Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome (GTPS), previously known as trochanteric bursitis, affects 1.8 per 1000 patients annually. GTPS results from degenerative changes affecting the gluteal tendons and bursa.[rx] 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.[rx]

GTPS contains a range of causes, including the gluteal tendinopathy, trochanteric bursitis, and external coxa saltans.[rx] While the pathogenesis is not completely understood, symptoms are associated with myofascial pain rather than inflammation.[rx] 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 maneuvers.[rx]

Pathophysiology of Greater Trochanteric Pain Syndrome

Repetitive friction between the greater trochanter and iliotibial band syndrome (ITB) causes microtrauma in the greater trochanter at the level of insertion with the gluteal tendons. Friction leads to local inflammation, degeneration of the tendons, and increased tension on the ITB. It is believed that chronic gluteal tendinopathy arises from the disorganization of the collagen bundles, hypercellularity, increased proteoglycan synthesis, and neovascularization.

Studies have shown that there’s a reduction in type 1 collagen and increased production of type 3 collagen in the gluteal tendons. This combination of collagen leads to poor fiber cross-links with subsequent deterioration in the mechanical strength of the tendons.[rx]

Causes of Greater Trochanteric Pain Syndrome

The etiology of this disease has been studied as multifactorial with both intrinsic and extrinsic components. The literature review states the following main causative factors.[rx][rx]

Some of the causes associated with the condition include

• Trauma – A history of falls or bumping the hip hard against something can cause trochanteric bursitis.
• Overuse – People who perform repetitive physical activities, such as running or biking, can cause inflammation of the bursa sacs in the hip.
• Poor posture – Sitting in a curved posture or another poor-posture position can place extra strain on the hips. Posture-related conditions, such as scoliosis, can also cause trochanteric bursitis.
• Bone spurs or calcium deposits – Sometimes a person may develop bony growths called bone spurs on the trochanter. These can rub against the bursa, resulting in inflammation.
• History of certain chronic diseases  – People who have chronic diseases, such as gout, thyroid disease, psoriasis, and rheumatoid arthritis, might be at higher risk of developing trochanteric bursitis.
• Previous surgery – A person is more likely to get trochanteric bursitis if they have had surgery on their hip in the past, including a hip replacement. Between 3 to 17 percent of people who have had a hip replacement have trochanteric bursitis. Sometimes, hip surgeries can result in a slight difference in leg length, which can also contribute to trochanteric bursitis.
• Being overweight – Excess weight or obesity can also contribute to trochanteric bursitis. This is because the excess weight places greater strain on the hip and area around it.
• Repetitive activity
• Mechanical overload
• Altered cellular response/failed healing
• Training errors: high-intensity training, high mileage
• Sedentary lifestyle
• Increased adiposity
• Scoliosis
• Leg length discrepancy

Symptoms Of Greater Trochanteric Pain Syndrome

• Pain, tenderness, swelling, warmth, or redness  may travel up or down the thigh or leg
• Initially, pain at the beginning of an exercise that lessens once warmed up; eventually, pain throughout the activity, worsening as the activity continues; may cause the athlete to stop in the middle of training or competing
• Pain that is worse when running down hills or stairs, on banked tracks, or next to the curb on the street
• Pain that is felt most when the foot of the affected leg hits the ground
• Possibly, crepitation (a crackling sound) when the tendon or bursa is moved or touched
• Stabbing or stinging pain along the outside of the knee
• A feeling of the snapping over the knee as it bends and straightens
• Swelling near the outside of your knee
• Occasionally, tightness and pain at the outside of the hip
• Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to a standing position
• Pain that is worse when running down hills or stairs.
• Pain that is felt most when the foot of the affected leg hits the ground.
• Possibly, a crackling sound when the bursa is moved or touched.

