Isolated trochanteric bursitis is now believed to occur rarely, and lateral hip pain is more often referred to as greater trochanteric pain syndrome, which most often originates from gluteal medius and minimus tendinopathy, sometimes with an associated bursitis. However, the injection technique (aimed at the point of maximal tenderness) is the same for both isolated trochanteric bursitis and greater trochanteric pain syndrome.
The deep bursae (trochanteric, subacromial, or anserine) lie between bone and overlying tendons. Bursitis of a deep bursa seldom manifests with visible swelling or erythema.
(See also Bursitis.)
Indications for Injecting a Trochanteric Bursa
For injections of glucocorticoid to treat inflammation
Symptoms of greater trochanteric pain syndrome are effectively treated with rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and stretch therapy. However, when trochanteric pain persists despite conservative measures, bursal area injection provides rapid relief.
Aspiration of fluid from the trochanteric bursa is not anticipated.
Contraindications to Injecting a Trochanteric Bursa
Absolute contraindications
Overlying cellulitis or skin ulcer, bacteremia, adjacent prosthetic joint
Hypersensitivity to an injected substance
For glucocorticoid injection, suspected septic bursitis
Relative contraindications
Unrecognized tendon or muscle injury: Analgesia provided by a glucocorticoid injection could delay accurate diagnosis.
Poorly controlled diabetes: Any benefit of glucocorticoids is weighed against risk of short-term worsening glycemic control.
Unresponsiveness to prior glucocorticoid injections into same site (although this recommendation has not been systematically studied).
Coagulopathy is not a contraindication (1).
Complications of Injecting a Trochanteric Bursa
Complications are uncommon and include:
Subcutaneous fat atrophy, skin atrophy and sinus tracts, and temporary skin depigmentation due to inadvertent subcutaneous glucocorticoid injection
Infection
In diabetic patients, hyperglycemia after a depot glucocorticoid injection
Equipment for Injecting a Trochanteric Bursa
Antiseptic solution (eg, chlorhexidine, povidone iodine, isopropyl alcohol)Antiseptic solution (eg, chlorhexidine, povidone iodine, isopropyl alcohol)
Sterile gauze and adhesive bandage
Gloves
Needle insertion site anesthesia: topical freezing spray (eg, ethyl chloride) and/or injectable 1% lidocaine without epinephrine, in a 3-mL syringeNeedle insertion site anesthesia: topical freezing spray (eg, ethyl chloride) and/or injectable 1% lidocaine without epinephrine, in a 3-mL syringe
For therapeutic injection, 10-mL syringe with approximately 3 to 5 mL 1% lidocaine (without epinephrine) mixed with injectable depot glucocorticoid (eg, triamcinolone acetonide, 40 mg)For therapeutic injection, 10-mL syringe with approximately 3 to 5 mL 1% lidocaine (without epinephrine) mixed with injectable depot glucocorticoid (eg, triamcinolone acetonide, 40 mg)
1.5-inch needle, 22 to 27 gauge (longer in larger patients)
Having an assistant is helpful.
Additional Considerations for Injecting a Trochanteric Bursa
For bursal injection, local anesthetic and depot glucocorticoid often are mixed in a single syringe. Adding the anesthetic helps confirm good needle placement when injection immediately relieves pain.
If the history or physical examination suggests the possibility of infection, withhold glucocorticoid injection.
Immediate analgesia after injection of local anesthetic helps confirm correct needle placement and that greater trochanteric pain syndrome is the source of pain.
Relevant Anatomy for Injecting a Trochanteric Bursa
Although tenderness at or near the greater trochanter is characteristic, the trochanteric bursae are usually not the only source of the pain.
Commonly affected trochanteric bursae are the subgluteus maximus bursa (multiloculated, lies between the greater trochanter and the gluteus maximus tendon) and the bursae between the greater trochanter and gluteus medius and minimus tendons. Other sources of pain include tendinopathy of the gluteus medius and minimus.
Pain elicited by palpation is used to determine the site of needle insertion.
Positioning for Injecting a Trochanteric Bursa
Place the patient lying laterally on the unaffected side, with affected leg slightly flexed and adducted to move the lateral muscles away from the greater trochanter.
To avoid vasovagal episodes, avert the patient's head and orient your work area so that the patient does not see the needles.
Step-by-Step Description of Injecting a Trochanteric Bursa
Prepare the site
Mark the site of needle entry on the skin.
Prepare the area with antiseptic solution.
Spray freezing spray at the needle insertion site until it just blanches and/or place a skin wheal of local anesthetic (eg, ≤ 1 mL).
Inject the bursa
Wear gloves (standard precautions).
Insert the needle perpendicularly to the skin at the point of maximum tenderness, aiming toward the greater trochanter.
When the tip of the needle touches the greater trochanter, retract the needle approximately 1 mm.
Gently pull back on the plunger prior to injection to exclude intravascular placement.
Slowly inject all of the anesthetic/glucocorticoid mixture and withdraw the needle.
If the injection meets resistance, the needle tip may be within an overlying tendon. Stop injecting and advance or withdraw the needle until the injection does not meet resistance.
Pain may be immediately relieved after a properly placed injection of anesthetic.
Apply an adhesive bandage or sterile dressing.
Aftercare for Injecting a Trochanteric Bursa
Prescribe limited hip activity (eg, avoid stairs, prolonged walking, running, weight-lifting), ice, and oral nonsteroidal anti-inflammatory drugs (NSAIDs) until pain subsides.
Limiting hip activity can help minimize the spread of the glucocorticoid into adjacent tissues and maximizes its therapeutic effect.
Instruct the patient to return for reassessment to exclude infection if pain is continuously and progressively increasing after several hours or persists for > 48 hours.
Warnings and Common Errors for Injecting a Trochanteric Bursa
To avoid damaging tendons, do not inject glucocorticoid against resistance.
Tips and Tricks for Injecting a Trochanteric Bursa
Appropriate positioning is very helpful. Explore the trochanteric and gluteal structures for multiple areas of tenderness that mimic the patient's pain.
Trochanteric syndrome is often caused by some change in gait from foot, knee, back, or hip pathology. Pre- and post-injection examination of these other anatomic areas should be performed. Consider hip radiographs if hip motion elicits significant lateral pain.
Reference
1. Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 92(8):1223–1226, 2017. doi: 10.1016/j.mayocp.2017.04.007
