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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

Repeat injection is not the next course of action

Cohen and colleagues are to be commended for demonstrating that the
use of fluoroscopy is unhelpful in improving outcome following injection
for greater trochanter pain syndrome (GTPS).1 Although the results are
unsurprising, the author’s conclusions provoke discussion.

GTPS is a commonly used term that fails to specifically identify the
underlying pathology. There are numerous anatomical structures that can
cause pain around the greater trochanter and it is well recognised that
pain experienced over the lateral aspect of the hip may be referred from
other sources. It is therefore inappropriate to manage all patients with
GTPS in the same way and a focussed history, examination and investigation
are required to accurately diagnose and treat these patients.

It is interesting that Cohen and colleagues chose to use fluoroscopy
to target injection therapy because although fluoroscopy is useful for
confirming intra-bursal injection the bursa itself is rarely involved
(hence a departure from the previously popular term “trochanteric
bursitis”). Although the authors recognise this, it remains unsurprising
that they showed no difference between the groups, as even in an extra-
bursal injection, the therapy cannot be accurately located to the site of
the lesion using the methodology described. Ultrasound would be more
useful in improving the accuracy of placement of therapeutic or diagnostic
injection and can also provide information about the degree of
tendinopathy, the presence of neovascularity and whether a partial or full
tear is present.2

It is surprising that Cohen et al, conclude that patients should be
referred to a pain clinic with fluoroscopic capability if they fail
landmark guided injection as they did not demonstrate any advantage of
fluoroscopic guided injection! In addition the role of corticosteroid
injection in tendinopathies in general, is controversial. Although
commonly administered there is concern about their influence on the
mechanical integrity of tendons and rupture is a recognised complication.3
Given the lack of studies evaluating the treatment effect of
corticosteroids it is fair to state that there is little evidence to
support their use in chronic tendon lesions and therefore referring a
patient for a second injection when the first did not work seems counter-
intuitive.3 It would perhaps be more important to try and accurately
determine the underlying pathology in these patients by means of focussed
clinical examination and further imaging. The 30-second single-leg stance
and resisted external de-rotation tests have been reported to have very
good sensitivity and specificity for the diagnosis of tendinous lesions
around the greater trochanter.4 MRI also has a role but the results must
be taken in context as a high proportion false positives occur, with up to
50% of asymptomatic patients demonstrating gluteal tendinopathy on T2
imaging sequences in one particular series.5

Patients with symptoms refractory to non-operative management, a
documented tear on imaging studies, a positive ultrasound guided injection
test and absence of retraction or fatty degeneration of the tendon should
be referred for a surgical opinion.6 Although there are no controlled
studies to estimate the treatment effect of surgery a recent review
article identified several case series that report good outcome.6 Patients
should be referred to a pain clinic if symptoms do not warrant surgery,
they are unfit for surgery or do not have a surgically amenable lesion.

1. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M,
et al. Comparison of fluoroscopically guided and blind corticosteroid
injections for greater trochanter pain syndrome: multicentre randomised
controlled trial. BMJ 2009;338:986-88.

2. Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal
tendinopathy in greater trochanteric pain syndrome. Eur Radiol
2007;17(7):1772-83.

3. Rees JD, Wilson AM, Wolman RL. Current concepts in the management
of tendon disorders. Rheumatology 2006;45:508–521

4. Lequesne M, Mathieu P, Vuilleman-Bodaghi V, Bard H, Dijan P.
Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome:
Diagnostic Value of Two Clinical Tests. Arthritis & Rheumatism
(Arthritis Care & Research) 2008;59(2):241-246

5. Blankenbaker DG, Ullrick SR, Davis KW, De Smet AA, Haaland B, Fine
JP. Correlation of MRI findings with clinical findings of trochanteric
pain syndrome. Skeletal Radiol 2008;37(10):903-9

6. Lequensne M. From “periarthritis” to hip “rotator cuff” tears.
Trochanteric tendinobursitis. Joint Bone Spine 2006;73:344-348

Competing interests:
None declared

Competing interests: No competing interests

25 April 2009
Adnan Saithna
Specialist Registrar, Trauma and Orthopaedics
Birmingham Heartlands Hospital