A 45-year-old woman comes to the office for evaluation of right lateral hip pain. The pain, which started 2 months ago after a long hike in the mountains, is burning, constant, and worse when the patient rises from a chair or climbs stairs. She tried rest, heat, and high-dose naproxen therapy without relief. The patient's other medical conditions include obesity and plantar fasciitis. Vital signs are within normal limits. BMI is 39 kg/m². Examination shows point tenderness over the greater trochanter. Passive leg abduction worsens the pain. Muscle power, deep tendon reflexes, and sensation are normal. Which of the following is the most appropriate therapy for this patient?

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11ec25c8_d86b_72a8_bc81_b36f4a0a704b_MD0003_00 This patient has greater trochanteric pain syndrome (GTPS). GTPS is an overuse syndrome involving the tendons of the gluteus medius and minimus where they run over the greater trochanter. GTPS is sometimes termed "trochanteric bursitis," although the bursae are not the source of pain in most patients. GTPS typically presents with chronic lateral hip pain that is worsened with repetitive hip flexion (eg, climbing stairs, walking uphill) or lying on the affected side. gluteus medius and minimus lateral hip pain This diagnosis of GTPS is based primarily on clinical findings. Physical examination shows local tenderness over the greater trochanter during flexion. Hip range of motion is normal, although abduction may aggravate the pain. X-ray is commonly performed to rule out concurrent hip joint disorders; ultrasound may show chronic degeneration/tendinosis in the affected tendons. Initial treatment of GTPS includes local heat, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs). Oral NSAIDs (eg, ibuprofen) are typically used, although topical NSAIDs (eg, diclofenac) are also effective. Physical therapy is often helpful as well. Patients with persistent symptoms despite conservative therapy often benefit from local corticosteroid injection, which is generally safe and provides rapid pain relief. (Choice A) Evidence to support the use of opioids (eg, hydrocodone) in GTPS is negligible, and these agents carry significant risks (eg, dependence, sedation). (Choice C) Pregabalin, an alpha-2 delta ligand, is indicated for the treatment of chronic pain due to fibromyalgia and neuropathic disorders (eg, diabetic neuropathy, postherpetic neuralgia). Fibromyalgia can be associated with tenderness over the greater trochanter, but the pain and tenderness are typically widespread. (Choice D) Arthroscopic or open surgical intervention is reserved for patients who have significant tendon rupture or who fail less invasive management. (Choice E) Although lidocaine is often injected with a corticosteroid to give immediate pain relief, topical lidocaine has no anti-inflammatory effects and is used only occasionally for GTPS. Educational objective: Greater trochanteric pain syndrome presents with lateral hip pain and tenderness over the greater trochanter during flexion. Initial treatment includes heat, activity modification, and nonsteroidal anti-inflammatory drugs. Patients with persistent symptoms may benefit from local corticosteroid injection. References: The management of greater trochanteric pain syndrome: a systematic literature review. (http://www.ncbi.nlm.nih.gov/pubmed/26955229)

A 45-Year-Old Woman Comes to the Office for Evaluation of Right