Overview of Greater Trochanteric Bursa Injection
Greater trochanteric pain syndrome (GTPS) is a condition that can cause pain in the side of the hip, buttock, and thigh. It can be caused by several different issues. These include swelling of a small sac, or bursa, that cushions the hip bone (a condition called greater trochanteric bursitis), damage to the tendons of the gluteal medius and minimus muscles (known as tendinopathy or tears), and problems with a band of tissue running down the side of the thigh (iliiotibial band snapping). In some cases, someone might have swelling in the bursa and damage to the tendons at the same time.
If someone has greater trochanteric bursitis, they’ll generally feel pain on the side of their hip. This pain can get worse when they walk upstairs, get up from a sitting position, or lie on the affected side. The most common tell-tale sign of this condition is if it hurts when pressure is applied to the hip bone — this key clue can help tell it apart from other hip conditions, which usually cause pain to spread to the groin. The pain might also get worse if the person moves their leg away from the body or if someone else moves the person’s leg towards the body.
GTPS is more common in women, people who are overweight or obese, and people between the ages of 40 and 60. The shape of a woman’s hips might put more strain on the iliotibial band over the hip bone, contributing to the development of this condition. Back pain, hip osteoarthritis (a type of joint damage), and other conditions that affect how the leg works — like knee pain that changes how forces act on the hip — can also occur alongside GTPS. To diagnose GTPS, a doctor will look at the person’s symptoms; there are no specific tests that can diagnose it. Medical imaging tests may be used and could show swelling in the bursa, damage to the gluteal tendons, or no inflammation at all.
Anatomy and Physiology of Greater Trochanteric Bursa Injection
The greater trochanter is an extension of the upper part of the femur (the thigh bone). This bump-like structure is prominent and juts out on the side. Its primary function is to anchor strong tendons that aid in the movement of your hip, specifically moving it away from the center of your body – a movement known as “hip abduction”. Several muscles contribute to this movement, including the tensor fascia latae, the gluteus medius, and the gluteus minimus.
There are four muscles situated on the outside of your hip, grouped into superficial (outermost) and deep (inner) layers. The gluteus maximus and tensor fasciae latae form the superficial layer, while the gluteus medius and gluteus minimus form the deep layer. These muscles attach to a fibrous tissue called fascia lata that starts at the greater trochanter. This attachment results in the formation of a structure known as the iliotibial band (ITB). The ITB and the tensor fascia latae function together as a supportive band that keeps the greater trochanter steady when there’s strain.
The greater trochanter consists of different facets or sides – front (anterior), side (lateral), and back (posterosuperior and posterior). Each one is used as an attachment site for the tendons (the strong tissue that connects a muscle to bone) of different muscles. Several fluid-filled sacs called bursae, located around the greater trochanter, support these tendons, resulting in smooth hip movement. Slang term “trochanteric bursa” refers to a particular bursa that’s positioned next to the greater trochanter, nestled between two muscles (the gluteus maximus and gluteus medius) and under the ITB and fascia lata.
The superior gluteal nerve, coming from the lower spine, is responsible for controlling the gluteus medius and gluteus minimus muscles.
A condition known as trochanteric bursitis may occur due to multiple reasons such as excess usage or damage to the gluteal muscles, being overweight, uneven leg length, direct injury, inflammation due to issues with the tendons of the gluteal muscles. The root of the issue lies in tiny injuries (microtrauma) to the tendons where they connect to the greater trochanter. This leads to an increase in friction between the greater trochanter and the ITB, causing the condition called greater trochanteric pain syndrome (GTPS). The anterior (frontal) fibers of the gluteal tendons are generally prone to take the maximum load and are frequently the first ones to tear.
Why do People Need Greater Trochanteric Bursa Injection
If you’ve been diagnosed with greater trochanteric bursitis, which is inflammation of the bursa (a small, fluid-filled sac) located at the outside point of the hip, you might receive a treatment called an injection to the trochanteric bursa. This treatment is often considered for folks who haven’t improved with simpler or ‘conservative’ treatments. However, it’s important not to wait too long before getting this treatment, as the pain from this condition can really interfere with your daily activities.
