Over the years we have seen many patients with hip pain. Many of them having a “hip bursitis,” or more commonly a trochanteric bursitis or iliopsoas bursitis. Sometimes both. The iliopsoas bursitis is felt in the groin area on the inside of the hip. The trochanteric bursitis is felt on the outer part of the hip.
However, most of the patients we see may or may not have a bursitis even though they have a diagnosis of one and they are on anti-inflammatory medications. Bursitis is an inflammation of the protective, fluid filled sacs that prevent excessive friction between the functional soft tissue of the hip, i.e., the ligaments and tendons, and the bones they attach to and rub against. These bursae can become irritated from injury, excessive pressure, and overuse. More often this diagnosis is actually a problem of tendonitis or tendinosis. However, for the purpose of this article, I will focus on the problem of bursitis.
Traditional treatment methods
The online medical publication STATPEARLS (1) describes trochanteric bursitis management as typically including “activity modification, physical therapy, weight loss, corticosteroid injection, and nonsteroidal anti-inflammatory medications (NSAIDs). The initial approach to treat greater trochanteric pain syndrome includes a range of conservative interventions such as physiotherapy, local corticosteroid injection, platelet-rich plasma (PRP) injection, shockwave therapy (SWT), activity modification, pain-relief and anti-inflammatory medication, and weight reduction. Most cases resolve with conservative measures, with success rates of over 90%.”
These treatments may be effective for many people as attested to in the citation above, up to 90% of the time. However they will be non-effective for others. Once the cortisone injection or injections fail to provide any relief, the patient will usually start seeking other options.
Clinical outcomes of PRP treatment in Greater trochanteric pain syndrome (trochanteric bursitis)
One option is Platelet Rich Plasma therapy or PRP. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. Why PRP? Because selected research suggests it can help people with Greater trochanteric pain syndrome. To be fair the research is limited. This is pointed out in a study published in June 2021. (2) The study author’s wrote: “Evidence supporting the use of platelet-rich plasma (PRP) injections in the treatment of Greater trochanteric pain syndrome is limited. In a systematic review of five articles and four published abstracts comprising 209 patients treated with PRP injections concluded that PRP represents a potentially viable treatment, although current evidence is based on small sample, low-quality studies.” Outlined below are some of these studies.
In January 2020, a study published in the medical journal Cureus, (3) offered the following on the comparison of PRP treatments to cortisone:
- 24 patients with greater trochanteric pain syndrome were enrolled and randomized into two study groups
- In Group A patients received ultrasound-guided PRP injection treatment, while group B patients received ultrasound-guided cortisone injections. Clinical outcomes in both groups were evaluated and compared using various patient reported scoring systems.
- Both groups showed improved scores compared to the pre-injection period, but patients in the PRP group had a statistically significant decrease in pain and increase in functionality at the last follow-up (24 weeks post-injection). No complications were reported.
- In conclusion, “patients with greater trochanteric pain syndrome present better and longer-lasting clinical results when treated with ultrasound-guided PRP injections compared to those with cortisone.
The effectiveness of the various nonoperative treatments for greater trochanteric pain syndrome
A July 2022 study (4) compared the effectiveness of the various nonoperative treatments for greater trochanteric pain syndrome including injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs and extracorporeal shockwave therapy. Thirteen randomized controlled trials and 1034 patients were included. For pain scores at 1 to 3 months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both 1 to 3 months and 6 to 12 months. No proposed therapies significantly outperformed the no treatment control group for pain scores at 6 to 12 months. Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months. Conclusion: Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.
A June 2023 paper (8) compared effectiveness of shock wave therapy versus therapeutic exercise, including the possibility of combining both therapies, in patients who did not respond to the first treatment. According to the paper the researchers were able to valid the effectiveness of both treatments (therapeutic exercise and shock wave therapy) in both single and combined modalities in patients not responding to a single treatment. . . . This combined treatment strategy allowed patients who had no benefit in terms of pain reduction after 2 months to recover promptly. However, although both treatments were effective, it was found that patients who received shock wave treatment alone had a more marked recovery from a functional point of view.
Greater trochanteric pain syndrome (trochanteric bursitis)
A 2018 study in the Journal of hip preservation (5) made these observations on the use of Platelet Rich Plasma injections for greater trochanteric pain syndrome.
- Greater trochanteric pain syndrome, (trochanteric bursitis), commonly affects middle-aged women.
- It is characterized by pain over the outer side of the hip. Recently the understanding of Greater trochanteric pain syndrome has evolved. Gluteal tendinopathy is believed to be the main contributory factor rather than bursal inflammation. There are numerous studies reporting little evidence of bursal inflammation in Greater trochanteric pain syndrome but found gluteal tendon tendinopathy more commonly associated with Greater trochanteric pain syndrome.
- Greater trochanteric pain syndrome has also been associated with low back pain, knee osteoarthritis and iliotibial band syndrome.
