The site of injection might determine whether a patient responds.
We often assume that bursitis is the cause of pain and tenderness over the greater trochanter of the hip. Patients with greater trochanteric pain syndrome often receive corticosteroid injections, not necessarily guided by imaging. However, the relevant anatomy is complex: Several different bursae are present, and the anatomy varies from person to person.
In this retrospective single-site study, researchers in Wisconsin reviewed records of 65 patients who received ultrasound-guided trochanteric corticosteroid injections and who returned pre- and postinjection pain questionnaires. Injections were initiated at the site of maximal tenderness in all patients, but the ultimate location of the needle tip was the greater trochanteric bursa (i.e., deep subgluteus maximus bursa) in 41 patients and into the subgluteus medius bursa in 24 patients. Location of the needle tip was at the discretion of injecting radiologists; no anatomic ultrasound findings distinguished between the two groups. Among patients who received injections into the greater trochanteric bursa, pain improved significantly at 14 days (median improvement, 3 points on a 10-point visual analog scale; P<0.01). In contrast, median improvement was 0 among those who received injections into the subgluteus medius bursa.
COMMENT
This study's flaws include nonrandomized assignment of injection sites and exclusion of an unspecified number of patients who did not return surveys. Nevertheless, the findings might explain why response to steroid injections is so variable in clinical practice. Although these injections are easily done in primary care settings, I believe that we should consider referring selected patients for ultrasound-guided injections, if a specialist who is familiar with these landmarks is available. A nice review of greater trochanter anatomy is available online free of charge (Anesth Analg 2009; 108:1662 [Free full-text Anesth Analg article PDF | PubMed® abstract]).
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