Greater Trochanteric Pain Syndrome
Original Editors - Kirianne Vander VeldenWendy Snyders as part of the One Page Project
Hip pain is a common orthopaedic problem. Greater trochanteric pain syndrome (GTPS), previously known as trochanteric bursitis, affects 1.8 per 1000 patients annually.
- Results from degenerative changes affecting the gluteal tendons and bursa.
- Patients complain of pain over the lateral aspect of the thigh that is exacerbated with prolonged sitting, climbing stairs, high impact physical activity, or lying over the affected area.
- A range of causes, including the gluteal tendinopathy, trochanteric bursitis, and external coxa saltans.
- The pathogenesis is not completely understood - symptoms are associated with myofascial pain rather than inflammation.
- The main bursae that associated with this GPTS are the gluteus minimus, subgluteus medius, and the subgluteus maximus.
- The hip joint withstands loads up to 6 to 8 times body weight during normal walking or jogging. Due to constant mechanical load, this joint is prone to wear and tear injury during athletic manoeuvres
Proposed clinical definition of GTPS:
“A history of lateral hip pain and no difficulty with manipulating shoes and socks together with clinical findings of pain reproduction on palpation of the greater trochanter and lateral pain reproduction with the FABER test.”
Clinically Relevant Anatomy
The greater trochanter is situated on the proximal and lateral side of the femur, just distal to the hip joint and the neck of the femur.
- The tendons of the gluteus medius (GMed), gluteus minimus (GMin), gluteus maximus (GMax) and the tensor fascia lata (TFL) attach onto this bony outgrowth (apophysis). The greater trochanter is seen to have 4 facets, the above-mentioned muscle attachments have been equated to the “rotator cuff of the hip”.
- External iliac fossa is the origin of the GMed and GMin muscles (GMed attaching to the lateral and superolateral facets and the GMin inserting onto the anterior facet).
- The TFL lies over the GMed and GMin tendons and inserts onto the ITB.
Number of bursa on average of 6 bursae. The locations of these bursae vary greatly - the size, location and number are not consistent.
- Four bursae are consistently present (multiple secondary bursa).
- The three chief bursae at the hip include the subgluteus maximus, the subgluteus minimus and the subgluteus medius bursa.
- These bursae and the periosteum of the greater trochanter are innervated by a small branch of the femoral nerve.
Hip joint stability
- GMax muscle tensions the ITB via its ITB attachment and assists with improving the hip joint’s passive stability.
- ITB is also tensioned by the vastus lateralis, TFL and limits hip internal rotation and adduction passivley.
- GMed prevents excessive hip adduction and is often seen as the primary stabilizer of the pelvis.
- Lateral hip pain affects 1.8 out of 1000 patients annually.
- Greater trochanteric pain syndrome is most prevalent between the fourth and sixth decades of life.
- Studies have shown that GTPS has a strong correlation with female gender and obesity.
Multi-factorial with both intrinsic and extrinsic components. The literature review states the following main causative factors.
- Repetitive activity
- Mechanical overload
- Altered cellular response/failed healing
- Training errors: high-intensity training, high mileage, running on an asymmetrical surface, cambered road
- Sedentary lifestyle
- Increased adiposity
- Leg length discrepancy
In people with weak hip abductors, particularly GMed, greater hip adduction is seen causing increased compression of the GMed and GMin tendons at the greater trochanter. With the increased adduction, the ITB exerts higher compressive forces on the gluteal tendons, amplifying the compression. Hip positions in higher ranges of flexion may also increase the compression of the GMed and GMin tendons due to increased tension in the ITB, explaining why pain that occurs with prolonged sitting.
Pelvic control in a single leg stance position - controlled 70% by the abductor muscles, ITB tensioners (GMax, TFL and vastus lateralis) account for the remaining 30%. People with gluteal tendinopathy tend to have GMed and GMin atrophy and TFL hypertrophy. Weakness and/or muscle bulk changes impact the balance of the abductor mechanism and increase the compression of the gluteal tendons.
Women are more prone to GTPS because of pelvic biomechanics, different activity levels in the population and hormonal effects. Females have a smaller insertion of the GMed tendon, resulting in: smaller area across which tensile load could be dissipated; moment arm shorter, causing reduced mechanical efficiency.
Increased fluid within the bursa is thought to be a consequence of the tendinopathy rather than it being due to inflammation of the bursa..
