modality to assess the gluteal tendons and the bursa for any inflammation. It is very useful in ruling out the presence of gluteal tendon tears, which can be seen in advanced cases. Ultrasound can also be used to perform a dynamic assessment of the gluteal tendons, which is useful when there is hip snapping. Ultrasound guidance is extremely useful when performing a steroid injection into the trochanteric bursa. Plenty of evidence shows that injections done under ultrasound guidance result in better outcomes, with better pain relief and improved function. A hip X-ray will provide useful information about the hip joint itself, but it will not assess the gluteal tendons. A hip MRI examination would be very useful for the assessment, especially if the ultrasound findings are inconclusive.

What is the treatment for trochanteric bursitis?

Management of greater trochanteric pain syndrome usually starts with a physiotherapy exercise program aimed to strengthen the hip muscles along with activity modification and patient education to reduce the stress upon the gluteal tendons. Anti-inflammatory tablets or topical treatments like creams can be also useful but you need to consult your GP before starting such medicines.

If the pain has not responded to physiotherapy and it is severe, interfering with sleep or daily activities, then an ultrasound-guided treatment option can be considered

What are the available injection treatments for greater trochanteric pain syndrome?

There are mainly two injection treatment options with good evidence in managing greater trochanteric pain syndrome.

Ultrasound-guided steroid injection. This usually provides rapid pain relief by reducing the inflammatory changes within the bursa. Corticosteroid (cortisone) is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis and tendinosis). A cortisone injection will reduce the inflammation in the injected area (like the hip joint or the trochanteric bursa) and allow you to manage the condition, usually by undergoing a physiotherapy program. To learn more, please read our article Steroid injections around the hip.
Platelets-rich plasma (PRP) injections and tendon fenestration of the gluteal tendons. In PRP injection, a blood sample is taken from the patient's vein and put in a special centrifuge machine to separate its different components. The layer on top is called “the plasma”, which contains platelets and other useful growth factors. This is injected into the tendon under ultrasound guidance to help stimulate healing. Please see our PRP injections article for more details. In tendon fenestration/tenotomy, a small needle is used to fenestrate the inflamed tendon multiple times under ultrasound guidance. Evidence shows that his process results in micro injury and the release of certain factors that help in tendon healing.

Should trochanteric bursa injections be done under ultrasound guidance?

Yes. This is our routine practice as there is plenty of evidence supporting the use of ultrasound guidance in Injection Hip Bursitis when performing musculoskeletal injections. Doing injections under ultrasound/imaging guidance allows for direct visualization of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint, or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes, compared to doing these injections without guidance. Ultrasound guidance ensures the avoidance of any sensitive structures (like nerves and vessels) during the procedure.

What are the possible side effects of a steroid injection?

Yes, generally these injections are very safe and routinely done in our practice. There is a very small risk of infection (about 1:10.000). The procedure will be explained to you in detail during your appointment and all your questions will be addressed. To find out more about cortisone injections in general, please see our FAQs.

How long will the effect of a hip bursa cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. The injections usually also contain a local anaesthetic that provides immediate pain relief lasting a few hours.

How soon will a steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. More commonly, the injected area will feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection.

How many trochanteric bursa steroid injections can I have?

We advise reducing the number of cortisone hip bursitis injection if possible, by combining any injection therapy with an effective physiotherapy program to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.

How long should I rest after a trochanteric bursa injection?

Usually, we advise patients to rest for 48-72 hours after having a hip bursa injection. This can vary depending on the type of treatment and severity of the condition. Usually, patients who have a trochanteric bursa corticosteroid injection are usually advised to rest for 48 hours, while patients who had a more advanced procedure like PRP injection into the gluteal tendons may be advised to rest for 5-7 days.