GREATER TROCHANTERIC PAIN SYNDROME
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.
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.
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.
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:
- Avoid sitting in a position with legs crossed.
- Stand evenly on both feet and hip width apart.
- Avoid lying on either side, but if side lying is the only option, then place a pillow between the legs to avoid the top leg falling into a position of adduction.
- Avoid stairs in the short term.
- Gluteal stretching is not recommended and will delay recovery due to compression of the gluteal tendons.
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.