Trochanteric bursitis, now more accurately termed greater trochanteric pain syndrome (GTPS), is a common cause of lateral hip pain affecting approximately 10–25% of the population, with an incidence of ~1.8 per 1,000 per year. [1-2] True isolated bursitis accounts for only ~20% of GTPS cases; the majority involve gluteal tendinosis (50%), thickened iliotibial band (28.5%), or gluteal tendon tears. [3] Below is a structured clinical summary.
1. History
- Location: Lateral hip pain over the greater trochanter, may radiate along the lateral thigh to the knee and occasionally below the knee or into the buttock [3-4]
- Aggravating factors: Lying on the affected side, climbing/descending stairs, prolonged standing, rising from a seated position, sitting with legs crossed, running [3-4]
- Onset: Usually insidious with no inciting injury; may follow a fall, post-hip arthroplasty, or biomechanical change (e.g., gait alteration from contralateral pathology) [1][5]
- Timing: Chronic or subacute; pain often worse at night when lying on the affected hip
- Important negatives: Absence of groin pain (suggests intra-articular pathology), no mechanical symptoms (clicking/locking suggests labral tear), no radicular features (numbness, weakness in a dermatomal pattern)
2. Alarm Features
- Acute trauma with inability to bear weight → rule out hip fracture
- Fever, warmth, erythema over the hip → consider septic bursitis or septic arthritis
- Night pain with constitutional symptoms (weight loss, night sweats) → consider malignancy or avascular necrosis
- Progressive weakness of hip abduction → suspect gluteus medius/minimus tendon tear [5]
- Pain with groin involvement + limited internal rotation → evaluate for intra-articular pathology (OA, AVN, labral tear) [5]
- History of systemic corticosteroid use, hemoglobinopathy, or alcohol use with hip pain → consider avascular necrosis [5]
3. Medications
- First-line treatment: Oral NSAIDs (ibuprofen 400–600 mg TID or naproxen 500 mg BID) and topical NSAIDs [2][4]
- Corticosteroid injection: Provides short-term relief (1–3 months); typical regimen is 40 mg triamcinolone acetonide in 4–6 mL local anesthetic injected at the point of maximal tenderness. Efficacy over placebo is debated; one RCT showed no significant difference vs. saline at 1 month [3]
- Avoid: Repeated corticosteroid injections (risk of tendon weakening); fluoroquinolones in patients with tendinopathy concerns
- Emerging options: PRP injections may provide longer-lasting benefit than corticosteroid, particularly for gluteal tendinopathy, with sustained outcomes at 2 years [3]
- Acetaminophen as adjunct for patients who cannot tolerate NSAIDs
4. Diet
- No specific dietary triggers for trochanteric bursitis
- Weight management is a key modifiable factor — obesity is a significant risk factor and weight loss is recommended as part of conservative management [2][6]
- Anti-inflammatory dietary patterns (Mediterranean diet) may provide modest adjunctive benefit for chronic musculoskeletal pain, though no specific evidence for GTPS
5. Review of Systems
- Musculoskeletal: Low back pain (20–35% of patients with chronic LBP have concurrent GTPS), contralateral hip or knee pain, gait changes [1]
- Neurologic: Radicular symptoms — up to 50% of GTPS patients have pain radiating past the knee, mimicking radiculopathy; 63% were previously evaluated by a spine surgeon [1][4]
- Rheumatologic: Morning stiffness, joint swelling (inflammatory arthropathy)
- Constitutional: Fever, weight loss, night sweats (infection, malignancy)
- Genitourinary/GI: Referred pain from intra-abdominal or intrapelvic sources [5]
6. Collateral History and Family History
- Prior hip or spine surgeries (GTPS occurs in up to 17% post-THA) [7]
- Activity level and occupational demands (repetitive hip loading, prolonged standing)
- Family history of inflammatory arthropathies, osteoarthritis
- Psychological assessment — baseline psychological impairment is associated with poorer outcomes and should be assessed [8]
7. Risk Factors
- Female sex (most common in women aged 40–60) [1][5]
- Obesity [2]
- Coexisting low back pain [1-2]
- Hip osteoarthritis [2]
- Iliotibial band tightness [2]
- Leg length discrepancy or abnormal gait biomechanics
- Post-hip arthroplasty (especially lateral/transgluteal approach) [7]
- Increased acetabular anteversion [8]
- Sedentary lifestyle or sudden increase in activity
8. Differential Diagnosis
- Gluteus medius/minimus tendinopathy or tear — the most common cause of GTPS; distinguished by weakness on resisted abduction and failure to improve with conservative therapy; MRI or US confirms [5]
- Hip osteoarthritis — groin pain predominates, limited internal rotation, pain with hip extension (unlike GTPS) [4]
- Lumbar radiculopathy (L3–L5) — dermatomal numbness/weakness, positive straight leg raise, MRI spine abnormalities; 63% of GTPS patients were previously misdiagnosed with radiculopathy [1][4]
- Iliotibial band syndrome — lateral knee pain more prominent, positive Ober's test
- External snapping hip (coxa saltans externa) — palpable/audible snap of the ITB over the greater trochanter with hip flexion/extension [8]
