A prospective, noncomparative cohort study investigated 72 patients in a rheumatology clinic who hadn’t improved after at least 2 weeks of treatment with NSAIDs, analgesics, or ointments.3 Of the 59 patients who consented to steroid injections, 42 improved after 1 injection of 40 mg methylprednisolone with 2 mL of 2% lidocaine, 13 improved after a second injection 3 weeks later, and the remaining 4 improved after a third injection. Improvement was defined as disappearance of pain and disability. Six patients (8%) experienced a recurrence of bursitis during a 2-year follow-up period. No local or systemic complications were associated with the corticosteroids or anesthetic solution.
Two retrospective studies also documented the efficacy of corticosteroid injection. One investigated treatment of 36 patients in a rheumatology practice.4 All received methylprednisolone (40-80 mg) or triamcinolone (20-40 mg), and all improved. Two thirds of the patients were symptom free after 1 or 2 injections. Symptoms usually resolved within 2 days to several months (typically 1 or 2 weeks) postinjection. About 25% of the patients relapsed within 2 years.
Another retrospective cohort study of 164 British patients found that those who received a corticosteroid injection were 2.7 times more likely to have recovered at 5 years than patients who had not received an injection (odds ratio=0.4; 95% confidence interval, 0.1-1.0).1
When to consider surgery
Surgical treatment may be necessary for patients with refractory trochanteric bursitis. Several case studies5-7 demonstrate successful outcomes with a variety of surgical techniques, including trochanteric reduction osteotomy and iliotibial band release. Newer techniques involve arthroscopic bursectomy.
Recommendations
UpToDate8 recommends conservative treatment initially. For persistent cases, a corticosteroid injection should be given and repeated in 6 weeks if pain persists. Surgery may be considered if these measures don’t relieve symptoms and pain lasts longer than 1 year.
The American Academy of Orthopaedic Surgeons similarly recommends NSAIDs and activity modification followed by corticosteroid injection.9 Surgery is rarely indicated.