- Up to 25% of middle-aged women can have GMed tears. It is also found in up to 10% of middle-aged men.
- Tears can be acute but degenerative tears are far more common. It was thought that the GMed tendon was most frequently affected but a study published in 2020 revealed that GMin tendons tears were more frequent than GMed tears. GMed and GMin tears were associated with tendon and enthesis degeneration.
- Tears at the GMed tendon insertion can be complete, intrasubstance or partial, with partial tears occurring most frequently. Complete tears of the GMed are associated with a coinciding GMin tear but MRI and ultrasound investigations very rarely identify the GMin tear.
- Most tears are found at the insertion of the anterior and middle portions of the GMed and GMin tendons.
- Most commonly found in dancers and professional athletes, but can also occur due to physical trauma.
- It can be intra-articular or extra-articular , with the extra-articular presentation being relevant to GTPS.
- Extra-articular coxa sultans most commonly involves the anterior part of GMax or the posterior ITB snapping over the greater trochanter, causing a catching or sensation of “giving way” and an inflammatory response in the trochanteric bursa..
- There is often an imbalance between TFL and GMax activation in these patients.
- Patients can report a sensation of subluxation and pain is worst with activities such as climbing stairs, hiking and running. There are, however, patients who do not experience pain when it snaps.
GTPS typically presents with lateral hip pain that may radiate down the lateral thigh and buttocks and occasionally to the lateral knee. It can be described as aching and intense at times of greater aggravation caused by passive, active and resisted hip abduction and external rotation. It is often characterised by the ‘jump’ sign where palpation of the greater trochanter causes the patient to nearly jump off the bed.
The symptoms include:
- Tender lateral hip when palpated, especially near the greater trochanter
- Pain with side-lying on the problematic side
- Pain with weight-bearing activities such as walking, climbing stairs, standing and running
- Pain may refer to the lateral thigh and knee
- Pain with prolonged sitting
- Pain with resisted abduction
- Sitting with crossed legs increases pain
- Pain can also occur when lying on the non-painful side if the painful hip falls into adduction
- Pain is usually episodic and will worsen over time with continued aggravation
- Weak hip abductors
To be able to treat GTPS correctly, accurate differential diagnosis is crucial. Conditions that may mimic GTPS include the following:
- Hip OA. Similar site of symptoms, aggravated by weight-bearing activity and weakness in hip abductors.
- Femoral head avascular necrosis (AV)
- Femoroacetabular impingement (FAI)
- Lumbar spine referral or degenerative disease
- Femoral-head stress fractures
- Labral tears
- Bony metastasis
- Neck-of-femur fracture
- Inflammatory disease such as RA
Diagnostic ProceduresThere is no one specific test to confirm GTPS and the tests available lack validity when done in isolation.
Diagnostic accuracy can however be improved when a combination of tests is used.
- The single leg stance test for 30 seconds has a positive predictive value (PPV) of 100% and also has a very high sensitivity when pain is produced within 30 seconds of standing on the painful side,.
- Resisted hip medial rotation, lateral rotation and abduction can also be used to asses for GTPS. Resisted lateral rotation has the highest sensitivity (88%) and specificity (97.3%) when compared to resisted medial rotation and abduction. The highest specificity is achieved when the test is done in 90° hip flexion.
- FADER, OBER and FABER - aim to increase the tensile load on the gluteal tendons.
- The ability to put one’s socks and shoes on without help will also help differentiate GTPS from OA, where the GTPS patient has no difficulty during the acitivity.
- The “jump sign” carries a PPV of 83% so direct palpation of the greater trochanter is helpful in diagnosing GTPS.
- The Trendelenburg sign is present in patients with GTPS and when used to assess for a GMed tear, it has a sensitivity of 73% and a specificity of 77%.
- If external coxa saltans is suspected - FABER, Ober test, Hula-Hoop test and active hip flexion followed by passive extension and abduction.
Imaging is only suggested in the following situations:
- When it comes to diagnosing gluteal tears. Ultrasound or MRI should be used to confirm the diagnosis if suspected clinically. Cook (2020) reports that ultrasound is the most accurate when assessing a tendon where MRI is helpful for differential diagnosis.
- When conservative treatment has failed.
- When diagnosis is unclear.
Below is a diagnostic flow chart created by Speers and Bhogal (2017) for the 3 most common causes of lateral hip pain.
