Hip bursitis is the inflammation of the greater trochanteric bursa, a small fluid-filled sac on the outer hip. This condition causes persistent pain on the side of the hip, often worsening with activity or when lying down. A cortisone injection is a frequent first-line treatment, delivering an anti-inflammatory steroid directly to the site of irritation. When this injection fails to provide lasting relief, it suggests the underlying problem is more complex than simple bursal inflammation. This lack of improvement requires a thorough re-evaluation of the diagnosis and a shift toward advanced treatment strategies.
Examining Possible Reasons for Limited Relief
The most frequent reason a cortisone injection fails is an initial misdiagnosis of the pain source. What is often called “hip bursitis” is more accurately described as greater trochanteric pain syndrome (GTPS), which involves pathology in nearby tendons. The pain often originates from gluteal tendinopathy—irritation or damage to the gluteus medius or minimus tendons. If the bursa is not the primary source of pain, the injection may offer only temporary masking of symptoms or no relief at all.
The technical accuracy of the injection also determines its success or failure. Many cortisone injections are performed using a manual, or “blind,” technique without imaging guidance. This technique risks missing the bursa, sometimes depositing the steroid into the sensitive gluteal tendons instead. Injecting the steroid directly into a tendon can be counterproductive, potentially weakening the tissue and preventing the desired healing response.
Significant underlying pathology can limit the corticosteroid’s effectiveness. If tendon damage is severe, such as a partial or full-thickness gluteal tendon tear, an anti-inflammatory injection will not repair the structural defect. Cortisone works best for acute inflammation, but chronic GTPS often involves degenerative changes in the tendon tissue. In these advanced cases, steroids have limited benefit and offer only fleeting symptomatic relief.
Exploring Alternative Conservative Treatments
Once a cortisone injection has failed, the next step involves advanced physical therapy and biomechanical correction. A specialized physical therapy program targets the specific muscle weaknesses and imbalances contributing to the hip issue. This includes a progressive loading program that gradually strengthens the gluteus medius and minimus muscles. Strengthening improves hip stability and reduces friction on the bursa and tendons. Research suggests that a structured exercise and education program can be more effective for long-term improvement in gluteal tendinopathy.
If the problem persists, a physician may consider alternative injection therapies that promote healing rather than reducing inflammation. Platelet-Rich Plasma (PRP) injections are one option, where a concentration of the patient’s own platelets is injected into the injured tendon site. These platelets release growth factors that stimulate tissue repair. This mechanism differs significantly from the purely anti-inflammatory action of cortisone. Studies comparing PRP to cortisone for GTPS suggest that PRP may lead to better long-term pain and functional outcomes.
Extracorporeal Shock Wave Therapy (ESWT)
Another non-invasive alternative is Extracorporeal Shock Wave Therapy (ESWT), which uses high-energy acoustic waves applied to the painful area. This modality stimulates a healing response in the damaged tendon and surrounding tissue by promoting blood flow and cell regeneration. ESWT is reserved for refractory cases of GTPS that have not responded to physical therapy and initial medication management.
Guided Injections
For any further injections, especially if the initial shot was blind, repeating the procedure with ultrasound guidance is considered a superior approach. Ultrasound guidance ensures accurate placement of the therapeutic agent, maximizing the chance of success.
The Role of Advanced Diagnostic Testing
When conservative treatments, including a cortisone injection, do not resolve the pain, a deeper diagnostic investigation is necessary to confirm the exact source of the discomfort. Advanced imaging studies are employed to visualize the soft tissues of the hip. Magnetic Resonance Imaging (MRI) is highly effective for identifying specific structural problems, such as a tear in the gluteus medius or minimus tendons, which can mimic bursitis pain. MRI can also rule out other potential causes of lateral hip pain, including early hip joint arthritis or stress fractures.
High-resolution diagnostic ultrasound provides real-time visualization of the bursa, tendons, and surrounding tissues. Ultrasound confirms the presence and extent of fluid in the bursa and assesses the thickness and integrity of the gluteal tendons. This information is instrumental in guiding the next treatment steps, as managing an isolated tendon tear differs from treating simple bursal inflammation. Identifying a tendon tear is a direct indication that surgical intervention may be required if conservative measures fail.
When Surgery Becomes the Necessary Option
Surgery is generally considered the last resort for greater trochanteric pain syndrome, reserved for patients who have endured chronic and debilitating pain for six to twelve months despite exhaustive conservative management. The primary surgical procedure is a bursectomy, which involves the removal of the inflamed trochanteric bursa. This is most often performed arthroscopically. If advanced imaging revealed an underlying structural issue, the surgeon will perform a concomitant repair of the gluteal tendons, such as reattaching a gluteus medius tendon tear to the greater trochanter bone.
The recovery period depends on the extent of the surgery. An isolated bursectomy typically allows a return to full activity within two to four months, often with immediate weight-bearing. Recovery is significantly longer, sometimes six months or more, if a major tendon repair is required. This necessitates a structured post-operative physical therapy protocol to regain strength and mobility.