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How To Inject a Trochanteric Bursa

By

Alexandra Villa-Forte

, MD, MPH, Cleveland Clinic

Last full review/revision Oct 2020| Content last modified Oct 2020
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Trochanteric bursal injection therapy is the process of puncturing a bursal sac with a needle and injecting anesthetics, sometimes with corticosteroids, to help treat greater trochanteric pain syndrome.

Isolated trochanteric bursitis is now believed to occur rarely, and lateral hip pain is more often referred to as greater trochanteric pain syndrome, which most often originates from gluteal medius and minimus tendinopathy, sometimes with an associated bursitis. However, injection therapy (aimed at the point of maximal tenderness) is the same for both disorders.

The deep bursae (trochanteric, subacromial, or anserine) lie between bone and overlying tendons. Bursitis of a deep bursa seldom manifests with visible swelling or erythema.

(See also Bursitis.)

Indications

  • For injections of corticosteroid to treat inflammation

Symptoms of nonseptic trochanteric bursitis and greater trochanteric pain syndrome are effectively treated with rest, nonsteroidal anti-inflammatory drugs, and exercise therapy. However, when trochanteric bursitis persists despite conservative measures, bursal injection provides rapid relief.

Bursal fluid analysis is needed to diagnose septic or crystal-induced bursitis.

Contraindications

Absolute contraindications

  • Overlying cellulitis or skin ulcer, bacteremia, adjacent prosthetic joint

  • Hypersensitivity to an injected substance

  • For corticosteroid injection, suspected septic bursitis

Relative contraindications

  • Unrecognized tendon injury: Analgesia provided by a corticosteroid injection could delay accurate diagnosis.

  • Poorly controlled diabetes: Any benefit of corticosteroids is weighed against risk of worsening glycemic control.

  • Previous corticosteroid injection into same site: Many experts advise waiting 3 to 4 months between injections and not exceeding a lifetime total of 4 injections.

Coagulopathy is not a contraindication (1).

Complications

Complications are uncommon and include

  • Subcutaneous fat atrophy, skin atrophy and sinus tracts, and temporary skin depigmentation due to inadvertent subcutaneous corticosteroid injection

  • Painful local reaction (sometimes called steroid flare) occurring within a few hours of depot corticosteroid injection and usually lasting ≤ 48 hours (probably an irritation due to crystals in the injection vehicle)

  • Infection

  • In diabetic patients, hyperglycemia that may persist for weeks after a depot corticosteroid injection

Equipment

  • Antiseptic solution (eg, chlorhexidine, povidone iodine, isopropyl alcohol)

  • Sterile drapes

  • Sterile gauze, sterile gloves, sterile adhesive bandage

  • Needle insertion site anesthesia (eg, topical freezing spray or injectable 1% lidocaine without epinephrine)

  • For therapeutic injection, 10-mL syringe with about 3 to 10 mL 1% lidocaine without epinephrine, with injectable depot corticosteroid (eg, triamcinolone acetate, 40 mg)

  • Hemostat

  • 2-inch needle, 22 to 25 gauge

  • Some 3-mL syringes

Having an assistant is helpful.

Additional Considerations

  • For bursal injection therapy, local anesthetic and depot corticosteroid often are mixed in a single syringe (the anesthetic eliminates the pain of the corticosteroid).

  • If the history or physical examination suggests the possibility of septic bursitis, withhold corticosteroid injection.

  • Immediate analgesia after injection of local anesthetic helps confirm correct needle placement and that greater trochanteric pain syndrome is the source of pain.

Relevant Anatomy

  • Although tenderness at or near the greater trochanter is characteristic, the trochanteric bursae are usually not the source of the pain.

  • Commonly affected trochanteric bursae are the subgluteus maximus bursa (multiloculated, lies between the greater trochanter and the gluteus maximus tendon) and the bursae between the greater trochanter and gluteus medius and minimus tendons.

  • Pain elicited by palpation is used to determine the site of needle insertion.

Positioning

  • Place the patient lying laterally on the unaffected side, with affected leg slightly flexed and adducted to move the lateral muscles away from the greater trochanter.

  • To avoid vasovagal episodes, avert the patient's head and orient your work area so that the patient does not see the needles.

Step-by-Step Description of Procedure

Do the procedure using sterile technique.

Prepare the site

  • Mark the site of needle entry on the skin.

  • Prepare the area with antiseptic solution.

  • Apply sterile drapes.

  • Spray freezing spray at the needle insertion site until it just blanches and/or place a skin wheal of local anesthetic (eg, ≤ 1 mL).

Inject the bursa

  • Wear sterile gloves.

  • Insert the needle perpendicularly to the skin at the point of maximum tenderness, aiming toward the greater trochanter. Gently pull back on the plunger as you advance to rule out intravascular placement.

    When the tip of the needle touches the greater trochanter, retract the needle about 1 mm.

  • Slowly inject all of the anesthetic/corticosteroid mixture and withdraw the needle.

    If the injection meets resistance, the needle tip may be within an overlying tendon. Stop injecting and advance or withdraw the needle until the injection does not meet resistance.

  • Pain is immediately relieved after a properly placed injection of anesthetic. 

  • Apply an adhesive bandage or sterile dressing.

Aftercare

  • Prescribe limited hip activity (eg, stairs, prolonged walking), ice, and oral nonsteroidal anti-inflammatory drugs (NSAIDs) until pain subsides.

  • Instruct the patient to return for reassessment to exclude infection if pain is continuously and progressively increasing after several hours or persists for > 48 hours.

  • Relative immobilization helps minimize the spread of the corticosteroid  into adjacent tissues and maximizes its therapeutic effect.

Warnings and Common Errors

  • To avoid damaging tendons, do not inject corticosteroid against resistance.

Tips and Tricks

  • Consider using a larger (20-gauge) needle to better avoid puncturing a tendon (a larger needle incurs more resistance when it meets a tendon than a smaller needle does).

Reference

  • 1. Yui JC, Preskill C, Greenlund LS: Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 92(8):1223–1226, 2017. doi: 10.1016/j.mayocp.2017.04.007

Drugs Mentioned In This Article

Drug Name Select Trade
KENALOG
ADRENALIN
XYLOCAINE
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