Introduction

Greater trochanteric pain syndrome (GTPS) is a common condition which causes lateral hip and buttock pain. The condition affects approximately 1 in 300 people per year. It most commonly affects women aged 40-60 years and is estimated to be the cause of hip pain in 10-20% of patients presenting to primary care with hip pain.

GTPS used to be referred to as trochanteric bursitis- however current research suggests that pain is more commonly caused by injury to the soft tissues (muscles and tendons) in these regions, rather than by inflammation of the trochanteric bursa.

Epidemiology

  • Incidence: 300.00 cases per 100,000 person-years
  • Peak incidence: 50-60 years
  • Sex ratio: more common in females 4:1
Condition Relative
incidence
Osteoarthritis of the hip1.67
Greater trochanteric pain syndrome1
Hip fracture0.42
Acetabular labral tear0.17
Avascular necrosis of the hip0.01
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

GTPS is most commonly cause by minor injury or inflammation to the soft tissue in the region of the lateral hip and buttock.

Causes of this include:

  • Trauma
    • A fall on to the lateral aspect of the hip.
  • Postural habit and/or over-use injury
    • Excessive weight-bearing exercise- e.g. walking or running.
    • Prolonged standing on one leg, and/or sitting with crossed legs.
  • Co-morbidity
    • Osteoarthritis of the hip/s or knee/s
    • Lower back pain
    • Previous hip surgery- with an implant, and/or associated scar tissue
    • Leg length discrepancies
  • Lifestyle
    • Inactivity- leading to weakness and reduced flexibility of the gluteal muscles.
    • Obesity

Commonly, a number of these causes contribute to a patient developing the syndrome.

Pathophysiology

The greater trochanter is a bony protrusion located at the lateral aspect of the proximal femur. It serves as an attachment for the two major abductor tendons of the hip: gluteus minimus and medius. The primary function of these muscles is to stabilise the head of the femur in the acetabulum during movement of the hip. The other major abductor of the hip is the tensor fascia lata. The fascia lata is a sheet of fibrous tissue which surrounds the muscles of the thigh. At the outer aspect of the thigh there is a thickening of this referred to as the ilio-tibial tract. The other large gluteal muscle- the gluteus maximus attaches to the ilio-tibial tract.

There are a variable number of bursae in trochanteric region. The largest- which is most often referred to as ‘trochanteric bursa’ (also known as the subgluteus maximus bursa)- is located lateral to the greater trochanter between the gluteus medius and maximus.

GTPS is associated with damage to the tendons of the gluteus medius and/or minimus muscles +/- inflammation of the trochanteric bursa.

This damage is thought to be caused by:
  • Compression by the iliotibial band on the gluteal muscle tendons and trochanteric bursa as the hip is adducted.

This compression is contributed to by:
  • Weakness of the abductor muscles of the hip
    • Causing lateral pelvic tilt.

Clinical features

At present there are no specific diagnostic criteria for GTPS.

Symptoms include:

  • Chronic, intermittent, lateral hip/thigh/buttock pain exacerbated by:
    • Weight bearing activity
    • Lying on affected side
  • Some patients report radiation of pain to the knee.

Signs include:

  • Pain on palpation of the greater trochanter
    • Associated positive predictive value (PPV) of 83% (for positive MRI features)
  • Pain within 30 seconds of standing of one leg
    • Associated PPV of 100% (for positive MRI features)
  • Positive Trendelenburg gait
  • Pain on movement of hip in directions that cause increased tension of the gluteus medius and minimus tendons- i.e. FABER test (flexion, abduction, and external rotation), FADER test (flexion, adduction, and external rotation), and ADD test (passive hip adduction)

Investigations

GTPS is generally a clinical diagnosis; made on the basis of history, and examination findings.

Ultrasound and MRI can be used to confirm the diagnosis.

Positive findings on ultrasound/MRI imaging include:
  • Inflammation of the trochanteric bursa
  • Tendinopathic echogenic findings
  • Tears of the gluteus medius or minimus muscles and/or tendons.

Abnormalities detected on imaging have to be correlated with clinical examination as they can be present in patients who are asymptomatic.

Patients in whom the diagnosis is unclear will often undergo a hip X-ray. This is to exclude the common differentials of GTPS e.g. hip osteoarthritis.

Differential diagnosis

  • Hip osteoarthritis
    • Similarities: lateral hip pain.
    • Differences: morning stiffness, associated groin pain, progressive, reduced range of movement of hip, pain particularly on internal and external rotation of hip.

  • Referred pain from lumbar spine pathology
    • Similarities: lateral hip pain.
    • Differences: history of associated lower back pain, tenderness on palpation in region of lower back, pain particularly on straight leg raise.

  • Labral tear
    • Similarities: lateral hip pain.
    • Differences: pain in groin and/or in region of buttock, ‘clicking’ or ‘locking’ sensation associated with movement at the hip joint.

  • Avascular necrosis of the femoral head
    • Similarities: lateral hip pain, worsening of pain on weight-bearing.
    • Differences: progressive pain and limitation of (active and passive) movement at the hip joint, radiation of pain down the leg (i.e. to knee).

  • Neck of femur fracture
    • Similarities: lateral hip pain.
    • Differences: pain in groin, severe pain on minimal movement at the hip joint in any direction, inability to weight bear.

Management

Management as recommended by the latest NICE CKS guidance is as follows:

GTPS is usually a self-limiting condition. Current research suggests that 6 out of 10 people will get better within a year. It will resolve in over 90% of people with conservative treatment.

Main management goals are to:
  • Reduce compressive forces across greater trochanter and gluteal tendons
    • Weight loss
    • Avoidance of positions of excessive hip adduction (i.e. Crossing legs, ITB stretching exercises).
  • Strengthen gluteal muscles (i.e. The hip abductors)
    • Physiotherapy

Conservative treatment
  • Rest
    • Short-term reduction/avoidance of weight-bearing exercises such as running
  • Analgesia
    • Paracetamol or a non-steroidal anti-inflammatory drug (NSAIDs)
    • (In early stages) use of ice pack wrapped in towel for 10-20 minutes several times per day.
  • Physiotherapy
  • Peri-trochanteric corticosteroid injection
    • Generally reserved for cases where other conservative treatment modalities have failed, or in the short-term to enable physiotherapy (which has been shown to improve the long-term outlook).
    • Evidence of short-term benefit – up to three months, with the most significant effect seen at six weeks.
    • At twelve months- existing studies show no different in outcome to a watch and wait approach.

Surgical intervention is reserved for the small portion of cases in which conservative management is unsuccessful. Procedures performed are dependent on the conditions underlying pathology but can include lengthening/release of the ITB and fascia lata; gluteal tendon tear repair; minimally invasive endoscopic bursectomy; or open reduction trochanteric osteotomy.

Shock wave therapy (i.e. Therapeutic ultrasound) has been used as a treatment modality for GTPS- however it is not readily available in NHS clinics, and there is currently no specific protocol for its use for GTPS. NICE has previously stated (2011) that: it should only be done by clinicians with specific training in its use, and as a treatment option for refractory GTPS. Further research is needed into its use.