Diagnosis of Greater Trochanteric Pain Syndrome

History and Physical

Patients with greater trochanteric pain syndrome usually have lateral hip pain, tenderness over and around the greater trochanter, pain at end-range hip rotation, abduction or adduction, pain with resisted hip abduction, and a positive Patrick-FABER test. Patients usually suffer from chronic back pain radiating to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract.[rx] They will often complain of the inability to lay on the affected hip. The mean duration of symptoms before treatment ranges from 7.1 weeks to 4.4 years. Young adults (18 to 35 years old) with hip pain often present with non-specific symptoms and vague findings from the history and physical examination, which may lead to a misdiagnosis of GTPS or trochanteric bursitis.[rx][rx]

Evaluation

A careful assessment of the patient’s history, examination, and focused diagnostic evaluation is essential for an accurate diagnosis. First, the health provider must obtain a thorough history from the patient which includes: presence/absence of trauma, mechanism of injury, nature of pain (type), duration, exacerbating and improving factors, recent instrumentation as well as medical (hypertension, diabetes mellitus, rheumatologic illness, cancer) and surgical history. Any nonsurgical treatments, including activity modifications, physical therapy, and oral medications.[rx]

Physical examination should begin with documentation of vital signs. Febrile patients with hip pain must be evaluated for possible septic hip arthritis. Attention should be paid to the position in which the patient keeps the hip while at rest. Patients with synovitis or a hip effusion will often keep the hip in a flexed, abducted, and externally rotated position, as this position places the hip capsule at its largest potential volume.

A systematic and reproducible physical examination of the hip is described below in five parts: the standing, seated, supine, lateral, and prone examinations.

Standing

The examination includes general body habitus (BMI, alignment), gait stability/ alignment, and leg stance. Clinical observation of abnormal gait patterns must be evaluated, such as antalgic gait, abductor deficient gait (i.e., Trendelenburg gait), pelvic wink, excessive internal or external rotation, short leg limp and abnormal foot progression.

An antalgic gait will have a shortened stance phase, and it is indicative of hip, pelvic, or low back pain.

A Trendelenburg gait is characteristic of abductor weakness. During the evaluation, the pelvis will drop on the contralateral side during the stance phase of the gait. The gluteus medius and minimus are not strong enough to keep pelvis at level, as this weakness progresses, a compensatory shift of weight toward the affected side may occur.

The single-leg stance phase stance is similar to the Trendelenburg test and helps identify a patient with weakened abductor muscles. Single leg stance evaluates the mechanics of the hip abductor musculature and proprioception.

Exam: while standing, the patient lifts the unaffected leg forward to 45° of hip flexion and 45° of knee flexion while holding this position for 6 seconds. A positive test is a pelvic shift or a decrease of more than 2 cm.

Seated

The seated exam evaluates for neuro circulation and range of motion. Evaluate motor function, sensation, and circulation. Motor functions include the assessment of muscles that are supplied by various nerves: femoral, obturator, superior gluteal, and sciatic nerves.

Supine

While the patient is placed in a supine position, evaluate the hip range of motion with specific concentration on flexion, extension, adduction, and abduction.

The internal rotation at the hip evaluates the stability of the pelvis with flexion in 90 degrees with a neutral abduction angle. The range of motion is dictated by a firm endpoint or by patient’s pain.

There are specific provocative maneuvers that can enhance the physical examination

• FADDIR – performed by flexion, adduction, and internal rotation of the thigh in 90 degrees. A positive test results when there is anterior or anteromedial pain. This occurs due to the impingement of the anterior and anterolateral part of the femoral neck against the superior and anterior acetabular rim.
• Superiorolateral impingement test – it is performed with passive movement of the thigh into flexion and external rotation. A positive test results when there is the recreation of anterolateral pain. This indicates the impingement of the superior and superolateral part of the head-neck junction against the superior or acetabular rim.
• DEXRIT/DIRI –  dynamic external rotatory impingement test and the dynamic internal rotatory impingement test (DIRI). Both tests consist of flexing contralateral leg while bringing the affected hip to a 90° degree flexion. In the DEXRIT test, the hip is passively ranged through a wide arc of abduction and external rotation. In the DIRI, the hip is passively ranged through a wide arc of adduction and internal rotation. For both maneuvers, the reproduction of a patient’s pain in a specific position will correlate with the site of bony impingement in a clockwise fashion.
• Faber – this test is performed with flexion, abduction, and external rotation of the hip. It facilitates the differentiation of hip pain in the abducted position. It is performed by palpating the greater trochanter, with resisted hip abduction, and resisted external derotation.
• Posterior rim impingement –  the patient is positioned at the edge of the bed, legs are hanging freely. The patient draws up both legs toward the chest, which eliminates lumbar lordosis. The affected leg is then extended off the table while also abducting and externally rotating the hip into full extension. This allows the evaluation of the congruence of the posterolateral part of the femoral neck against the posterior acetabular rim. A positive test is noted when posterior pain is recreated at this position; if anterior pain is recreated, the patient may be diagnosed with hip instability.

