Greater Trochanteric Bursa Injection

Anne Boyd, MD and Scott Wissink, MD
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Subject: Greater Trochanteric Bursa Injection

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Introduction

Several bursae surround the greater trochanter of the femur. Two bursae that lie between the gluteus maximus muscle and the greater trochanter are thought to be of greatest clinical significance. The superficial bursa is immediately beneath the gluteus maximus over the lateral surface of the greater trochanter. Beneath the superficial bursa, is the appropriately named deep bursa. The deep bursa is larger and blankets the “cuff” of tissue around the greater trochanter formed by the attachment of the gluteus medius (posteriorly), gluteus minimus (anterolaterally), and vastus lateralis (anteriorly). 
Although the term bursitis suggests that the primary pathology is inflammation at one or more of the peritrochanteric bursae, recent magnetic resonance imaging (MRI) evidence indicates that the majority of patients with clinical findings consistent with the diagnosis of trochanteric bursitis have tendinosis, or a partial or complete tear of the gluteus medius or minimus as their primary pathology, not trochanteric bursae inflammation. Current theory holds that gluteal tendinosis induces muscle atrophy, femoral head subluxation, and bursitis in the contiguous bursae and that subsequent impingement of the distended bursae results in painful range of motion. Regardless of the associated pathology, injection at the trochanter is often successful in treating symptoms. Most (61%) patients report improvement at 6 months following trochanteric bursa injection. 
Leg length discrepancy, tight iliotibial band, arthritis of the hip, obesity, and lumbar spondylosis may be predisposing factors for the development of trochanteric bursitis. Once lumbar spine, hip, and other pathology have been excluded, the clinical presentation is usually sufficient to make a presumptive diagnosis. Patients complain of localized, lateral hip pain that is often worse when lying on the affected side at night. On examination, there is focal tenderness to palpation, and occasionally swelling, at the greater trochanter. 
The differential diagnosis of hip pain includes osteoarthritis of the hip, iliotibial band syndrome, and adductor tendenopathy. 

Equipment

  • Syringe, 10 mL.

  • Needle (22–25 gauge, 1.5 inches) on a 10-mL syringe (consider a longer needle for the obese patient).

  • Methylprednisolone acetate (40 mg Depo-Medrol; 1 mL if 40 mg/mL). One mL of 40 mg/mL triamcinolone acetonide (Kenalog) is a reasonable alternative to Depo-Medrol but may carry a higher risk of atrophy than Depo-Medrol.

  • 1% lidocaine (5 mL) without epinephrine.

  • Consult the ordering information that appears in Appendix I. Needles, syringes, and corticosteroid preparations may be ordered from surgical supply houses or local pharmacies. A suggested tray for performing soft tissue aspirations and injections is listed in Appendix I. Skin preparation recommendations appear in Appendix E.

Indications

  • Symptomatic discomfort at the greater trochanter of the hip

Contraindications

  • Drug allergy to injectable materials

  • Infection: septic arthritis, bacteremia, or cellulitis at the injection site

  • Minimal relief after prior injections (relative)

  • Underlying coagulopathy or uncontrolled anticoagulation (relative)

  • Uncontrolled diabetes (relative)

  • Joint prosthesis (scarring changes anatomy; foreign body increases risk for infectious complications) (relative)

The Procedure

Step 1

After informed consent is obtained, hands are washed, materials are prepared, and gloves are applied. Position the patient in the lateral recumbent position with the affected side up. 

Step 2

Identify the point of maximal tenderness, and mark the site with a pressure mark from a needle cap, pen, or fingernail. 

Step 3

Swab the patient’s skin with povidone-iodine, chlorhexidine solution, or 70% ethanol. (See Appendix E.) Do not touch the injection site after swabbing. 

Step 4

Insert the needle perpendicular to the skin and advance until the needle tip touches the bone. Withdraw the needle 2 to 3 mm, then aspirate and inject the steroid and lidocaine mixture. Have patient rest in the office for 20 to 30 minutes postinjection to ensure the patient tolerates the procedure and to review postprocedure instructions. 
  • PEARL: Maximal tenderness is often found at the muscle insertions along the superior and posterior borders of the greater trochanter. This may require larger injection volumes and/or a fanned technique to disperse the medication to the deep bursae, which superficially blankets the tendons described previously.

  • PITFALL: Long-acting, low-solubility, fluorinated glucocorticoids (such as triamcinolone hexacetonide [Aristospan]) are considered inappropriate for soft tissue injections by some authors because of a higher risk of tissue atrophy. Triamcinolone acetonide (Kenalog) is a fluorinated triamcinolone, but solubility is intermediate to high. This makes Kenalog a reasonable alternative for this procedure but it may carry a higher risk of tissue atrophy than methylprednisolone.

Complications

Local Effects

  • Local infection (reported incidence range 1:3,000 to 1:50,000).

  • Local reactions (swelling, tenderness, and warmth for up to 2 days).

  • Steroid flare (1% to 10%; crystal-induced synovitis within 24 to 48 hours).

  • Fat atrophy (especially at superficial soft tissue sites; worse with triamcinolone because it is less soluble and is fluorinated).

  • Damage to local cartilage or nerves.

Systemic Effects

  • Facial flushing (<15% of patients; within hours; lasts <3 or 4 days; women)

  • Adrenal suppression (usually mild and transient; worse with stress)

  • Transient increase in glucose

Pediatric Considerations

Trochanteric bursitis is rarely seen in children. 

Postprocedure Instructions

Cover the injection site with a bandage. Ask the patient to gently move the area to spread the injected fluid. Advice about rest and timing between repeat injections is variable. Generally, avoiding aggravating activities for 24 hours is sufficient in this situation. Although evidence-based studies are lacking, general recommendations advise a respite of 6 weeks between injections and no more than three to four injections into the same region within a given year. 

Coding Information and Supply Sources

ICD-9 Code

Trochanteric bursitis 726.5 

Bibliography

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Bird PA, Oakley SP, Shnier R, et al. Prospective evaluation of MRI and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138–2145. [View Abstract]
Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the hip and knee. Amer Fam Phys.  2003;67(10):2147–2152. [View Abstract]
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Ines L. Soft tissue injections. Best Pract Res Clin Rheum.  2005;19(3):503–527. [View Abstract]
Kingzett-Taylor A, Tirmal PF, Feller J, et al. Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. Am J Roentgenol.  1999;173:1123–1126. [View Abstract]
Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract.March 2005:199–204.
Oakley SP, Bird P, Kirkham BW. Gluteus medius tears presenting as the clinical syndrome of trochanteric bursitis (abstract). Arthritis Rheum. 1999;42(Suppl 9):S340.
Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc.  1996;71:565–569. [View Abstract]
Walker P, Kannangara S, et al. Lateral hip pain. Clin Orthop Relat Res.  2007;Apr;457:144–149.
2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
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