Greater Trochanteric Pain Syndrome
Greater Trochanteric Pain Syndrome (GTPS) is the most common cause of lateral hip pain. It commonly occurs in females between the ages of 40 and 60. GTPS represents 10-20% of patients who present to primary care physician with hip pain. Long distance runners commonly are affected by GTPS.
This condition was previously thought to be due to trochanteric bursitis, however there are numerous soft tissue structures at the greater trochanter that have nociceptive capacity. Surgical, histological and imaging studies have shown that GTPS is due to tendinopathy of the gluteus medius and/or minimus with or without coexisting bursal pathology. These abnormalities most commonly occur near the tendon insertion and include tendinosis and partial or full-thickness tendon tears. Overall, there is the same pathological mechanism and therefore the relative local contribution may be less pertinent in the early conservative management.
- Age (40-60)
- Increased mechanical loading without adequate rest
- Midline or cross midline striking pattern
- Abnormal hip biomechanics
- Compressive forces causing impingement of the gluteal tendons and bursa onto the greater trochanter by the ITB as the hip moves into adduction.
- Diabetes Mellitus
- Collagen vascular disorders
- Hydroxyapatite deposition disease
- Seronegative spondyloarthritides
The greater trochanter is a bony protuberance arising from the femoral neck and shaft interface.
There are four facets that serve as attachments sets for abductor tendons and bursa:
Gluteus minimus tendon attaches to the anterior facet, and is completely covered by the gluteus medius muscle.
Glutues medius tendon attaches to the superoposterior facet, the inferior aspect of the lateral facet and more anteriorly to the gluteus minimus tendon. This tendon is covered by the iliotibial tract
Posterior facet has no tendon attachments
Large variety of bursae have been described. The 3 most consistently identified are:
- Subgluteus minimus – lies deep to the gluteus minimus tendon
- Subgluteus medius – between the lateral insertion of gluteus medius tendon and the superior part of lateral facet
- Subgluteus maximus – largest bursa that covers the posterior facet and lies deep to the gluteus maximus muscles
Figure 1 and 2: Greater Trochanter Anatomy and muscle attachments
Mechanism of Injury1,2,3,6:
- Gluteus medius tearing may be secondary to chronic degeneration of acute trauma (2)
- Seen more frequently in patients with normal hip morphology than in patients with FAI – particularly if < 40 years old
- Usually a result of increased mechanical loading
- Role of compression
- Compression increases tenocyte production of proteoglycan molecules that bind water within the tendon resulting in a thicker tendon more resistant to compression.
- In response to excessive compression the bursa and ITB
- This results in a reduced tensile loading capacity of a tendon because of disorganization and enzymatic resorption of large type 1 collagen fibres.
- These tendons then fail at lower tensile strain rates – tendons are thicker (early/adaptive stage) or attenuated/thinner with partial or full thickness tearing (later stage)
- Compressive loading of the lateral soft tissues is strongly influenced by hip join position and particularly by hip adduction.
- There are 4N of compressive load at neutral. This load increases 9-fold at 10 degrees, and 25-fold at 40 degrees.
- Running with a midline or cross midline striking pattern may increase the risk of developing lateral hip pain, due to cumulative loading stimulus.
Figure 36: Compressive forces causing GTPS.
- Gradual onset of dull, achy, lateral hip pain, typically related to sudden unaccustomed exercise, falls, prolonged weightbearing, or sporting over use (long-distance running)
- Aggravating factors:
- walking, running, prolonged sitting/standing, and side lying at night
- Single-leg weight-bearing. Eg. Standing on one leg to dress, ascending stairs/hills (especially those involving higher eccentric loads or a stretch-shortening cycle – running, bounding or hopping)
- Radiation: greater trochanter down lateral aspect of the thigh to the knee. Extending into the upper lateral leg along the line of the ITB.
- Significant morbidity
- Pain on side lying can affect sleep
- Reduction in physical activity – negative implications for general health, employment, and well being
- Single clinical tests lack validity but a combination can be used to increase diagnostics accuracy.
- Jump sign: Pain on direct palpation of the greater trochanter
- PPV: 83% for positive MR findings
- Single leg stance test: Pain within 30 seconds of standing on one leg
- High sensitivity and 100% PPV for positive MR findings
- FABER, FADIR, ADD (passive hip adduction in side lying)
- Increase tensile load on gluteus medius/minimus tendons
- Replicate patient’s lateral hip pain
- Positive findings with the two above tests can increase diagnostic accuracy
- Other tests:
- Step up and down test
- Positive Trendelenburg gait
- Osteoarthritis of the hip
- “difficulty putting on shoes and socks” = OA, not GTPS
- Lumbar spine referred pain
- Pelvic pathology
- SI Joint dysfunction
- External coxa saltans (lateral snapping hip syndrome)
- Iliotibial band syndrome
- Hip pointer
- Clinical diagnosis
- Recalcitrant cases or with mixed clinical picture require imaging to exclude or confirm the diagnosis.
