Intended for healthcare professionals

Rapid response to:

Research

Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1088 (Published 14 April 2009) Cite this as: BMJ 2009;338:b1088

Rapid Response:

Corticosteroid injections for greater trochanteric pain syndrome not the best option

Sir,

we read with interest the recent article by Cohen et al. “Comparison
of fluoroscopically guided and blind corticosteroid injections for greater
trochanteric pain syndrome: multicentre randomised controlled trial“ [2]
highlighted in the Editorial from Bahr and Khan “Management of lateral hip
pain”. [1]

The study in question [2] had a main follow-up of one month, and, at
three months, outcome data from 39 of 65 subjects (= 60%) were provided.
The trial design did not provide any news on how to improve our management
of greater trochanter pain syndrome, focusing on the usefulness and
economic issues of performing local imaging guided steroid injection.

In a trial recently accepted for publication in the American Journal
of Sports Medicine, [4] we tested the null hypothesis that local
corticosteroid injection, home training, and repetitive low-energy shock
wave therapy produced equivalent outcome at four months from baseline.
In a quasi-randomized controlled clinical setting, 229 patients with
refractory unilateral greater trochanter pain syndrome were assigned to a
home training program, a single local corticosteroid injection without
imaging guidance (25 mg prednisolone), or repetitive low-energy radial
shockwave treatment. Patients underwent outcome assessments at baseline
and a one, four, and 15 month follow-up from baseline. The primary outcome
measures were degree of recovery, measured on a 6-point Likert scale
(subjects with rating -completely recovered- or -much improved- were rated
as treatment success), and severity of pain over the past week (0-10
points) at four month follow-up.
At one month from baseline, the results after corticosteroid injection
(success rate 75%; pain rating: 2.2 points) were significantly better than
after home training (7%; 5.9 points) or shockwave therapy (13%; 5.6
points).
Regarding treatment success at four months, radial shockwave therapy lead
to significantly better results (68%; 3.1 points) than home training (41%;
5.2 points), and than corticosteroid injection (51%; 4.5 points). The null
hypothesis was rejected.
Fifteen months from baseline, radial shockwave therapy (74%; 2.4 points)
and home training (80%; 2.7 points) were significantly more successful
than the corticosteroid injection (48%; 5.3 points).
We concluded that the role of corticosteroid injection for GTPS needs to
be reconsidered. Patients should be informed about the advantages and
disadvantages of the treatment options, including the economic burden. The
significant short-term superiority of a single corticosteroid injection
over home training and shockwave therapy declined after one month. Both
corticosteroid injection and home training were significantly less
successful than shockwave therapy at four month follow-up. Corticosteroid
injection was significantly less successful than home training or
shockwave therapy at 15 month follow-up.

This study [4] contradicts three assumptions of the Editorial by Bahr
and Khan [1].
Firstly, the study [4] demonstrated that there is an investigation of
therapeutic exercises specifically related to the gluteal region.
Secondly, home exercises and shockwave therapy should be tried before
surgery is recommended. Thirdly, in light of another upcoming study [3] on
shockwave treatment for greater trochanter pain - winner of the 2009
Achilles Orthopaedic Sports Medicine Research Award of the International
Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
(ISAKOS) - management of greater trochanter pain syndrome needs no longer
to be based on evidence from other anatomical sites.

Sincerely,

Jan D. Rompe, John P. Furia, Nicola Maffulli
(on behalf of the International GTPS study group)

References:
1. Bahr R, Khan K. Management of lateral hip pain. BMJ 2009; 338:b713.
2. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M, Gross
A, Kurihara C, Nguyen C, Williams N. Comparison of fluoroscopically guided
and blind corticosteroid injections for greater trochanteric pain
syndrome: multicentre randomised controlled trial. BMJ 2009;338:b1088.
3. Furia JP, Rompe JD, Maffulli N. Low energy extracorporeal shock wave
therapy as a treatment for greater trochanteric pain syndrome. Am J Sports
Med/2008/058008. Accepted January 21, 2009.
4. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home
training, local corticosteroid injection or radial shockwave therapy for
greater trochanter pain syndrome. Am J Sports Med/2008/059485. Accepted
Feb 6, 2009.

Competing interests:
None declared

Competing interests: No competing interests

09 May 2009
Nicola Maffulli
Centre Lead and Professor of Sports and Exercise Medicine, Consultant Trauma and Orthopaedic Surgeon
Mile End Hospital, 275 Bancroft Road, London E1 4DG
Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry