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Greater Trochanteric Bursa Injection

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.

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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.

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Step 2

Identify the point of

maximal tenderness, and mark the site with a pressure mark from a

needle cap, pen, or fingernail.

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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.

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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.

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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

View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 20610 Arthrocentesis, aspiration, and/or injection of large joint

or bursa $ 176.00 0 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

Coding Guide.

ICD-9 Code

Trochanteric bursitis

726.5

Bibliography

1Alvarez-Nemegyei J, Canoso JJ.

Evidence-based soft tissue rheumatology III:

trochanteric bursitis.J Clin

Rheumatol. 2004;10(3):123 " 124. [View Abstract] 2Bird 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] 3Cardone DA, Tallia AF.

Diagnostic and therapeutic injection of the

hip and knee. Amer Fam

Phys.

2003;67(10):2147 " 2152. [View Abstract] 4Dunn T, Heller CA, McCarthy SW,

et al. Anatomical study of the

"trochanteric

bursa. " Clinical

Anat.

2003;16:233 " 240. [View Abstract] 5Ines L.

Soft tissue injections.

Best Pract Res Clin

Rheum.

2005;19(3):503 " 527. [View Abstract] 6Kingzett-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] 7Lievense A, Bierma-Zeinstra S, Schouten B,

et al. Prognosis of trochanteric pain in primary

care. Br J Gen

Pract.March 2005:199 " 204. 8Oakley SP, Bird P, Kirkham BW.

Gluteus medius tears presenting as the

clinical syndrome of trochanteric bursitis

(abstract). Arthritis

Rheum. 1999;42(Suppl

9):S340. 9Shbeeb MI, Matteson EL.

Trochanteric bursitis (greater trochanter

pain syndrome). Mayo Clin

Proc.

1996;71:565 " 569. [View Abstract] 10Walker P, Kannangara S,

et al. Lateral hip pain.

Clin Orthop Relat Res.

2007;Apr;457:144 " 149. 112008 MAG Mutual Healthcare

Solutions,

Inc. 'sPhysicians '

Fee and Coding Guide. Duluth,

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Healthcare Solutions,

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