When a Person Should Avoid Greater Trochanteric Bursa Injection
There are certain situations when it is not safe to have a bursal injection, a type of treatment used to lessen pain and inflammation. These situations include if the patient doesn’t want the treatment, if they have a severe infection that’s affecting their entire body, if they have a skin infection near where the injection would be, or if they have a major problem with their immune system that makes it hard for them to fight infections.
The risk of getting a bleeding joint, also known as hemarthrosis, from the injection is low. So, it’s generally safe to continue taking blood thinners without making changes to their dosage. So, tests for blood clotting are typically not needed before the injection.
However, if a patient’s blood clotting levels are too high, as measured by a test called the International Normalized Ratio (INR), they should postpone the treatment. It’s safer to wait until their INR returns to a healthy level.
Equipment used for Greater Trochanteric Bursa Injection
To perform a trochanteric bursal injection, which is a type of shot given to relieve pain and inflammation in the hip, specific types of medical equipment are needed or suggested. Here are the details:
An 18 G needle is required for pulling out the medications from their containers. A smaller needle, referred to as a 25 G hypodermic needle, is used to apply local anesthetic to the skin and area under the skin.
A 22- to 25-gauge spinal needle, which is a long, thin needle, is also used. This needle is 3.5 inches long.
1% lidocaine is used as a local anesthetic for numbing the skin and the area under the skin. This prepares the patient for the injection and helps decrease discomfort.
Another local anesthesia, such as 0.25% bupivacaine, is used as well because it can provide pain relief for a longer period. However, other medicines can be used in its place if needed.
A steroid, such as 40 mg/mL triamcinolone, is also used because of its long-acting effects. As with the bupivacaine, alternative medicines can be used if necessary.
An imaging suite with a C-arm fluoroscopy is recommended but not necessary. This device helps doctors see the area being treated in more detail.
A contrast agent, like 240 mg/mL iohexol, is used if fluoroscopy is being utilised, helping to increase the visibility of certain body parts under imaging.
An ultrasound machine might be used as an optional tool.
Who is needed to perform Greater Trochanteric Bursa Injection?
An injection into the trochanteric bursa, a small fluid-filled sac near your hip, is generally done by highly trained healthcare providers or doctors. These doctors may have specialized training in areas such as general medical care, pain management, anesthesiology (which involves managing pain before, during, and after surgeries), physical medicine and rehabilitation, interventional radiology (using imaging to guide treatments), or orthopedic surgery (surgery of the bones). During this procedure, a skilled team member is usually there to assist. If images need to be taken to help guide the injection, a person skilled in using a fluoroscopy machine, a type of X-ray machine, will be there to help too.
Preparing for Greater Trochanteric Bursa Injection
This procedure usually takes place in an outpatient center, which means you won’t have to stay overnight in a hospital. Before your doctor begins the procedure, they will have a conversation with you about what will happen, the potential benefits and risks involved, and any other options you might have. This is done to make sure you understand everything and can make an informed decision. You’ll need to provide written consent – a formal agreement that you understand and accept the risks of the procedure – before it can proceed.
When preparing for the procedure, your doctor will mark the area of your body where the treatment will be applied. After this, the skin around this area will be carefully cleaned with a disinfectant – this is what medical professionals call “prepping the skin”. They’ll then cover the surrounding area with sterile drapes to keep everything as clean and germ-free as possible.
Before the procedure starts, all medical staff involved will take a moment called a “time out”. This is done to double-check important details. They’ll confirm your name and the specifics of your procedure, make sure they’re aware of any allergies you have, and have checked your lab results. They’ll also confirm that they’re treating the correct part of your body. This is all done to ensure your safety during the procedure.
How is Greater Trochanteric Bursa Injection performed
If your doctor suspects you have inflammation in your hip (specifically the bursa, which is a little cushioning sac located where your muscles and tendons move over a bony spot), they might suggest a trochanteric bursa injection. This procedure can be performed with or without image guidance, like ultrasound scans or fluoroscopy (a type of X-ray).
Ultrasound provides a neat and dependable way for doctors to find tendons and inflamed areas, which can make the injection more precise compared to using physical features and points of reference on your body. This also allows your doctor to clearly see the needle and how the medicine spreads. On the other hand, if it is difficult to feel your hip bone or the first injection didn’t provide relief, fluoroscopy might help to reduce the risk of improper placement of the injection needle.
