Injections for the Treatment of Hip Bursitis: What is more effective?
Hip bursitis, otherwise known as greater trochanteric bursitis is a condition characterised by pain over the outside of the hip that radiates along the outside border of the thigh. lateral hip bursitis is also associated with gluteal tendinopathy. It is more common in women aged 40 to 60 years, and in overweight individuals.
Hip bursitis can be caused by direct trauma, prolonged pressure on the hip, repetitive movements, unaccustomed vigorous exercise, long-lasting weight bearing on one leg, hip instability and sports injuries. Traditionally hip bursitis was thought to be caused by inflammation of the bursa (trochanteric bursitis), but further studies have shown that is attributable to chronic tendinitis and insertional dysfunction of the tendon of gluteal muscles onto the side of the bone. Also, the tensor fascia latae tissue overlining the surface of the bone and bursa. Inflammation of these tendons leads to secondary inflammation of the bursa. Another cause is tightness of the gluteal muscles and the iliotibial band, which also runs over the bone and can irritate the bursa
The main symptom involves localised pain which may radiate down the lateral thigh. Pain may progressively worsen over time and be exacerbated by pressure, for example lying on the affected side, with prolonged standing, sporting overuse, repetitive motions, weight-bearing, walking, long-distance running, falls and sitting with crossed legs.
The main treatment goals are: to mobilise and to strengthen gluteal muscles. Majority of cases can be managed conservatively with weight loss, physical rehabilitation therapy, load modification and lifestyle modifications. Corticosteroid injections can be effective in chronic cases and give patients short term pain relief. But often this can be short lived, if the modifications are not adapted.
More recently, regenerative therapies like platelet-rich plasma (PRP) have become very popular among the musculoskeletal and orthopaedic community as a minimally invasive method of promoting repair and tissue healing in many chronic conditions. It has been proved that PRP promotes soft tissue healing and repair by delivering a high concentration of platelet-derived growth factors to the damaged area.
Chronic lateral hip bursitis is characterised by lateral hip pain and tenderness. Symptoms can be increased by simple daily activities such as walking or lying on the side of the affected hip. The underlying conditions include chronic tendinitis or tears of the gluteal tendons at the bone insertion point and not just bursitis. Gluteus medius is most commonly affected than gluteus medius, due to it’s stabilising properties. Thus, the treatment of lateral hip pain and bursitis should be directed to the treatment of the underlying disorder. In the vast majority of patients, treatment is effective with normal conservative measures such as physical rehabilitation therapy, manual therapy and lifestyle modifications. However, if conservative treatments fail, other more invasive options may be applied like local corticosteroid or PRP injections.
A traditional way of treating chronic lateral hip pain is via the use of steroid injections. When applied superficially to tendinosis, in most cases, pain relief levels improve, due to their anti-inflammatory properties. However, steroid injections in the majority of cases only provide only short-term pain relief, and is not a long-term solution. This is supported by numerous studies that found that there is no association between gluteal tendinopathies and serious inflammations, which means that steroid injections cannot provide long-term pain relief. Furthermore, with repeated injections, there will be a level of associated tissue weakening and a risk of rupture if steroid is injected into a tendon.
The use of PRP in treating various different cases of tendon issues has become increasingly popular in recent years. This is due to the fact that PRP contains concentrated platelets, biologically active molecules and proteins, which activate and accelerate the body's mechanisms of healing into forming new tissue. PRP contains high concentrations of different growth factors like vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), fibroblast growth factor (FGF), platelet- derived growth factor (PDGF) and transforming growth factor β1 (TGF-β1) . VEGF stimulates angiogenesis of avascular chronically torn tendons . IGF-1 stimulates collagen synthesis at the site of tendon injury [12,16]. FGF controls chemotaxis, cell proliferation and collagen synthesis. PDGF improves tendon matrix remodeling, stimulates collagen synthesis, and increases cell proliferation and chemotaxis . These growth factors, in combination with anti-inflammatory components, activate the healing cascade and reverse the degenerative process . here by, PRP works very different to steroid. Many studies have provided strong evidence of PRP promoting growth factor-mediated and anti-catabolic (breakdown) and pro anabolic (new tissue formation) processes which are associated with proper tendon healing.
The recent study below looked to evaluate and compare the outcomes of PRP injections against steroid in the treatment of lateral hip pain and bursitis. This was achieved by applying a single injection of each intervention to each patient in the two groups and evaluating pain relief and functional outcomes at 4-,12- and 24-week follow-ups. When analysing outcomes, initially both groups of patients showed improvement in pain relief at the 4- and 12-week follow-ups. PRP patient were found to have significantly improved pain scores at 24-week follow-up compared with the steroid group. At the end of 12 weeks the pain score was not statistically different than that before the steroid application. Thus, concluding that the pain relief effectiveness of steroid is only short-term. In the PRP group, after 12 weeks, the pain score remained significantly low and progressively decreased further at 24 weeks, which means that PRP efficacy is gradually improving and is significantly longer compared to steroid. From the above results, there is clear understand that in the treatment of lateral hip pain and bursitis, PRP injections are initially as effective as steroid, but unlike steroid, the efficacy of PRP does not deteriorate over time. In this study, PRP injections had slower onset action than steroid, but achieved much better pain relief and functional scores after the 12-week and 24-week follow-ups, proving long-term effectiveness. Additionally, PRP treatment is considered very safe with no complications other than mild pain at the injection site. Also, PRP has antimicrobial properties that help prevent infections. Comparison to steroid, there are many studies that do not recommend the routine use of CSI due to their detrimental long-term effects.
To conclude, patients with lateral hip pain and bursitis present better and longer-lasting clinical results when treated with PRP injections compared to those with steroid, with less associated side-effects and complications. Further studies are needed to optimise preparation protocols of PRP.
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