Performing an Ultrasound Guided Trochanteric Bursa Injection
Introduction
Greater trochanteric pain syndrome is a common condition and can be found in up to 15% of active adults (3). The greater trochanter is the proximal and lateral portion of the femur and is commonly mistaken by patients as the “hip joint”. This is a busy area, as it is the insertion of 7 muscles (1). The most common tendons that are subject to tendinosis and are the cause greater trochanteric pain syndrome are the gluteus medius and gluteus minimus. The gluteus minimus will insert on the anterior facet of the trochanter and the gluteus medius tendon inserts on both the lateral and superoposterior facet (1). What we typically refer to as the greater trochanteric bursa is the sub-gluteus maximus bursa, which is found superior to the lateral and posterior facets of the trochanter (1). There are two other bursas overlying the greater trochanter, which are the sub-gluteus medius and sub-gluteus minimus bursa (1).
Three bursa located at the greater trochanter (9)
Patients with greater trochanteric pain syndrome will typically complain of lateral sided hip pain. Pain may worsen when lying down and walking up and down stairs (6).
Procedure
An injection of corticosteroids or platelet rich plasma into the sub-gluteus maximus bursa is a treatment option for greater trochanteric pain syndrome. The patient is typically placed in the lateral decubitus position with their knees in slight flexion. The provider will sit behind the patient and will use their curvilinear probe for the procedure. Needle size can vary from a 22g 2 inch needle to a 22g 3.5 inch needle depending on patient habitus. Typically, scanning should be done in a distal to proximal direction on the patient. The greater trochanter will be found when the triangle shaped intersection of the anterior and lateral facet are visualized (2). The superficial muscles at this location are the gluteus maximus and tensor fascia lata (10). The thickened portion of the fascia lata is the IT band and is the site of three quarters of the gluteus maximus insertion (10). The deeper muscle insertions are the gluteus medius and minimus as seen in the image below (10). There may be a trace amount of fluid visualized in the bursa (4).
Visualization of the lateral and anterior facet (2)
The needle will be guided in plane in a posterior to anterior direction (2, 3). Anesthetic can be used for bursa location. The sub-gluteus maximus bursa is found when the needle passes through the gluteus maximus/IT band and superior to the gluteus medius tendon insertion on the lateral facet (2).
Posterior to anterior needle direction (1)
PRP can also be used as an injectate into the trochanteric bursa. The advantage of PRP is that the PRP can also safely be injected into the gluteus medius and minimus tendon
Conclusion
Greater trochanteric pain syndrome is a common cause of lateral hip pain. Trochanteric bursa injections can be done to assist in pain relief. Ultrasound guidance can improve accuracy of the injection to 92% compared to only 67% with a landmark injection (5).
By Gregory Rubin, DO
rubinsportsmed.com
– More Hip Pain @ Sports Med Review: https://www.sportsmedreview.com/by-joint/hip/
– More Greater Trochanteric Pain Syndrome: https://wikism.org/Greater_Trochanteric_Pain_Syndrome
References
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2) Furman, Michael B., et al. Atlas of Image-Guided Spinal Procedures: Atlas of Image-Guided Spinal Procedures E-Book. Elsevier Health Sciences, 2017.
3) Chang, Ke-Vin, et al. “Ultrasound Imaging and Guided Injection for the Lateral and Posterior Hip.” American Journal of Physical Medicine & Rehabilitation, vol. 97, no. 4, Apr. 2018, pp. 285–91. PubMed, gttps://doi.org/10.1097/PHM.0000000000000895.
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6) Mallow, Michael, and Levon N. Nazarian. “Greater Trochanteric Pain Syndrome Diagnosis and Treatment.” Physical Medicine and Rehabilitation Clinics of North America, vol. 25, no. 2, May 2014, pp. 279–89. PubMed, https://doi.org/10.1016/j.pmr.2014.01.009.
7) Lancaster, Timothy P., et al. “Hip Imaging and Injections.” Clinics in Sports Medicine, vol. 40, no. 2, Apr. 2021, pp. 241–58. PubMed, https://doi.org/10.1016/j.csm.2020.11.002.
8) McCarthy, Eoghan, et al. “Ultrasound-Guided Interventions for Core and Hip Injuries in Athletes.” Radiologic Clinics of North America, vol. 54, no. 5, Sept. 2016, pp. 875–92. PubMed, https://doi.org/10.1016/j.rcl.2016.04.008.
9) Waldman, Steven D., editor. “Copyright.” Atlas of Pain Management Injection Techniques (Fifth Edition), Elsevier, 2023, p. iv. ScienceDirect, https://doi.org/10.1016/B978-0-323-82826-0.12001-2.
10) Mu, Alex, et al. “Landmark-Guided and Ultrasound-Guided Approaches for Trochanteric Bursa Injection: A Cadaveric Study.” Anesthesia and Analgesia, vol. 124, no. 3, Mar. 2017, pp. 966–71. PubMed, https://doi.org/10.1213/ANE.0000000000001864.
