This is something that once I found out about it I started diagnosing it with great enthusiasm, sometimes beyond what the patients presentation could really support.
We see lots of patients with MSK pain, pain here, pain there, pain everywhere. We love it when there’s an antecedent injury cause then we can easily call it a soft tissue injury when the xray’s normal and be done with it. (of course it’s much more complicated than that but we at least feel we can get away with that on a cognitive level)
However, the pressure is really on when the joint is sore and there’s nothing wrong on the xray… We really should have something sensible to say.
The pressure is really on when it’s something like the hip – these big joints cause significant mobility issues and patients who were coping with their ADLs just fine are suddenly starting down an acute admission unless we can diagnose and provide management.
All this to say I’ve recently rediscovered my love of joint and soft tissue injections. No doubt there’s some placebo involved here but it really does seem to do the job.
Let’s look at the hip. And no, i’m not injecting hip joints (yet…) but I will inject the lateral hip at the greater trochanter (with ultrasound of course, not that you need it but ultrasound makes everything more fun…)
Some learning points for me
- It’s actually not called trochanteric bursitis any more. No one bothered to tell me but turns out that a lot of the time it’s not bursitis but a tendinopathy or any number of pain generating structures. While bursitis as a concept is beautiful in its explanatory prowess it turns out it’s more complicated than that.
- It’s now called greater trochanteric pain syndrome. Which is much less sexy but reflects the fact that it’s actually rarely a busitis and more of a tendon problem
- The main muscles involved are gluteus minimus and medius
- these are hip ABductors and are vital in pelvic tilting when standing on one leg and normal gait (do you remember Trendelenburg’s test…)
- there are no clear published diagnostic criteria and what you were already doing to diagnose “trochanteric bursitis” is probably still true here (below adapted from UpToDate)
- lateral hip pain
- pain on palpation lateral hip
- pain on lying on that side
- The common site of tenderness is a little more superior and posterior than you might think – so just above and behind the palpable greater trochanter
- To distinguish it from joint pain the key thing seems to be pain on active versus pain on passive movement. Pain with passive movement as you range the hip joint is more suggestive of hip joint pathology whereas pain on active movement is more suggestive of soft tissue involvement. This is not a firm rule by any means
- paracetamol/NSAIDs as usual
- exercise, UpToDate suggests pool walking, not walking on water but in it… walking against the resistance is thought to be helpful
- injections are commonly recommended and fairly straightforward and can be done blindly or with ultrasound. I’ve been doing with an in plane technique in the longitudinal plane as shown in the video below.