During the procedure, you will lie down on your back while your hip is in a neutral position. Your doctor will identify the hip bone by feeling for a hard prominence on the side of your hip. A very thin needle is then placed on the skin. The doctor will use fluoroscopy to make sure the needle is correctly placed and then inject local anesthetic there to numb the spot. The doctor then used a slightly longer needle through the numbed area to reach the bursa. To confirm the needle is in the right spot, a contrast (a dye that shows up on X-rays) will be injected. If the dye indicates that the needle is properly placed, a mixture of steroids and more anesthetic will be injected into the bursa. At the end of the injection, the needle is removed, the skin is cleaned, and a bandage is applied.
The anesthetic usually provides immediate, although temporary, relief – up to about 6 hours depending on the type used. The steroids start showing results between two and five days after the injection with the strongest effect usually showing up between ten and fourteen days post-injection. Most patients get the highest level of relief after approximately six weeks. The steroids can maintain pain relief for three to six months, but your experience may vary. Steroid injections can be given more than once but they are generally limited to three or four times per year. This is because the more steroids you get, the higher your risk is for side effects.
The procedure might be painful, especially when the needle reaches the bursa and you should be aware of and prepared for this. Remember, your doctor aims to relieve your pain and improve your comfort, and knowing what the treatment entails could help alleviate some of the related anxiety.
Possible Complications of Greater Trochanteric Bursa Injection
Generally, the procedure of injecting medicine into the trochanteric bursa, a part of your hip, is considered safe, with a low chance of experiencing any serious bad reactions. Some common risks you should be aware of include pain, bleeding, infection, allergic reactions, and the chance of injury to nearby body parts.
If you continue to feel pain at the site where the injection was given or if the skin around it looks red or seeps pus, it’s possible you may have an infection. Other signs of infection might include having a fever, feeling cold, or showing other signs of infection. However, the overall possibility of developing a severe joint infection called septic arthritis is low, at less than 0.3%. Another very rare condition that has been reported is Necrotizing fasciitis, a severe skin infection, following the injection.
Some common side effects of the injection, which may contain steroids, include a headache, a hot flushed feeling, having trouble sleeping, and higher than usual blood sugar levels. Long term treatment with injectable steroids can make your tendons, the cords connecting muscles to bones, weaker and might increase the chance of tearing your tendons.
Sometimes after getting a steroid injection, you might feel severe localized pain and other symptoms that simulate septic arthritis. This is known as steroid flare and often happens 1 to 3 days following the injection, lasting up to 5 days. On the upside, this flare-up does not hinder the effectiveness of the treatment and is usually treated with medications containing NSAIDs that help to reduce pain and inflammation. Lastly, a steroid injection can cause the fat cells where the injection was given to deteriorate, and you may notice a small dent in your skin where the injection was given.
What Else Should I Know About Greater Trochanteric Bursa Injection?
Greater trochanteric bursitis is a condition that causes severe pain and can disrupt your normal activities. This condition often gets better on its own, but it may need treatment to help manage the pain and allow you to continue your regular activities. Treatment usually involves rest, physical therapy, and weight loss if needed. Medication such as NSAIDs (nonsteroidal anti-inflammatory drugs), which reduce pain and inflammation, can also be helpful.
In some cases, your doctor may suggest an injection of corticosteroids, which are powerful anti-inflammatory drugs, to help reduce your pain. This injection can be done using only a mark on your skin for guidance (landmark-based), or with the help of imaging methods like fluoroscopy (an X-ray technique) or ultrasound to guide the direction of the needle for precise placement.
It’s worth mentioning that while these imaging methods can assure the needle is placed directly inside the inflamed area (the bursa), studies have shown that they don’t necessarily make a significant difference in relieving pain compared to landmark-based injections.
However, there is evidence showing that ultrasound-guided injections are generally more accurate in targeting the inflamed bursa than landmark-based injections. As a result, if a landmark-based injection doesn’t relieve your pain, or if images show inflammation in the bursa, your doctor may consider using image-guided injections.