- VISA-G - GTPS-specific outcome measure
- HOOS - Hip Disability and Osteoarthritis Outcome Score
- HHS - Harris Hip Score
- iHOT - International Hip Outcome Tool
GTPS is a clinical diagnosis which means the diagnosis is based on the medical history as well as the signs and symptoms. Assessment must include
- Good subjective assessment, so as to gather the necessary information regarding the signs and symptoms.
- Hip assessment
- Special tests - can be used to help confirm or negate the suspected diagnosis of GTPS. In 2017, Ganderton et al. validated the following tests for GTPS: FABER, resisted external derotation test, greater trochanter palpation and resisted abduction (Click on the link to each test for more detailed information and/or a video regarding each test).
Trendelenburg Test: This is a quick test for assessing hip abductor muscle function and it can also be used to help determine if a tear is present in the hip abductors.A drop of the pelvis on the contralateral side of the stance leg indicates weakness of the stance leg's hip abductors and results in a positive test. Test administration is demonstrated here.
Noble Test: This is used to verify Iliotibial tightness and helps to distinguish iliotibial tightness from other common causes of lateral knee pain, such as lateral collateral ligament strain, bicipital or popliteal tendinopathy, knee OA and lateral meniscal pathology.Test administration is demonstrated here.
Modified Ober’s Test:This test and its modification are used to assess the TFL and ITB. The test is positive if the thigh does not go further than 10 degrees adduction.
Renne’s Test: This test is used to assess ITB syndrome and can be done alone or in conjunction with the Noble Test.
(30 second ) Single leg stance test: The person being tested must stand, unassisted, on one leg with their eyes open and one finger on a wall. As soon as the person’s foot is lifted of the floor, the 30 seconds start. A positive test for patients with GTPS is lateral hip by 30 seconds. Grimaldi and Fearon (2015) suggest holding the position until reproduction of symptoms.
Resisted external de-rotation test and modified external de-rotation test: The patient lies in supine and the examiner then passively flexes the hip to 90° with external rotation. The hip should be in neutral abduction/adduction. Slightly reduce the external rotation to decrease the compression of the tendon. The patient then actively rotates their leg to neutral against the therapist’s resistance. The modified test is exactly the same, but done in full hip adduction.
Resisted abduction test: The examiner passively abducts the testing-limb to 45° abduction with the patient in side-lying or supine. The patient must then maintain this position against the examiner’s resistance. The resistance must be applied 1cm superior to the lateral malleolus. This test has a 73% sensitivity and 87% specificity for GMed pathology.
Resisted internal rotation: This test has a 92% sensitivity, 85% specificity and 88% accuracy for diagnosing GMed tears . To perform the test, place the problematic limb into 90° hip and knee flexion with 10° hip external rotation while the patient lies in supine. While the examiner provides resistance to the movement, the patient must perform active hip internal rotation. The test is positive if the patient experiences pain and/or weakness.
The initial approach to treat Greater trochanteric pain syndrome includes a range of conservative interventions such as physiotherapy, local corticosteroid injection, PRP injection, shockwave therapy (SWT), activity modification, pain-relief and anti-inflammatory medication and weight reduction.
- Most cases resolve with conservative measures, with success rates of over 90%. For the majority of the cases, GTPS is self-limiting.
Non-surgical treatment options include the following:
- Physiotherapy, which includes manual therapy and therapeutic exercise
- Low energy extracorporeal shockwave therapy (ESWT)
- Corticosteroid injection is effective in the short-term only (3 to 4 months) and is advised for bursitis rather than tendinopathy. It is more effective to inject the greater trochanteric bursa than the subgluteus medius bursa.
- Platelet-Rich Plasma injections have been found to be a feasible alternative but it is unknown whether it or corticosteroids are more effective. This link has an explanation of PRP injections
- Non-steroidal anti-inflammatory drugs (NSAIDs) may help with analgesia in the acute phase or in primary bursitis, but it is not advised in chronic gluteal tendinopathy or gluteal tendon tears as NSAIDs have been found to potentially have a negative impact on tendon healing.
Exercise is promoted from early in treatment for tendinopathy and the main goals should include:
- Load management
- Reduction of compressive forces
- Strengthening of the gluteal muscles and
- Management of any co-morbidities
See comprehensive exercise treatment regimes further below
- ESWT was found to be more effective than corticosteroid injections and multimodal therapy at a 1 year follow-up. The long-term results of ESWT are however controversial. A study that combined exercise and ESWT found that this approach was superior to corticosteroid injection for pain relief at 15 months follow-up.