- Greater trochanteric pain syndrome can be resolved with conservative treatments such as relative rest and anti-inflammatory medication in the majority of patients. If conservative measures fail then progressively more invasive treatment options including shockwave therapy, corticosteroid injections, PRP and surgery may be required.
- Lately PRP has become very popular among the orthopedic community as a minimally invasive way of enhancing tissue healing. It is thought that PRP promotes soft tissue healing by delivering a higher than normal concentration of platelets and therefore increased concentration of platelet derived growth factors to the diseased area. This has been shown in various studies.
- The use of PRP in treating Greater trochanteric pain syndrome has become more prevalent in recent times.
- There is a lack of studies providing high-quality evidence as to what is causing the pain in Greater trochanteric pain syndrome. Quite often the pathology may be in the gluteus medius and minimus tendon and not exclusively the bursa, therefore the site of injection (treatment) needs to be considered.
- In most improvements were observed during the first 3 months after PRP injection . Significant improvements were reported when patients were followed up to 12 months post treatment. There are, however, conflicting results between the randomized studies as to whether PRP is superior to corticosteroid. Considering these factors, PRP seems a viable alternative treatment with the current evidence in patients with Greater trochanteric pain syndrome not responding to conservative measures. Further large-sample and high-quality randomized clinical trials in the future should be conducted to present evidence of the efficacy for PRP as a treatment in Greater trochanteric pain syndrome.
Method of how PRP is given can impact the effectiveness of the treatment
I want to bring attention to a December 2019 study (6) that questions whether PRP is an effective treatment for Greater trochanteric pain syndrome. In this study, patients with chronic lateral hip pain were randomised to either a PRP injection (intervention group) or a saline injection (control group) and both groups were prescribed identical eccentric exercise. The researchers found that there were no differences in any outcomes between the two groups at any follow-up point. They concluded a single injection of PRP resulted in no significant improvement for Greater trochanteric pain syndrome compared with a placebo injection.
- A single injection is typically not as effective as “poking” the hip a few times within the single treatment. Patients will usually benefit from two or three PRP treatments. This would need to be confirmed before treatment begins.
This was a recent study published in the Journal of pain research.(7) It hits upon some good points that describe how PRP works and when PRP may not work.
- Variability in treatment can lead to failure: “Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief.” To summarize that, you need to see a doctor or clinician that has developed effective protocols for the PRP treatment you are seeking. We have been doing regenerative medicine for over 25 years.
When surgery is indicated for greater trochanteric pain syndrome?
A conscious statement from the doctors of the The 2022 International Society for Hip Preservation (9) suggested that “the indications for surgical management vary based on individual patient characteristics and surgeon-specific criteria. These findings may include imaging evidence of a Gluteus Medius tear, failed previous appropriate conservative management, a severe gait deviation, the inability to abduct hip against gravity, and tissue quality. Although 60–90% of individuals with Greater trochanteric pain syndrome will respond positively to conservative management, those with prolonged pain and dysfunction despite appropriate conservative interventions may require surgical intervention.”
1 Gomez LP, Childress JM. Greater Trochanteric Syndrome. InStatPearls [Internet] 2021 Apr 25. StatPearls Publishing.
2 Pianka MA, Serino J, DeFroda SF, Bodendorfer BM. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE Open Medicine. 2021 Jun;9:20503121211022582.
3 Begkas D, Chatzopoulos ST, Touzopoulos P, Balanika A, Pastroudis A. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study. Cureus. 2020 Jan;12(1).
4 Gazendam A, Ekhtiari S, Axelrod D, Gouveia K, Gyemi L, Ayeni O, Bhandari M. Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine. 2021 Mar 12.
5 Ali M, Oderuth E, Atchia I, Malviya A. The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. J Hip Preserv Surg. 2018 Aug 30;5(3):209-219. doi: 10.1093/jhps/hny027. PMID: 30393547; PMCID: PMC6206702.
6 Thompson G, Pearson JF. No attributable effects of PRP on greater trochanteric pain syndrome. N Z Med J. 2019 Dec 13;132(1507):22-32. PubMed PMID: 31830014.
7 Kuffler DP. Variables affecting the potential efficacy of PRP in providing chronic pain relief. J Pain Res. 2018;12:109-116. Published 2018 Dec 21. doi:10.2147/JPR.S190065 —
8 Notarnicola A, Ladisa I, Lanzilotta P, Bizzoca D, Covelli I, Bianchi FP, Maccagnano G, Farì G, Moretti B. Shock Waves and Therapeutic Exercise in Greater Trochanteric Pain Syndrome: A Prospective Randomized Clinical Trial with Cross-Over. Journal of Personalized Medicine. 2023 Jun 10;13(6):976.
9 Disantis A, Andrade AJ, Baillou A, Bonin N, Byrd T, Campbell A, Domb B, Doyle H, Enseki K, Getz B, Gosling L. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement. Journal of Hip Preservation Surgery. 2023 Jan 1;10(1):48-56.