Injection at the superior trochanter

A local anesthetic block placed just under the gluteus medius tendon and just short of the periosteum of the superior aspect of the trochanteric process can be used to confirm the presence of bursitis of the deeper trochanteric or gluteus medius bursa. The patient is placed in the lateral decubitus position with the affected side up and the knees flexed to 90 degrees. The superior, posterior, and anterior edges of the trochanteric process are palpated and marked. The point of entry for injection of the superficial bursa is approximately 2 to 2.5 cm (0.75 to 1 in) above the midpoint of the most superior portion of the trochanter. Topical anesthetic (eg, ethyl chloride) is applied to the skin. Local anesthetic is placed at the gluteus medius tissue plane (1 mL) and at the periosteum of the femur (0.5 to 1 mL). A 4 cm (1.5 in), 22-gauge or 22-gauge spinal needle is inserted at a 45 degree angle in direct alignment with the femur; the depth is 2.5 to 6.4 cm (1 to 2.5 in) to the gluteus medius tendon, and 4 to 7.5 cm (1.5 to 3 in) to the superior trochanter. The needle is held lightly and advanced through the low resistance of the subcutaneous fat to the firm, rubbery resistance of the gluteus medius tissue plane. Following anesthesia at this level, the needle is advanced with firm pressure approximately 1.3 cm (0.5 in) farther to the periosteum of the femur. The patient will usually experience sharp pain as the needle touches the periosteum. Injection at this deeper level requires firm pressure. The needle should be rotated 180 degrees or withdrawn slightly if excessive pressure is encountered. If the trochanter tenderness is significantly relieved with anesthetic injection, 1 mL of triamcinolone acetonide 40 mg/mL can be injected through the same needle.