- Dry-needling is a commonly-used intervention in physiotherapy. A study published in 2017 compared dry-needling to corticosteroid injections for pain relief in GTPS and found that corticosteroid injections did not offer greater pain relief or to dry-needling. There was also no difference in function improvement between the two groups. Based on this, dry needling may be a viable option for pain relief in GTPS.
- Other modalities like TENS, cross-frictions and low-level laser have not been assessed properly for GTPS. Ice and heat have been suggested for pain management, but there is limited supporting evidence and there are no studies proving the effectiveness of ultrasound.
Myofascial restrictions of the joints below the hip, the hip itself and the lumbar spine can result in increased friction at the lateral hip and myofascial release is therefore indicated if a restriction is found. Where joint restrictions exist at the lumbar spine, hip, knee and/or ankle, joint mobilisation can be done to improve mobility, thereby correcting hip biomechanics and reducing friction at the lateral hip.
Patients must be made aware of activities and positions that may further compress the gluteal tendons/bursa resulting in aggravated symptoms. Patients should avoid:
- Climbing stairs
- Hip adduction across the midline
- Walking uphill
- Sitting with legs crossed
- Sitting with their knees higher than hips
- Standing with more weight on one leg
- Side-lying positions. If the patient struggles not to lie on their side, they should place pillows between their knees and ankles (modified side-lying) or lie on an eggshell overlay
- Stretching of the ITB, gluteal muscles
Advice regarding modification of exercise and activity should also be given. This is further discussed in the therapeutic exercise paragraph below.
Sadly, there is little evidence of the effect of exercise on pain and dysfunction in GTPS. More recently, some studies have examined different exercise approaches which include the following:
Isometric contractions (for gluteal tendinopathy)
Isometric contractions are now commonly used as they release cortical inhibition targeting both peripheral and central pain drivers. This cortical inhibition causes immediate pain reduction and for 45 minutes afterwards. Cook (2020) reported that the analgesic effect can last for 4 to 8 hours after isometrics. Isometric contractions must be heavy to effectively achieve pain relief in the tendon. The exact duration of the contraction is unknown, but 5 repetitions of 45 seconds has been found to be very effective. A rest period of 2 minutes must occur between each of the isometric contractions.
Stretching should be avoided when treating insertional tendinopathies as stretching, especially into adduction with the hip in flexion or extension increases the compression forces on the tendon.
Exercise is important in the management of all the possible causes of GTPS:
- Gluteal tendinopathy requires gradual loading of the tendons to condition the tendon again so that it can tolerate load. More information about gluteal tendinopathy management can be found on the Gluteal tendinopathy page.
- Since Trochanteric bursitis is reported to most likely be secondary to a gluteal tendinopathy, gradual loading is also indicated in these patients.
- In patients with gluteal tendon repair, strengthening will be essential for optimal function and to improve the repaired tissue’s tensile strength.
- Patients with external coxa saltans may be experiencing the problem due to muscle imbalances or increased muscle tension which will require modification of neuromuscular control. This is achieved through the correct strengthening and/or motor control exercise.
Therapeutic exercise should be started early and consist of progressive tensile loading exercises in minimally adducted hip positions. GMed has been found to activate better in weight-bearing positions compared to non-weight-bearing positions. Exercise should be started at a moderate effort level and repetitions should be low. When night pain improves in patients with a gluteal tendinopathy, it is a good indicator that the tendon is responding to the exercise. If night pain increases it may indicate that the load was too high.
Strengthening should not only include the hip abductors but also the core and lumbopelvic stabilisers.
Ebert et al. (2018) provide a guideline for postoperative management for abductor tendon repair. This guideline can be found in Table 2 below.
Ganderton et al. (2018) compared the GLoBE programme to a sham exercise programme for management of GTPS. There was no added benefit of either exercise program when added to education but the subjects in the GLoBE exercise group reported a better outcome than the sham exercise group. Ganderton et al. reported that this likely indicates sub-groups exist in GTPS. The GLoBE exercise programme is outlined below in Table 3.
