Lateral hip pain, in the region of the greater trochanter, is commonly greater trochanteric pain syndrome (GTPS). The condition may also be referred to as “trochanteric bursitis” or “gluteal tendinopathy”.
Pain originates in the gluteus medius and minimus tendons, and less frequently, the associated bursae. It was previously thought the primary source of pain was inflammation of the trochanteric bursa, and thus called “bursitis", however it has more recently been shown that true bursitis is rarely present. Sonographic research identified 8% of GTPS patients presented with isolated bursitis, compared with 41% with gluteal tendon pathology. Risk factors for developing greater trochanteric pain syndrome include older age, reduced oestrogen levels, and excessive or sudden changes in load. GTPS is seen in both men and women across the lifespan, although women are more likely to suffer from GTPS due to biomechanical forces of having a wider pelvis and greater body adiposity. Post-menopausal women are most burdened by the condition due to hormonal changes. ASSESSMENT AND DIAGNOSIS Greater trochanteric pain syndrome is a clinical diagnosis and imaging is not required. There is poor correlation between pathology on imaging and symptoms. History commonly includes a change in load (eg, starting a walking program or new exercise routine) and pain in positions where the tendons may be compressed (eg, sitting with legs crossed and lying on (either) side). Other common reports include pain with sit-to-stand, after a period of sitting, and walking up and down stairs or slopes. Asking patients about their ability to manipulate shoes and socks can differentiate between GTPS and hip osteoarthritis (OA). Those with GTPS typically are not restricted in functional range of motion, so are not impaired when putting on shoes and socks. A battery of clinical tests are recommended to diagnose greater trochanteric pain syndrome. The most sensitive objective measure is palpation over and around the greater trochanter. Other valuable pain provocation tests include: FABER, resisted hip abduction, and Trendelenburg sign. TREATMENT Corticosteroid injection (CSI) can have an adverse effect on tendon health and is not recommended. Benefits of CSI are short-term only, with high rates of recurrence. A single, ultrasound-guided, intratendinous platelet-rich plasma (PRP) injection is better than CSI, but no better than placebo injection. Robust evidence demonstrates that exercise and education on avoiding gluteal tendon compression is better than injections in the longterm. Strength based exercise prescribed in conjunction with education about avoiding gluteal tendon compression, and advice regarding load management, provides the most benefit. Education involves instruction to avoid positions of hip adduction, including:
Isometric loading has been advocated over dynamic strengthening. In post-menopausal women with GTPS, a randomised control trial investigating menopausal hormone therapy (MHT) and exercise as interventions found that transdermal MHT is better than placebo when BMI<25.
Load Management For Injury PreventionManaging training load is crucial in injury prevention and treatment. A graphic in Tom Goon’s recent blog visualises how training load outweighs all other factors. Historically we have advised that training loads shouldn’t increase by more than 10% a week. I’m not sure where this number comes from. I’ve got no problem with it, it seems reasonable, and I’ve quoted it hundreds of times. There’s a 2015 BJSM podcast interview with Tim Gabbett on load management for injury prevention. Specifically Tim talks about this paper:
Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers
- Billy T Hulin, Tim J Gabbett, Peter Blanch, Paul Chapman, David Bailey, John W Orchard, 2013. It is research into fast bowlers, but I think the principles apply just as well to any athlete. The authors measured the acute workload of the last 7 days (and call it “fatigue”) and compare that to the chronic workload of the previous 4 weeks (which they call “fitness”). Measuring Training Load
For runners, if the training is reasonably homogenous, we could most simply measure the workload as the total kms/week.
Or we could be more accurate and account for a mixed training program that may include a variety of hills / sprints / cross training etc, by giving each session a rate of perceived exertion (RPE) out of 10, and multiply that score by the number of training minutes:
Training load = session RPE x duration (minutes)
This is called a Foster’s Score, and provides a simple method for quantifying training loads from a variety of different training modalities.
The research subtracted the current one-week average from the previous 4-week average and called this number the “training-stress balance”. A negative training-stress balance increases the risk of injury by 4 times. So:
[Last 7 days’ session RPE x duration (minutes)] - ([Last 4 weeks’ session RPE x duration (minutes)] / 4) = TRAINING-STRESS BALANCE
Negative balance = 4 times risk of injury
Essentially this formula means you shouldn’t increase your training load by more than 25% a week.
For people that may be more vulnerable to injury I would change the 4-week average to a 6-week average, therefore, bringing the increase in load each week down from 25% to 16%. This more cautious group could include:
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