Continuing Education Activity
Greater trochanteric pain syndrome (GTPS) is a degenerative condition that affects the gluteal tendons and bursa. Repetitive friction between the greater trochanter and iliotibial band causes microtrauma of the gluteal tendon at the greater trochanter insertion site. This activity illustrates the evaluation of GTPS and the role of the interprofessional team in improving care for patients with this condition.
- Identify the etiology of greater trochanteric pain syndrome.
- Explain the common physical exam findings associated with greater trochanteric syndrome.
- Outline the management options available for greater trochanteric pain syndrome.
- Describe interprofessional team strategies for improving care coordination and communication to enhance the care of patients with greater trochanteric pain and improve outcomes.
Hip pain is a common orthopedic problem. 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. 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. GTPS contains a range of causes, including gluteal tendinopathy, trochanteric bursitis, and external coxa saltans. While the pathogenesis is not completely understood, symptoms are associated with myofascial pain rather than inflammation. The main bursae that are associated with 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.
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:
- Repetitive activity
- Mechanical overload
- Altered cellular response/failed healing
- Training errors: high-intensity training, high mileage
- Sedentary lifestyle
- Increased adiposity
- Leg length discrepancy
Cited in a Journal of Sports Medicine, it is believed that the evolution of tendinopathy is caused by repetitive microtrauma, especially when an abnormal pelvic width is present.
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.
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 is 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.
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 (flexion abduction external rotation) test. Patients usually suffer from chronic back pain radiating to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract. 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.
A careful assessment of the patient's history, examination, and focused diagnostic evaluation are 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.
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 four parts: the standing, seated, supine, and prone examinations.
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 gait. The gluteus medius and minimus are not strong enough to keep the pelvis 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.
The seated exam evaluates 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.
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 the 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 at 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: This 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/dynamic internal rotatory impingement test). Both tests consist of flexing the 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.
The prone position is optimal for identifying the precise location of pain related to the SI (sacroiliac) 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.
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.
Due to the high prevalence of sport-related activity, it is critical to rule out trauma-related causes of hip pain, such as femoral neck fractures. 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. 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 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.
Treatment / Management
First described in the 1930s, trochanteric bursitis management typically includes activity modification, physical therapy (PT), weight loss, corticosteroid injection, and nonsteroidal anti-inflammatory medications (NSAIDs). The initial approach to treat greater trochanteric pain syndrome includes a range of conservative interventions such as physiotherapy, local corticosteroid injection, platelet-rich plasma (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.
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).
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.
Differential diagnosis of lateral hip pain can be challenging, even to the most experienced clinicians:
- Acetabular labral tear
- Stress fracture, dislocation, contusion
- Osteonecrosis or avascular necrosis
- Muscle strain or tear
- Ligament sprain
- Sacroiliac joint dysfunction
- Snapping hip syndrome
- Femoral acetabular impingement
- Nerve entrapment syndrome
- Inflammatory disorders: rheumatoid arthritis, seronegative arthropathy
- Metabolic disorders
- Childhood disorders: Legg-Calve-Perthes disease
- Primary or secondary osteoarthritis
Sarno et al. concluded from their small number, retrospective case study, that at six weeks, topical NSAIDs have an equal benefit to oral NSAIDs for greater trochanteric pain syndrome. GTPS has a high incidence of recurrence despite conservative treatment efforts. Patients often describe short-lived pain relief with medication. For refractory cases of GTPS, there are surgical options that include iliotibial band release or the more invasive endoscopic trochanteric bursectomy.
In some cases, injection therapy may lead to swelling and an increase in local pain. Greater trochanteric pain syndrome negatively affects work, physical activity, and quality of life. Patients with greater trochanteric pain syndrome have a poor quality of life due to pain and physical impairment. After careful and thorough literature evaluation, a longitudinal study would be necessary to identify outcome-proven interventions.
Deterrence and Patient Education
Patient education and providing clear expectations are essential for patients presenting with GTPS. Health providers must educate patients that greater trochanteric pain syndrome can take 2 to 3 months (or longer) to resolve with conservative management. Physical therapy and activity modifications must be encouraged. Patients should be made aware of the concern for the use of corticosteroid injection (CSI) resulting in the possibility of weakening the tendon structure in the long term.
Enhancing Healthcare Team Outcomes
Currently, there is no evidence-based protocol for the management of greater trochanteric pain syndrome. Patients with GTPS are most effectively managed with an interprofessional team approach. This team may include primary clinicians, physical therapists, sports medicine clinicians, and orthopedic surgeons. The diagnosis for GTPS is clinical. It is essential to perform a thorough physical examination. Treatment interventions have been developed to target the proposed GTPS pathologies at the cellular level. Thus, to determine the best treatment protocol, further research and studies should be developed to determine the exact pathology of GTPS.