|Table 3: GLoBE exercise phases|
|1||Isometric hip hitch||Start with hip hitch with wall support. Progress to hip hitch without wall support, but with arm support. The unaffected limb should be hitched. Both knees should be kept straight. Begin with 2 x 15 second holds and progress to 4 x 40 second holds|
|Wall squats on both legs||Double leg quarter wall squats with hips in 20° external rotation. Progress to half wall squat. Begin with 1 set of 5 repetitions and increase to 4 sets of 5 repetitions.|
|Calf raises on both feet||Calf raises on both feet with arm support. Begin with 2 x 5 repetitions and increase to 2 x 10 repetitions.|
|2||Hip hitch with toe taps||Hip Hitch with toe taps onto 7.5cm step. Progress to a 10cm step. Begin with 2 x 5 repetitions and increase to 2 x 15 repetitions.|
|Sit to stand||Sit to stand off a standard chair with arms crossed over the chest. Gradually decrease the height of the chair as tolerated. Begin with 1 x 5 repetitions and increase to 2 x 10 repetitions.|
|Calf raises with toe tap||Sustained calf raise with toe taps on the spot. Use a wall or chair for balance. Start with 2 x 5 repetitions and increase to 2 x 10 repetitions.|
|3||Hip hitch with hip swing||The affected limb is the stance limb. Perform a sustained hip hitch on the affected limb. Complete hip swings 10° forwards and backwards with the contralateral leg. Begin with swings and then increase to 2 x 15 contralateral hip swings.|
|Sit to stand with split stance||Sit to stand off a standard chair with affected leg placed slightly behind the unaffected leg. Start with 2 x 5 repetitions and increase to 4 x 5 repetitions.|
|Single leg calf raises||Single leg calf raise with arm support. Start with 2 x 5 repetitions and increase to 4 x 5 repetitions.|
|4||Single leg wall squat||2 x 5 repetitions|
|Step ups||2 x 10 repetitions.|
|Single leg calf raises with arm support||2 x 15 repetitions.|
Mellor et al. (2018) found exercise plus education to be superior to corticosteroid injections and it remained that way at 52 weeks follow-up. This study showed that exercise plus education was even superior to corticosteroid injections in the first 8 weeks, showing that exercise plus education is effective from early on. They made use of a progressive exercise programme that can be found below in the LEAP trial images p1 to p5..
It is clear that strengthening of the hip abductors is an important component of GTPS management, but what exercise is most effective? Firstly, all prescribed exercise must patient-specific and should be determined by the phase of tissue healing, the patient’s tolerance of the exercise and/or the principles of progressive loading. A study published in 2017 assessed various exercises to determine their degree of GMed activation. A short summary of the results is found below in Table 4.
It is worth mentioning that the popular clam exercise was found by to produce negligible activation in the GMed (particularly the anterior and middle portions) by Ganderton et al. (2017). In this same study, the hip hitch was found to best activate the GMed and GMin.
|Table 4: GMed exercises in order of degree of activation|
|Low||Moderate||Moderate to High||High to very High|
|Abbreviations: NWB, non-weight-bearing; WB, weight-bearing; IR, internal rotation|
This intervention used to be carried out by open surgery, but now it is most commonly done arthroscopically. Fox et al. (2002) found that arthroscopic trochanteric bursectomy is a minimally invasive technique, that appears to be a safe and an effective approach for managing GTPS. In a more recent study by Mitchell et al. (2016) successful management of GTPS was achieved with endoscopic arthroscopic bursectomy together with an iliotibial band release.
Iliotibial band surgical options
Surgery is not the first choice of management but in cases where functional impairment is present, surgery can be done. There are three options in these patients: iliotibial tract (ITT) release, ITT bursectomy and lateral synovial recess resection. Another study released in 2012 also found surgical ITT release and trochanteric bursectomy to be an effective and safe treatment.
Reduction-osteotomy of the greater trochanter
This is an option should bursectomy and ITT release fail.
- Large incision of 7 to 10 cm
- Highest rate of complications.
- During the procedure a 5 to 10mm slice of bone was removed deep to the greater trochanter and continued distally beyond the vastus ridge, GMed was left attached, fixation with two lag screws was done once transfer of the medial and distal trochanter was completed.
Reconstruction/Repair of the abductor tendon
When MRI and clinical findings are consistent with a tendon tear, surgical repair is an option.
Ebert et al. (2018) published a postoperative management protocol for patients with abductor repairs, see ref
Take Home Message
- Conservative treatment is the gold standard for GTPS.
- Greater trochanteric pain syndrome is often under-diagnosed.
- Encourage physical therapy and activity modifications.
- Concern for the use of CSI is the possibility of weakening the tendon structure in the long-term
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