Trochanteric syndrome is an important cause of lateral hip pain. Injection in to the trochanteric area can be of diagnostic benefit and therapeutic value in patients with lateral hip pain. Ultrasound enables us to target the appropriate bursae or the gluteal tendons, as may be the case. Pulsed radiofrequency treatment or cryotherapy can be used for sustained pain relief in patients who get a positive response to the initial injection. However it is important to note that in some cases injection treatment may not provide the desired results or the pain relief may not be sustained. At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs trochanteric bursa injections under ultrasound guidance for greater accuracy and improved safety. Ultrasound gives the added advantage of targeting the surrounding tendons and muscles, which can be contributory to pain.
At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs trochanteric bursa injections under ultrasound guidance for greater accuracy and improved safety. Ultrasound gives the added advantage of targeting the surrounding tendons and muscles, which can be contributory to pain.
The term ‘greater trochanteric pain syndrome’ (GPTS) may better characterize the condition because pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh, may be associated with myriad other causes such as tendinitis, muscle tears, trigger points, iliotibial band disorders (ITB), and general or localized pathology in surrounding tissues. GTPS, which to some extent has already replaced trochanteric bursitis as the most frequent designator for chronic lateral hip pain in light of the inherent difficulties in elucidating the true etiology of symptoms, can most accurately be described as a regional pain syndrome that often mimics pain generated from other sources, including, but not limited to, myofascial pain, degenerative joint disease, and spinal pathology.
Bursae are fluid-filled sacs that provide cushioning between bony prominences and the surrounding soft tissues. Overlying the lateral aspect of the greater femoral trochanter, the trochanteric bursae are commonly implicated as a cause of lateral hip pain. Four bursae have been consistently described outside the greater trochanter, with three being present in most individuals. These bursae serve to provide cushioning for the gluteus tendons, ITB and tensor fascia latae.
The gluteus minimus bursa is a minor bursa located cephalad and ventral to the greater trochanter. The two major bursae are the subgluteus maximus and subgluteus medius bursae. The subgluteus maximus bursa is located lateral to the greater trochanter, juxtaposed between the gluteus medius tendon and the gluteus maximus muscle. This largest of the greater trochanteric bursae is most frequently incriminated in GTPS.
Greater trochanteric pain syndrome typically presents as chronic, persistent pain in the lateral hip and/or buttock that is exacerbated by lying on the affected side, with prolonged standing or transitioning to a standing position, sitting with the affected leg crossed and with climbing stairs, running or other high impact activities. Approximately, 50% of patients experience pain radiating along the lateral aspect of the thigh to the knee, and occasionally below the knee. Invariably, there is tenderness along the lateral or posterior aspect of the greater trochanter. Pain extending to the groin or down the lateral thigh that mimics lumbar disc herniation (i.e pseudoradiculopathy) may be reported by some individuals. Pain radiation patterns may complicate the diagnosis of GTPS because of anatomical overlap with the iliotibial tract and mid-lumbar dermatomes (L2–4). Not only nerve roots, but radiation patterns from other structures in the lumbar spine, including the facet joints, sacroiliac joint, and intervertebral discs and ligaments, can replicate trochanteric bursitis/ GTPS.
The physical examination in trochanteric bursitis/ GTPS characteristically reveals point tenderness (“jump sign”) in the posterolateral area of the greater trochanter. Typically, this will be at either the site of the gluteus medius tendon insertion or in a more cephalad position overlying the insertion of the gluteus minimus tendon on a ridge lateral to the anterior triangular area of the greater trochanter.
Pain reproduction can be accomplished by active resistance to abduction and external rotation, and sometimes by internal rotation. Rarely is pain reproduced by hip extension. In contrast, intraarticular hip disease is frequently characterized by pain elicited with flexion and extension of the hip.
Causes of lateral hip pain, such as ITB syndrome and meralgia paresthetica can be differentiated from trochanteric bursitis by physical examination signs, such as a positive Ober’s test and sensory deficits, respectively. Apart from point tenderness at the lateral hip, there are a paucity of signs with high specificity for GTPS.
When conservative treatments fail, bursa or lateral hip injections performed with corticosteroid and local anesthetics have been shown to provide pain relief, with response rates ranging from 60% to 100%. Although there are no placebo-controlled trials evaluating the efficacy of corticosteroid injection therapy, several prospective studies have been published.
Diagnostic local anesthetic injections into the trochanteric bursa can potentially be helpful when the diagnosis is uncertain.
Corticosteroids are often injected into the bursa when other conservative measures are unsuccessful.
Injections are generally avoided in patients with systemic infection or skin infection over puncture site, bleeding disorders or coagulopathy, allergy to local anaesthetics or any of the medications to be administered.
The procedure is usually done on an outpatient basis. Trochanteric bursa injection is performed under ultrasound guidance to ensure accuracy of needle placement. Patients need to be aware that the outcome of the procedure is variable and they may not receive the desired benefits. Similarly, they must be aware of the transient nature of the therapeutic benefits and that there may need repeated injections.
Generally a mixture of local anaesthetic and steroid is injected. The local anaesthetic agent within the injectate may act on the nociceptive fibres , whereas corticosteroids may reduce inflammation. The anaesthetic is probably responsible for immediate pain relief, whereas steroids are believed to be responsible for pain relief 2–6 days after their administration.
Complications are rare, particularly if the injections are performed using a precise needle-positioning technique. Possible complications include bruising, infection, hematoma, nerve injury and reaction to the injectates. Infection can be avoided with appropriate aseptic precautions. Severe allergic reactions to local anaesthetics are uncommon. Steroid injections may produce local reactions, occurring most often immediately after injection. These local reactions last for 24 to 48 hours, and are relieved by application of ice packs. Post-procedural pain flare-up may occasionally occur, and may be treated with pain killers. Neurological complications including paraesthesias and numbness have been described but are extremely rare.