- Sacroiliac joint dysfunction — posterior pain, tenderness over SI joint, positive provocation tests [4]
- Femoral neck stress fracture — cannot-miss diagnosis; pain with weight-bearing, history of overuse/energy imbalance [5]
- Avascular necrosis — groin pain, limited ROM, risk factors (steroids, alcohol, sickle cell) [5]
- Referred pain from intra-abdominal/pelvic pathology [5]
- Septic bursitis — rare; fever, erythema, warmth
9. Past Medical History
- Prior episodes of lateral hip pain or GTPS
- History of hip or spine surgery
- Chronic low back pain (strong association) [1]
- Osteoarthritis of hip or knee
- Prior corticosteroid injections (number, timing, response)
- Rheumatologic conditions
- History of falls or trauma
10. Physical Exam
- Point tenderness over the greater trochanter — highly sensitive and specific, nearly pathognomonic for GTPS [4]
- Positive jump sign — exaggerated pain response to palpation [3]
- Pain with resisted hip abduction in side-lying [1][4]
- FABER test (Patrick's test) — lateral hip pain at end-range flexion, abduction, and external rotation [1]
- Trendelenburg test/gait — suggests gluteus medius weakness or tear [5][8]
- Resisted external derotation test — positive in GTPS [5][8]
- Single-leg stance test — reproduces lateral hip pain [8]
- Hip lag sign — suggests abductor tear [8]
- Ober's test — traditionally used for ITB tightness, but utility for GTPS is questionable [1]
- Negative findings: No pain with hip extension (distinguishes from hip OA), no groin pain with internal rotation, no neurologic deficits in a dermatomal pattern [4]
11. Lab Studies
- Routine labs are not indicated for typical presentations
- If infection is suspected: CBC, ESR, CRP, blood cultures; consider aspiration of bursal fluid for cell count, Gram stain, and culture
- If inflammatory arthropathy is considered: ESR, CRP, RF, anti-CCP, uric acid
- If AVN is a concern: evaluate for underlying causes (lipid panel, hemoglobin electrophoresis)
12. Imaging
- Imaging is usually unnecessary — the diagnosis is clinical [1]
- Plain radiographs (AP pelvis, lateral hip): First-line if imaging is pursued; useful to rule out hip OA, fracture, calcific tendinitis, or bony abnormalities [5]
- Ultrasound: Best first-line advanced imaging; can identify bursal fluid (anechoic collection), tendinopathy, and gluteal tears; also allows dynamic assessment and guided injection [3][6-7]
- MRI: Gold standard for soft tissue evaluation; high signal intensity of bursa on fluid-sensitive sequences confirms bursitis; best for evaluating gluteal tendon tears, fatty atrophy, and surgical planning [1][6-7]
- Imaging is indicated when: Diagnosis is uncertain, symptoms fail to improve with 4–6 weeks of conservative therapy, or gluteal tendon tear is suspected [5]
13. Special Tests
- Diagnostic injection: >50% pain relief after corticosteroid injection (40 mg triamcinolone in 6 mL local anesthetic) under ultrasound guidance supports the diagnosis of trochanteric bursitis [3]
- Ultrasound-guided analgesic injection can differentiate peritrochanteric vs. intra-articular pain generators [9]
- No validated scoring systems specific to GTPS; the Harris Hip Score and VISA-G (Victorian Institute of Sport Assessment for Gluteal Tendinopathy) are used in research [3]
- Point-of-care ultrasound can be performed in the ED or clinic to identify bursal effusion and guide injection
14. ECG
- Not applicable for trochanteric bursitis
- ECG is not indicated unless there are concurrent cardiac concerns or pre-procedural requirements
15. Assessment
- GTPS/trochanteric bursitis is a clinical diagnosis based on lateral hip pain with point tenderness over the greater trochanter [4]
- Most cases are self-limited with conservative management [2]
- True isolated bursitis is less common than previously thought (~20%); gluteal tendinopathy is the predominant pathology [3]
- Up to 50% of patients have pain radiating past the knee, frequently leading to misdiagnosis as lumbar radiculopathy [1][4]
- Failure to respond to conservative treatment should prompt reconsideration of the diagnosis and imaging to evaluate for gluteal tendon tears [1][5]
- Psychological comorbidities may impact outcomes and should be assessed [8]
16. Treatment Plan
Initial/Conservative (first-line for all patients):
- Activity modification: avoid lying on the affected side, avoid prolonged standing, avoid crossing legs [4]
- Ice application to the lateral hip for 15–20 minutes several times daily
- Oral NSAIDs (ibuprofen or naproxen) for 2–4 weeks [2][4]
- Education plus exercise is the most effective intervention — a physiotherapy-led program of load management education and progressive hip abductor strengthening showed superior outcomes to corticosteroid injection at both 8 weeks and 52 weeks (NNT = 2 at 8 weeks) [10-11]
Second-line:
- Corticosteroid injection: 40 mg triamcinolone acetonide or 25 mg prednisolone in 4–6 mL local anesthetic at the point of maximal tenderness; provides faster short-term relief (1–3 months) but no long-term superiority over exercise [3][10]
- Ultrasound-guided injection improves accuracy and may provide longer-lasting pain reduction [3]
