Trochanteric Bursa Injection

Other Names

The greater trochanter and bursa

• Greater Trochanteric Bursa Injection
• Trochanteric Bursitis Injection
• Sub Glute Max Bursa Injection

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Background

Key Points

• Needle: 22 gauge, 3.5 inch
• Transducer: high frequency, curvilinear (but depends on body habitus)

Anatomy of the Greater Trochanter

• Muscle attachments:: Obturator Internus, Obturator Externus, Gemelli, Piriformis, Gluteus Minimus, Gluteus Medius
  • Attach to anterior, lateral and superoposterior facets
• 'Trochanteric Bursa': Largest of the subgluteus maximus bursa
  • Also called subglute max bursa
  • Lies between gluteus maximus and posterior part of gluteus medius

Palpation vs Ultrasound Guided

• This injection can be performed with either ultrasound or palpation guidance
• In a cadaveric study, Mu found palpation guided was 67% accurate while ultrasound guided was 92% accurate
• Estrela found improvement in patients perception but no intermediate term benefit when comparing landmark and ultrasound guided approaches

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Indications

• Greater Trochanteric Pain Syndrome

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

(A,B) Probe position and short axis image of the gluteus minimus (asterisk) sitting on the anterior facet with "rooftop appearance" (C). (D,E) Probe position and short axis view of posterior (diamond), anterior (asterisk) facets. White arrow indicates normal subglute max bursa

Ultrasound guided trochanteric bursa injection. (A) Patient and probe position, (B) ultrasound view shows trochanteric bursa (arrowhead) within glute medius tendon (open arrow) and deep to gluteus maximus (arrow), (C) Needle approach into bursa, (D) Bursal distension following injection

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: 22 gauge, 3.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Common ultrasound findings include:
  • Inflammation
  • Tendon thickening
  • Fluid accumulation in the subglute max bursa
  • interstitial, partial-thickness, or full-thickness tears of the gluteus medius and minimus tendons
• Scanning protocol
  • Begin superficial, parallel to the lateral facet
  • Slide anteriorly to visualize the “rooftop” appearance of the anterior, lateral facets, gluteus medius tendon
  • Slide posteriorly and carefully scan the broad flat anterior gluteus medius tendon and the ovoid-appearing posterior gluteus medius

Technique: In Plane

• Patient Position
  • Lateral decubitus position
  • Optional: pillow between legs
• Transducer position
  • Oblique axis to bursae
• Needle Approach/ Orientation
  • In plane
  • Anterior-Posterior: subglute max bursa
  • Inferior-Superior: subglute medius, minimus bursa
• Target
  • Subglute max bursa
  • Subglute medius, minimus bursa
• Pearls and Pitfalls
  • Subglute max bursa located between glute max and minimus muscle-tendon layer
  • Avoid injecting into tendon or tendon tears

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Aftercare

• No significant restrictions
• Can augment with ice, NSAIDS

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Complications

• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

Internal

• Procedures Main
• Ultrasound Main
• Hip Pain Main

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