Pain over the outside of the hip is one of the most common presentations in musculoskeletal practice, and one of the most commonly mislabelled. It is routinely called trochanteric bursitis when the problem is frequently the tendon rather than the bursa.
Getting the target right starts with an anatomical fact that surprises people.
The muscle that does not insert there
Dr. Glenn Barnes treats the anatomy as non-negotiable before this injection: “the anatomy here is important.”
The greater trochanter of the femur is the attachment point for several muscles arising from the pelvis. For this procedure, the two that must be known are the gluteus medius and the gluteus minimus.
And the correction that matters: “the gluteus maximus does not insert into the greater trochanter. Instead, it inserts into the posterior aspect of the iliotibial band.”
That single fact reorganises the region. What you are looking at over the greater trochanter is medius and minimus tendon with the bursa between tendon and bone. The gluteus maximus is passing over the area on its way to the IT band, not attaching to it.
Mistake one for the other on the screen and you inject the wrong structure with faultless needle technique.
Bursitis, tendinopathy, or both
The term trochanteric bursitis persists, but imaging routinely shows tendinopathy of gluteus medius or minimus with or without bursal fluid. The broader term now used is greater trochanteric pain syndrome, precisely because the label named one structure while the pathology sat in another.
This distinction has a treatment consequence rather than being merely semantic. A corticosteroid is an anti-inflammatory, and degenerate tendon is not primarily an inflammatory problem. Repeated steroid around a degenerate tendon is a decision with a cost, discussed in corticosteroid injections.
Ultrasound is what separates them. Tendinosis appears hypoechoic — darker than healthy tendon — and bursal fluid is visible as a distinct collection. You are not guessing.
Which probe
Depth decides, and in this region it depends heavily on the patient.
Barnes's rule is that structures deeper than five or six centimetres call for a curvilinear probe, and he names hips among the targets typically greater than three or four centimetres deep. In a slimmer patient the greater trochanter may sit within range of a high-frequency linear probe, which gives better resolution of tendon architecture.
Scan first and decide from what you see rather than from a default.
Guidance technique
In-plane, for the reasons that apply throughout guided injection: the whole needle including the bevel stays visible, which Barnes says “maximises safety and accurate placement.”
Out-of-plane here would be a poor choice. The bright white dot marking the needle only tells you where the needle crosses the imaging plane at that moment, and advancing beyond its first appearance means the tip travels unseen — unnecessary in a region with room for a parallel approach.
The probe hand needs at least two fingers anchored on the patient. Gel makes the probe slide, and a sliding probe makes needle visualisation impossible.
Sterile requirements here
This one generally falls on the simpler side of the rule. The needle enters at a distance from the probe rather than immediately alongside it, so it does not pass through ultrasound gel.
By Barnes's criterion that means sterile preparation of the injection site, without a sterile probe cover or sterile gel — the same category as an intra-articular knee injection rather than a carpal tunnel or foot injection. Confirm against your own needle path, since that is what the rule turns on.
Watch where the injectate goes
The advantage guidance offers over landmark technique is not only seeing the needle but seeing the drug.
Barnes applies this at the hip joint, where the injectate should be seen spreading and remaining underneath the joint capsule. The same principle applies laterally: fluid should be seen entering the bursal space or tracking along the tendon as intended, not disappearing into subcutaneous fat.
Spread that looks wrong is the earliest indication the tip is not where you believe it is — earlier than any other signal available.
Why it comes back
An injection into this region frequently works and then stops working, which is worth explaining to the patient in advance rather than at the review appointment.
Greater trochanteric pain is commonly driven by load: gluteal weakness, altered gait, hip abductor mechanics, sometimes a leg length difference or lumbar contribution. The injection reduces pain. It does not change any of those.
That makes the injection a window rather than a treatment — useful precisely because it allows rehabilitation that pain was preventing. A patient who has three injections and no strengthening programme is being treated with something that was never going to hold.
When it is not the trochanter at all
Lateral hip pain has mimics worth excluding before injecting:
- Referred lumbar pain, particularly L4 or L5
- Hip joint pathology referring laterally rather than to the groin
- Meralgia paraesthetica, which is sensory and anterolateral
- An unrecognised gluteal tendon tear, where weakness rather than pain dominates
Ultrasound helps with several of these directly, which is part of the argument for scanning before injecting rather than scanning to guide a decision already made.
Learn blocks with your hands, not from a page
Empire’s Pain Management Training (THE Pain Show) is accredited for 25.25 AMA PRA Category 1 Credits™, jointly provided by AKH, Inc, and Empire Medical Training. For narrower peripheral work, Joint, Extremity and Non-Spinal Injection Training carries 6.75 credits for the complete in-person hybrid program, and Advanced Musculoskeletal Ultrasound Guided Injections builds the guidance skills above.
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