- Usually normal
- Excluded osteoarthritis and fractures
- High PPV
- Fluid-filled and thickened bursa with evidence of inflammation
- Tendinopathic findings or tears within the gluteus medius or minimus tendons
- When further diagnostic clarification is required
- Asymptomatic patients may have changes so results should be correlated clinically
Figure 45: Coronal‐oblique ultrasound image at the level of anterior facet of greater trochanter shows a mildly thickened and heterogeneous gluteus minimus tendon (arrows). The gluteus medius muscle overlies the gluteus minimus tendon
Figure 55: Coronal‐oblique (A) and transverse (B) ultrasound images demonstrate a full‐thickness gluteus medius tendon tear (demarcated by calipers). There is tendinosis (seen as thickening and heterogeneous echogenicity) of the underlying gluteus medius tendon (arrows). Observe the cortical irregularities of the greater trochanter.
- Optimal management is unclear
- Manage load
- Reduce compressive forces
- Strengthen gluteal muscles
- Treat comorbidities
- First-line treatment:
- Load modification
- Runner’s should avoid banked tracks or high cambered roads
- Weight Loss
- NSAIDs – oral or topical
- Foot Orthotics
- Gluteal strength and control
- Hip abductor muscle strengthening
- Optimize biomechanics
- Lumbopelvic postural control
- Reduced compressive loads
- Avoid positions of excessive hip adduction (crossing legs, ITB stretching)
- Sleep with 1-2 pillows between legs
- Recalcitrant Cases
- Corticosteroid injection
- Short term analgesia in 70-75% of cases
- 12 month trials show no difference compared to watch and wait
- Non-randomized trial
- 75 patients CSI vs. 76 patients home exercise group
- Success rates: 1 month (75% vs 7%), 15 months (48% vs 80%)
- Provides analgesic window in which patient can fully engaged with effective rehabilitation program
- Shockwave therapy
- Platelet-rich plasma
- Lee et al. 2016
- 21 patients with moderate to severe pain due to recalcitrant tendinosis and/or partial thickness tears received an ultrasound guided PRP injection.
- Significant improvement in all outcomes at 1 year follow up
- Better long term outcomes in pain and function compared to CSi
- Needling also performed
- Did not distinguish between tendinosis vs tear
- Further studies needed
- Systematic Review (Ali et al. 2018)
- Lack of adequately powered studies providing high-quality evidence when considering global GTPS pathology
- Consider site of injection
- Improvement at 3 months after injection
- Limitations: Different PRP systems, concentrations, volumes, variable pain and functional outcomes, small samples
- PRP viable if:
- Take into consideration above limitations
- GTPS refractory to conservative measures
- Definitive role is debatable
- Surgical treatment
- Cases that have failed optimal conservative management
- High grade partial or full thickness tears
- Open and arthroscopic techniques described
- Functional outcomes are generally good
- Procedure depends on underlying pathology
- Lengthening or release of ITB and TFL
- Gluteal tendon tear repair
- Endoscopic bursectomy
- Open reduction trochanteric osteotomy
Alessandro Francella, MD, CCFP (SEM), Dip. Sport Med. (Dec 15, 2019 PR ND)
- Plinsinga ML, Ross MH, Coombes BK, Vicenzino B. Physical findings differ between individuals with greater trochanteric pain syndrome and healthy controls: A systemic review with meta-analysis. Musculoskelet Sci Pract. 2019 Oct;43:83-90.
- Reid D. The management of greater trochanteric pain syndrome: A systematic literature review. J Orthop. 2016 Mar; 13(1): 15-28.
- Speers C, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. Br J Gen Pract. 2017 Oct;67(663):479-480.
- Ali M, Oderuth E, Atchia I, Malviya A. The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. J Hip Preserv Surg. 2018 Aug 30;5(3):209-219.
- Kani K, Porrino J, Nirvikar D, Talijanovic M, Mulcahy H, Chew F. A visualization of the Greater Trochanter and Peritrochanteric Soft Tissues. PM R. 2017 Mar; 9(3):318-324.
- Kemp J, et al. Chapter 31: Hip Pain. In Brukner P, K Kahm (Eds). Brunker & Khan’s Clinical Sports Medicine 5th Edition Volume 1: Injuries. (pp. 593-628). Australia: McGraw-Hill.