Prone

The prone position is optimal for identifying the precise location of pain related to the SI joint region and assessing femoral anteversion. Craig’s test is performed by flexing the knee to 90, and while using the leg as a lever, the hip is internally rotated until the greater trochanter is felt to be most prominent. Femoral anteversion (normally between 8° and 15°) or retroversion is measured by the angle between the tibia and an imaginary vertical line. If there is a significant difference in IR in the extended and seated flexed position, the examiner should differentiate between osseous and ligamentous causes.

• The due high prevalence of sport-related activity, it is critical to rule out trauma-related causes of hip pain, such as femoral neck fractures.
• After a thorough history and physical examination have been performed, clinicians should obtain plain film radiographs of the pelvis to rule out fractures or other osseous abnormalities. In the setting of trochanteric bursitis/GTPS, films will be unremarkable.
• Although rarely necessary in its diagnosis, advancements in magnetic resonance imaging (MRI) have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. MRI can distinguish between extra-articular and intra-articular causes of hip pain in patients.[rx]
• A point of care ultrasound has been used as an adjunctive tool. Sonography of the hip shows tendon thickening with loss of normal fibrillar pattern with a hypoechoic fluid. Bursitis, on the other hand, is defined as an anechoic fluid collection in the expected location of either the greater trochanteric bursa or subgluteus medius bursa.[rx]

Treatment of Greater Trochanteric Pain Syndrome

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.

• Rest – People with ischial bursitis may need to cut back on the intensity, duration, and frequency of activity that leads to ischial bursitis pain (for example, reduce running or cycling mileage). People with moderate to severe and trochanteric bursitis pain may need to take time off from their sport and works. It can be frustrating and difficult for active people to cut back on their training schedules; however, rest is necessary for the injury to heal.
• Ice – Apply ice to the affected area for 5-10 minutes at a time three to five times per day to help reduce inflammation. Make sure you wrap the ice in a thin towel to prevent an ice burn from occurring. You may need to ice the area every day for around 6-12 weeks.
• Warm-up – Five to 10 minutes of gentle exercise and stretching can literally increase the body’s temperature, helping muscles become more elastic and responsive, and reducing the chance of trochanteric bursitis or other injuries.
• Change footwear – Switching out shoes and/or getting orthotic inserts can alter a person’s biomechanics and reduce the risk of trochanteric bursitis pain.
• Massage – Much like the foam roller exercise, massage may help relieve tension and improve blood flow in-band thereby reducing pain.
• Avoid Sitting on Hard Seats – Avoiding hard seats or stools is one of the best ways to reduce the pain from bursitis. If you do need to sit down for long periods, use a pillow or a doughnut cushion. Also, sit upright and maintain a good posture while sitting.
• Stretching – A doctor may recommend stretching or yoga to promote flexible muscles and other soft tissue.
• Change running biomechanics – Runners may consider shortening their stride and running on soft, flat surfaces, such as tracks and even, grassy trails.
• Change cycling biomechanics – Cyclists may consider adjusting saddle position and pedal clips. Even a small adjustment can alter the biomechanics of their pedaling and reduce ischial bursitis pain.
• Ultrasound – Efforts to heal ischial bursitis and reduce pain may get a small boost from ultrasound and electrical muscle stimulation.
• Iontophoresis – Doctors and physical therapists occasionally recommend iontophoresis, which uses a mild electrical current to administer an anti-inflammatory medicine (e.g. dexamethasone) through healthy skin and into the sore area. This treatment may be appropriate for people who can’t tolerate injections or want to avoid injections.
• Frictional massage – It is recommended to use friction massage additional to the therapy on chronic bursitis because it affects the adhesions in chronic bursal problems. It breaks down scar tissue, increases extensibility and mobility of the structure, promotes normal orientation of collagen fibers, increases blood flow, reduces stress levels, and allows healing to take place. Friction massage is beneficial to the underlying structures. By using the Graston technique of friction massage the patient should be forewarned because it may initially aggravate a chronic subacute inflammation that is present. It is postulated that deep friction, especially with the Graston technique instruments, may initiate a new inflammatory cascade, which is necessary to reach the remodeling stage of the inflammatory process and result in healing of the area.
• Low-energy shock wave therapy – Acoustic shock waves are passed through the skin with a targeted device. One analysis showed that more than two-thirds of patients given shock wave therapy were cured or greatly improved after 4 months.

