Pain in the region of the greater trochanter of the hip is a common presentation in primary care. The term 'trochanteric bursitis' is often used to label the problem, frequently in the absence of any evidence of an inflammatory process in a bursa – of which there are several in the area. Unfortunately it is difficult to determine a precise diagnosis in patients with lateral hip pain. MRI scanning, as is often the case, discloses abnormalities (gluteal tendinopathy, complete and partial tendon tears) that are as common in asymptomatic individuals as in those with pain. This is another example of pain arising from where (or near to where) tendon meets bone, and despite increasingly sophisticated investigative techniques there is, as yet, no definitive understanding of what exactly is going on and what to do to relieve symptoms. In an editorial accompanying the
BMJ injections study cited above, Bahr and Khan suggest a pragmatic 5-step approach to manage lateral hip pain: 1
Eliminate the lumbar spine as a cause of symptoms. L3–4 refers to the lateral hip. Resisted hip abduction should elicit the patient's pain.
Eliminate the lateral hip pain with a local anaesthetic injection to the trochanteric region.
Assume that the problem is a gluteal tedinopathy and prescribe (or refer to physiotherapy for) a programme of progressive eccentric loading exercises.
As the injection study demonstrated that 47% of patients had a positvie outcome 3 months after blind injection of steroid, this could be offered.
In patients who fail to make progress, consider imaging and surgical referral for repair of any tendon tears identified.
In conjunction with this consider a Synovium editorial hobby horse:
'As with other tendinopathies there is likely to be little potential for benefit and much potential for harm in the prescription of non-steroidal anti-inflammatory drugs.'