- Extracorporeal shockwave therapy (ESWT): Similar efficacy to CSI at 3 months, potentially superior at 12 months [3][11]
Refractory cases:
- PRP injection: Emerging evidence suggests sustained benefit at 2 years, particularly for gluteal tendinopathy [3]
- Surgical intervention (endoscopic bursectomy, gluteal tendon repair) for cases refractory to ≥6 months of conservative management [1][9]
- Orthopedic referral for large partial or complete gluteal tendon tears [5]
17. Disposition
- Discharge is appropriate for the vast majority of presentations — this is an outpatient condition [2]
- Admission is not indicated unless there is concern for septic bursitis/arthritis, hip fracture, or other acute surgical pathology
- Observation is not typically required
- Specialist consultation triggers:
- Failure to improve after 4–6 weeks of conservative therapy → consider imaging and orthopedic or sports medicine referral [5]
- Suspected gluteal tendon tear on exam or imaging → orthopedic referral [5]
- Refractory pain despite injection therapy → pain medicine or orthopedic referral
- Diagnostic uncertainty (concern for intra-articular pathology, radiculopathy) → appropriate specialist evaluation [9]
18. Follow Up / Return Precautions
- Follow-up: Primary care or sports medicine in 4–6 weeks to assess response to conservative therapy
- Expected course: Most cases resolve within 6–12 months with conservative measures; some patients have recurrent or chronic symptoms [2]
- Return precautions — advise patients to seek reassessment for:
- Inability to bear weight or worsening pain
- New numbness, weakness, or bowel/bladder dysfunction (suggests neurologic emergency)
- Fever, redness, or swelling over the hip (infection)
- Pain that fails to improve or worsens despite 4–6 weeks of treatment
- Patient counseling:
- Emphasize that this is a benign, self-limited condition in most cases
- Adherence to physical therapy and home exercise program is the most important factor for long-term improvement [10]
- Weight loss if overweight/obese [2]
- Sleep positioning: pillow between the knees when side-lying to reduce pressure on the trochanter
- Avoid repetitive hip-loading activities during the acute phase
References
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2. Musculoskeletal mimics of lumbosacral radiculopathy. — Bateman EA, Fortin CD, Guo M. Muscle & Nerve. 2025.
3. Musculoskeletal mimics of lumbosacral radiculopathy. — Bateman EA, Fortin CD, Guo M. Muscle & Nerve. 2025.
4. Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. — Williams BS, Cohen SP. Anesthesia and Analgesia. 2009.
5. Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment. — Williams BS, Cohen SP. Anesthesia and Analgesia. 2009.
6. Use and Safety of Corticosteroid Injections in Joints and Musculoskeletal Soft Tissue: Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. — Benzon HT, Provenzano DA, Nagpal A, et al. Regional Anesthesia and Pain Medicine. 2025.
7. Use and Safety of Corticosteroid Injections in Joints and Musculoskeletal Soft Tissue: Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. — Benzon HT, Provenzano DA, Nagpal A, et al. Regional Anesthesia and Pain Medicine. 2025.
8. Musculoskeletal mimics for lumbosacral radiculopathy. Part 2: Specific disorders. — Jorgensen SP, Chiodo AE. Muscle & Nerve. 2025.
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11. Hip Pain in Adults: Evaluation and Differential Diagnosis. — Chamberlain R. American Family Physician. 2021.
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14. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. — Weissman BN, Palestro CJ, Fox MG, et al. Journal of the American College of Radiology : JACR. 2023.
15. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. — Weissman BN, Palestro CJ, Fox MG, et al. Journal of the American College of Radiology : JACR. 2023.
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18. Editorial Commentary: Treatment of Concomitant Intra-Articular Pathology in Patients With Greater Trochanteric Pain Syndrome Is Indicated by Provocative Impingement or Instability Physical Examination and Ultrasound-Guided Analgesic Injection Testing. — Domb BG, Curley AJ. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2023.
19. Editorial Commentary: Treatment of Concomitant Intra-Articular Pathology in Patients With Greater Trochanteric Pain Syndrome Is Indicated by Provocative Impingement or Instability Physical Examination and Ultrasound-Guided Analgesic Injection Testing. — Domb BG, Curley AJ. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2023.
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21. Education Plus Exercise Versus Corticosteroid Injection Use Versus a Wait and See Approach on Global Outcome and Pain From Gluteal Tendinopathy: Prospective, Single Blinded, Randomised Clinical Trial. — Mellor R, Bennell K, Grimaldi A, et al. BMJ. 2018.
22. The Efficacy of Gluteal Tendinopathy Treatments: A Systematic Review. — Bremer T, Nicklen P, Fearon A, Morrissey D. Clinical Rehabilitation. 2025.
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