Over the years we have seen many patients with hip pain. Many of them having a “hip bursitis.” If you have a diagnosis of bursitis, you know what it is, as most you have been diagnosed with a trochanteric bursitis or an iliopsoas bursitis. Sometimes both. The iliopsoas bursitis is felt in the groin area on the inside of the hip. The trochanteric bursitis is felt on the outer part of the hip.

However, most of the patients we see may or may not have a bursitis even though they have a diagnosis of one and they are on anti-inflammatory medications. Bursitis is an inflammation of the protective, fluid filled sacs that prevent excessive friction between the functional soft tissue of the hip, i.e., the ligaments and tendons, and the bones they attach to and rub against. These bursae can become irritated from injury, excessive pressure, and overuse. More often this diagnosis is actually a problem of tendonitis or tendinosis. However, for the purpose of this article, I will focus on the problem of bursitis.

Once a diagnosis of bursitis is made, the patient will typically be given a “healing,” regiment that will include:

• Activity modification and rest
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Physical therapy.
• Injection of a corticosteroid

These treatments may be effective for some, non-effective for others. Once the cortisone injection or injections fail to provide any relief, the patient will usually start seeking other options. One option is Platelet Rich Plasma therapy or PRP. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. Why PRP?

Clinical outcomes of PRP treatment in Greater trochanteric pain syndrome (trochanteric bursitis)

In January 2020, a study published in the medical journal Cureus, (1) offered the following on the superiority of PRP treatments to cortisone:

• 24 patients with greater trochanteric pain syndrome were enrolled and randomized into two study groups
• In Group A patients received ultrasound-guided PRP injection treatment, while group B patients received ultrasound-guided cortisone injections. Clinical outcomes in both groups were evaluated and compared using various patient reported scoring systems.
• Both groups showed improved scores compared to the pre-injection period, but patients in the PRP group had a statistically significant decrease in pain and increase in functionality at the last follow-up (24 weeks post-injection). No complications were reported.
• In conclusion, “patients with greater trochanteric pain syndrome present better and longer-lasting clinical results when treated with ultrasound-guided PRP injections compared to those with cortisone.s.

Greater trochanteric pain syndrome (trochanteric bursitis)

A 2018 study in the Journal of hip preservation (2) made these observations on the use of Platelet Rich Plasma injections for greater trochanteric pain syndrome.

• Greater trochanteric pain syndrome, (trochanteric bursitis), commonly affects middle-aged women.
• It is characterized by pain over the outer side of the hip. Recently the understanding of Greater trochanteric pain syndrome has evolved. Gluteal tendinopathy is believed to be the main contributory factor rather than bursal inflammation. There are numerous studies reporting little evidence of bursal inflammation in Greater trochanteric pain syndrome but found gluteal tendon tendinopathy more commonly associated with Greater trochanteric pain syndrome.
• Greater trochanteric pain syndrome has also been associated with low back pain, knee osteoarthritis and iliotibial band syndrome.
• Greater trochanteric pain syndrome can be resolved with conservative treatments such as relative rest and anti-inflammatory medication in the majority of patients. If conservative measures fail then progressively more invasive treatment options including shockwave therapy, corticosteroid injections, PRP and surgery may be required.
• Lately PRP has become very popular among the orthopedic community as a minimally invasive way of enhancing tissue healing. It is thought that PRP promotes soft tissue healing by delivering a higher than normal concentration of platelets and therefore increased concentration of platelet derived growth factors to the diseased area. This has been shown in various studies.
• The use of PRP in treating Greater trochanteric pain syndrome has become more prevalent in recent times.
• There is a lack of studies providing high-quality evidence as to what is causing the pain in Greater trochanteric pain syndrome. Quite often the pathology may be in the gluteus medius and minimus tendon and not exclusively the bursa, therefore the site of injection (treatment) needs to be considered.
• In most improvements were observed during the first 3 months after PRP injection . Significant improvements were reported when patients were followed up to 12 months post treatment. There are, however, conflicting results between the randomized studies as to whether PRP is superior to corticosteroid. Considering these factors, PRP seems a viable alternative treatment with the current evidence in patients with Greater trochanteric pain syndrome not responding to conservative measures. Further large-sample and high-quality randomized clinical trials in the future should be conducted to present evidence of the efficacy for PRP as a treatment in Greater trochanteric pain syndrome.

Method of how PRP is given can impact the effectiveness of the treatment

I want to bring attention to a December 2019 study (3) that questions whether PRP is an effective treatment for Greater trochanteric pain syndrome. In this study, patients with chronic lateral hip pain were randomised to either a PRP injection (intervention group) or a saline injection (control group) and both groups were prescribed identical eccentric exercise. The researchers found that there were no differences in any outcomes between the two groups at any follow-up point. They concluded a single injection of PRP resulted in no significant improvement for Greater trochanteric pain syndrome compared with a placebo injection.

• A single injection is typically not as effective as “poking” the hip a few times within the single treatment. Patients will usually benefit from two or three PRP treatments. This would need to be confirmed before treatment begins.

This was a recent study published in the Journal of pain research.(4) It hits upon some good points that describe how PRP works and when PRP may not work.

• Variability in treatment can lead to failure: “Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief.” To summarize that, you need to see a doctor or clinician that has developed effective protocols for the PRP treatment you are seeking. We have been doing regenerative medicine for over 20 years.

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References

1 Begkas D, Chatzopoulos ST, Touzopoulos P, Balanika A, Pastroudis A. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study. Cureus. 2020 Jan;12(1).
2 Ali M, Oderuth E, Atchia I, Malviya A. The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. J Hip Preserv Surg. 2018 Aug 30;5(3):209-219. doi: 10.1093/jhps/hny027. PMID: 30393547; PMCID: PMC6206702.
3 Thompson G, Pearson JF. No attributable effects of PRP on greater trochanteric pain syndrome. N Z Med J. 2019 Dec 13;132(1507):22-32. PubMed PMID: 31830014.
4 Kuffler DP. Variables affecting the potential efficacy of PRP in providing chronic pain relief. J Pain Res. 2018;12:109-116. Published 2018 Dec 21. doi:10.2147/JPR.S190065 — 1418