Greater Trochanteric Pain Syndrome (GTPS) is a common hip condition that causes pain over the outside of your thigh/buttock muscle. The cause for these symptoms is usually an injury to the soft tissues that lie over the upper aspect of the thigh bone. This condition occurs primarily from an overuse injury to the tendons on the outside of the hip. Adults who walk, run or play sports are more likely to get this injury.
In the acute phase, pain can be managed with rest, ice, soft tissue therapy, taping, and medications (NSAIDs and/or paracetamol). Runners should avoid banked tracks or roads with excess camber. Exercise and load management are the cornerstones of effective tendinopathy management. Most trochanteric bursitis resolves on its own after two weeks. If home treatment hasn’t relieved your discomfort after two weeks, it’s time to see a doctor. A specialist in orthopedics, rheumatology, or physical medicine and rehabilitation can help.
Other Names
- Greater Trochanteric Pain Syndrome (GTPS)
- Trochanter Pain Syndrome
- Gluteal Tendinopathy
- Greater Trochanteric Bursitis
- Troch Bursitis
- Trochanteric Bursitis
Pathophysiology
- Gluteus medius and minimus tendinopathy, which can include a partial tear, enthesopathy
- Rarely bursitis alone
- Etiology is not entirely understood
- Believed to be due to repetitive mechanical stress
- Provocative activities include: hip abduction and pelvic stabilization in walking, stair climbing, running, and standing on one leg
- It May be mistaken for other primary causes of pain such as hip OA, lumbar back pain, pelvic pathology
- Can co-occur with these diseases as well
Causes
- Repetitive friction between greater trochanter, IT band associated with hip flexion and extension
Associated Pathology
- Low Back Pain
Pathoanatomy
- Greater Trochanter
- Site of attachment for: Obturator Internus, Obturator Externus, Gemelli, Piriformis, Gluteus Minimus, Gluteus Medius
- ‘Trochanteric Bursa’: Largest of the subgluteus maximus bursa
- Female gender
- Obesity
- Greater waist girth
- Knee pain
- Low back pain
- Foot Pain
- Psychosocial[7]
- Psychological distress
- Poorer quality of life
Differential Diagnosis
- Fractures And Dislocations
- Pelvic Fracture
- Hip Fracture
- Acetabular Fracture
- Femoral Neck Stress Fracture
- Pelvic Stress Fracture
- Hip Dislocation
- Arthropathies
- Osteitis Pubis
- Avascular Necrosis of the Hip
- Hip Osteoarthritis
- Femoroacetabular Impingement
- Transient Osteoporosis of the Hip
- Muscle and Tendon Injuries
- Hip Flexor Tendonitis
- Piriformis Syndrome
- Hamstring Strain
- Proximal Hamstring Tendinopathy
- Adductor Strain
- Greater Trochanteric Pain Syndrome
- Bursopathies
- Iliopsoas Bursitis
- Ischial Bursitis
- Ligament Injuries
- Acetabular Labrum Tear
- Neuropathies
- Meralgia Paresthetica
- Other
- Snapping Hip Syndrome
- Septic Arthritis
- Gout
- Leg Length Discrepancy
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Diagnosis
- History
- Pain that localizes to the lateral hip
- Worse with weight-bearing activities, laying on the affected side at night
- Worse with standing for long periods, sitting cross-legged
- Mayor may not radiate down to the knee
- Worsens over time
- Triggered by or exacerbated by a change in exercise, trauma, prolonged weight-bearing, sporting over-use[8]
- Physical Exam: Physical Exam Hip
- Pain to palpation of greater trochanter
- The comparison should be made to the contralateral side
- They may demonstrate an antalgic gait including Trendelenburg Gait
- Special Tests
- Single Leg Stance Test: Stand on the affected limb for 30 seconds to reproduce pain
- Jump Sign: Palpation of greater trochanter reproduces pain, causes ‘jump’
- FABER Test: Flexion, abduction, external rotation
- Ober Test: Often positive, not specific to GTPS
- Resisted External Derotation Test: hip and knee flexed to 90°, hip is externally rotated, patient brings back to neutral against resistance
- Passive Adduction With Resisted Abduction: Abduct or adduct limb and then ask the patient to abduct further against resistance
- Resisted Internal Rotation: Knee, hip flexed to 90°, add 10° hip external rotation, internally rotate against resistance
- Primarily a clinical diagnosis, however imaging is useful in the mixed or unclear clinical picture
Coronal view of STIR sequence showing free fluid within the trochanteric bursa, between the glute medius and glute minimus tendons[9]
Radiographs
- Standard Radiographs Hip
- The screening tool, often normal
- May show ensthesopathy at the greater trochanter
- May show calcific tendinopathy of glute medius or minimus
MRI
- Findings
- Look for gluteus tendinopathy or tearing
- Enhancement within the trochanteric bursa
- Muscle atrophy, fat replacement, enthesopathy, bursal effusion
Ultrasound
- High PPV for GTPS (need citation)
- Findings
- Fluid-filled and thickened trochanteric bursa with evidence of inflammation
- Tendinopathic echogenic findings
- Tears within the gluteus medius or gluteus minimus tendons
Management
Prognosis
- Early diagnosis is important
- Delay in management or mismanagement can worse prognosis due to recalcitrant symptoms
Nonoperative
- First line and primary management in most cases
- Relative rest and activity modification
- Runners should avoid banked tracks, roads with excess camber
- Minimize vertical activity such as climbing stairs, running or walking uphill
- Avoid exaggerated adduction
- Avoid crossing legs while sitting
- Sit with hips flexed above knees
- Weight bear symmetrically on both legs
- Avoid side-lying
- Exercise
- Mellor et al: At 8 weeks, exercise + education was superior to corticosteroid injection or placebo for global improvement, pain reduction[10]
- Physical Therapy
- Goals: manage load, compressive forces across greater trochanter, strengthen gluteal muscles
- Optimization of biomechanics
- Improved lumbopelvic postural control
- Medications
- Analgesics including NSAIDS
- Ice
- Weight Loss
Procedures
- Corticosteroid Injection with or without ultrasound
- Mellor et al: provides effective short term relief in 70-75% of cases, although no benefit showed at 12 months[10]
- They also found that exercise group had 80% relief at 15 months whole CSI group had only 48%
- Shock Wave Therapy
- Platelet Rich Plasma Injection
- Role is unclear at this point
Operative
- Indications
- Failure of conservative measure for ?months
- Technique
- Bursectomy
- Tenotomy
Previous
