Chronic Trochanteric Tendonitis

[Craig Guensch]

Hi,

Let me take a minute to explain my problem. I am currently 44 years old. From age 29 thru 39 I raced bicycles as an amateur here in the U.S logging upwards of 16,000 kilometers per year. At the end of the 1999 race season I was training for the state time trial. Pushing a lot of big gears on mostly flat terrain. I started to feel a pulling and burning sensation behind my right hip. At first I didn't think much of it, but over the next month it became worse and also started to show up in my left hip as well. I went to the orthopedic specialist who sponsored our race team and he diagnosed me with trochanteric tendonitis/busitis.

What I probably needed at the time was rest. But, like most endurance athletes, that was the last thing I wanted to be told. The doctor told me to continue training so that he could tell if his treatment was working. He prescribed Medrol and also put me on Celebrex. After a month with no improvement, he administered a series of cortisone injections. After 4 months of treatment, nothing worked. I decided to give up on getting it fixed.

A few months later I started to ride again, but usually in some level of discomfort. I've been riding about 4,000 miles per year ever since then, but most of the time I'm in pain and I am not able to train enough to race. In Feb. of 2003 I had surgery on the right hip. A bursa sack was removed, a bone spur shaved down and the periformis was released. Unfortunately my condition did not improve.

I read about aprotinin injections and am wondering if you think I would be a candidate and or what your recommendation would be.

Thanks for your time.

Craig Guensch

[sydunisportsmed]

Hi Craig,

I'd be happy if you told me that this wasn't the case, but I don't think Aprotinin is available in the USA. Here is Australia it is only registered for use in Cardiac surgery (where it actually reduces blood loss) but we are able to get the vials designed for cardiac surgery and use them for tendon injections. I believe in Europe and the UK they can get small ampoules that are designed for tendon injection use.

The fact that none of the cortisone injections or surgery seemed to work in your case makes me question the diagnosis. It is possible you have a hip joint or lumbar spine degenerative problem that is referring pain into the buttock. If your doctors feel as though the diagnosis is not definite ask them for more scans to rule out anything co-existing. A good way to work out whether this is a local tendon/bursa problem or a referred pain is to go for a ride until you get pain, then have a local anaesthetic injection (perhaps done with the help of an ultrasound) into the area of the tendon/bursa, then ride straight afterwards. If the pain is completely blocked by the local from the injection, then the diagnosis is that it is a tendon/bursa problem, but if the pain doesn't go away, perhaps it is a referred pain from your back or hip.

Generally with tendon and bursa injuries, cortisone can provide short term pain relief, so it is relevant whether the pain was affected all by the cortisone (but the effect disappeared quickly) or whether the cortisone literally did nothing.

If it does turn out you have tendinopathy then Aprotinin would be something you could consider if it was available, but it is pretty hard to advise you on this without examining you.

[Craig Guensch]

Thanks for responding. I have probably had a total of 6 cortizone injections and none of them had any effect, short or long term.

It's interesting that you mention the possibility of pain being referred from a degenerative problem in the lower back. In my 20's I competed in power lifting and injured L5/S1. After having an MRI, the neurologist diagnosed L5/S1 as being degenerative. He advised me to give up competitive powerlifting. That is when I started racing bicycles.

Is there any test that could be done on the back to indicate if pain was being referred to the hips?

Thanks again for the info.

Craig


Hi Craig,

I'd be happy if you told me that this wasn't the case, but I don't think Aprotinin is available in the USA. Here is Australia it is only registered for use in Cardiac surgery (where it actually reduces blood loss) but we are able to get the vials designed for cardiac surgery and use them for tendon injections. I believe in Europe and the UK they can get small ampoules that are designed for tendon injection use.

The fact that none of the cortisone injections or surgery seemed to work in your case makes me question the diagnosis. It is possible you have a hip joint or lumbar spine degenerative problem that is referring pain into the buttock. If your doctors feel as though the diagnosis is not definite ask them for more scans to rule out anything co-existing. A good way to work out whether this is a local tendon/bursa problem or a referred pain is to go for a ride until you get pain, then have a local anaesthetic injection (perhaps done with the help of an ultrasound) into the area of the tendon/bursa, then ride straight afterwards. If the pain is completely blocked by the local from the injection, then the diagnosis is that it is a tendon/bursa problem, but if the pain doesn't go away, perhaps it is a referred pain from your back or hip.

Generally with tendon and bursa injuries, cortisone can provide short term pain relief, so it is relevant whether the pain was affected all by the cortisone (but the effect disappeared quickly) or whether the cortisone literally did nothing.

If it does turn out you have tendinopathy then Aprotinin would be something you could consider if it was available, but it is pretty hard to advise you on this without examining you.

[injuryupdate]

Another X-ray or scan might help to see how bad the degeneration was. However, the best test may be to have a guided cortisone injection (under a CT scan) around the L5 nerve root on the side where you get your problems. Since the cortisone injections in the buttock haven't helped, if one around the nerve root DID help (even if short term) it would indicate this is where the pain is coming from.