Medication

• Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your painful area. Steroids make the inflammation go down. The corticosteroid will provide prolonged anti-inflammatory protection by inhibiting the inflammatory mediators. Patients will most likely be symptom-free within days to weeks without treatment.[rx]
• Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time. The lidocaine will help by providing immediate relief from the pain by blocking the sodium channels in the surrounding tissue, inhibiting the transmission of the pain signal.
• Muscle Relaxants – These medications provide relief from muscle spasms.
• Neuropathic Agents: Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids  – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.

Longer-Term Treatment 

• Strengthening Exercises –  Strengthening the glutes, quads, and hamstrings improves how the hip and knee function which reduces the friction on bursitis. Visit the knee strengthening section for exercises that will help
• Stretching Exercises – Stretching the quads, hamstrings, and bursitis also helps reduce the friction at the knee. Visit the stretches section to see if tight muscles are likely contributing to your ischial bursitis
• Gluteus stretch – Lie stretched out on your back with your head supported by a cushion. Bend one knee. With both hands around the knee, pull it slowly toward your chest and hold the position for 5 to 10 seconds. Slowly straighten your leg, and do the same with your other knee. Repeat 5 to 10 times.
• Piriformis stretch – Sit on the floor with both legs straight. Cross one leg over the other, with your foot along the knee. With the opposite hand, gently pull your bent knee across the middle of your body. Hold this position for 10 to 30 seconds. You should feel a stretch in the muscles of your outer thigh. Repeat with the other leg.
• Taping – Taping can also be used to reduce the forces going through ischial bursitis – see you physical therapist/ sports injury specialist for more information
• Massage – Deep tissue massage to the Iliotibial Band can reduce tightness, but it can be quite painful
• Injections – If other treatments have failed, a cortisone injection can be given to help reduce pain and inflammation. However, it should always be accompanied by strengthening and stretching exercises to ensure the problem doesn’t return
• Orthotics – Special insoles can be worn in your shoes to correct poor foot positions such as flat feet. See an orthopedist for a full assessment and advice

In terms of physiotherapy, exercise is promoted early in treatment for tendinopathy. Eccentric exercise (EE) is recognized as a superior approach when compared to a generic exercise regimen. In eccentric exercise, the main goal is to identify an appropriate workload, thus promoting safe exercise participation, thus encouraging adequate muscle healing, musculoskeletal health, and general fitness. Research has shown that the gradual introduction of eccentric training results in large strength improvement in older adults without concomitant adverse changes in clinical markers of muscle damage (serum creatine kinase, tumor necrosis factor).[rx]

Surgery

In some patients, pain persists despite conservative treatment and time. These refractory cases may require surgical intervention such as bursectomy, iliotibial band (ITB) lengthening techniques, trochanteric reduction osteotomy, or gluteal tendon repair.[rx]

Prevention

You can stop trochanteric bursitis from becoming worse — or never have it at all — if you take care of your hips (and the rest of your body) properly. Among the things you can do:

• Exercise the right way – It’s great being active, but train properly. That means stretching, warming up, and listening to your body.
• Wear proper orthotics or inserts – One cause of trochanteric bursitis is having one leg shorter than the other. Inserts can even out your gait.
• Drop some pounds if you’re overweight – It’s a sure way of taking pressure off your hips.

References

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• https://www.ncbi.nlm.nih.gov/books/NBK513340/
• https://www.ncbi.nlm.nih.gov/books/NBK557433/
• https://www.ncbi.nlm.nih.gov/books/NBK470331/
• https://www.ncbi.nlm.nih.gov/books/NBK525773/
• https://pubmed.ncbi.nlm.nih.gov/8642885/
• https://www.ncbi.nlm.nih.gov/books/NBK513340/
• https://www.ncbi.nlm.nih.gov/books/NBK557433/
• https://www.ncbi.nlm.nih.gov/books/NBK470331/
• https://www.ncbi.nlm.nih.gov/books/NBK525773/
• https://pubmed.ncbi.nlm.nih.gov/8642885/

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