Greater Trochanteric Pain Syndrome

What is greater trochanteric pain syndrome?

Greater trochanteric pain syndrome (GTPS) is an umbrella term used to describe a group of lateral hip disorders such as trochanteric bursitis, abductor tendon pathology, and external coxa saltans (external snapping hip). It is usually caused by pain or inflammation in the muscles, tendons, fascia (connective tissue), or the bursae (fluid-filled sacs) of the hips.  

Relevant anatomy of the hip and thigh

The greater trochanter is a part of the neck of the femur bone and is a part of the hip joint. It is an important site of attachment of muscles that move the leg. Tendons belonging to the gluteus muscles (buttocks) such as the gluteus minimus (GMin), gluteus medius (GMed), and gluteus maximus (GMax) and the tensor fascia lata (TFL) muscle attach to this bony growth (apophysis). Collectively, this formation is called the “rotator cuff of the hip”.

Parts of the GMin and GMed muscles attach to the external posterior surfaces of the wings of the pelvis (alia). The TFL lies on top of the GMin and GMed and inserts into the iliotibial band (ITB), which is a thick band of connective tissue which is attached at the other end to the main lower leg bone, the tibia. In general, the GMed, GMax and ITB are responsible for hip abduction (movement of the leg away from the midline of the body) and are also the primary stabilisers of the pelvis during walking etc. The nerve supply for these muscles comes from the obturator nerve, the femoral nerve, and the sciatic nerve.¹     

The bursae are small fluid-filled sacs that reduce the friction between the moving parts in the joints of our hips. There are four main bursae present in the hips: the trochanteric bursa, the iliopsoas bursa, the gluteus medius bursa and the ischio-gluteal bursa. A branch of the femoral nerve supplies the bursae of the greater trochanter. Bursae can become inflamed by abnormal actions of other parts of the hip joint complex.

Prevalence

GTPS affects all age groups, however, is primarily seen in adults between the ages of 40 and 60, with females being predominantly affected.² It is the most common cause of hip pain with rates as high as 1.8 per 1000 adults in primary care settings.³ In younger adults, it is common in runners, footballers, and dancers.⁴

Signs and symptoms

The signs and symptoms of GTPS include:

• Pain presenting within the outer bottom, lateral thigh or buttock areas
• Pain increases when lying on the affected side
• Pain increases with physical activity, e.g., walking, running, or standing
• Areas of pain are tender to the touch
• Pain when sitting with your legs crossed
• The pain gradually increases over time⁵

Causes and risk factors

GTPS can be caused by:

Tendinopathy of the GMin and GMed muscles

Tendinopathy is often caused by a multitude of sub-causes, that include:¹

• An overuse or mechanical overload on the GMin/GMed muscles in the buttocks area (e.g., resulting particularly from intense exercises)⁶
• Pre-existing injuries to the hip area which have caused incomplete healing (e.g., particularly injury from falls in the elderly)⁶
• Abnormalities in the attachments of the tendons, ligaments, fascia, or joint capsule to the hip bone⁷
• The presence of weak hip abductors resulting in poor control of hip abduction and greater hip adduction (movement towards and across the midline of the body). During increased adduction, resultant increased tension in the ITB produces higher compressive forces on the underlying GMin and GMed tendons. When the hip is in a flexed position the compressive forces are further increased by the ITB, which is the primary reason why pain occurs during prolonged sitting^7,8
• Atrophy (muscle wasting) of the GMin/GMed and hypertrophy (overgrowth) of Tensor Fascia Lata (TFL) changes the overall muscle balance of the abductor mechanism, which can also increase compression of the gluteal tendons.⁷
• People assigned female at birth (AFAB) are more susceptible to GTPS due to their different pelvic anatomy and biomechanics, i.e., a flared pelvic brim (wider hip bone), which subsequently changes the pull of the ITB, increasing the compression on the gluteal tendons.⁹ Furthermore, hormonal effects (especially effects on bursal irritation as a pain generator) and different physical activity levels can also be causative factors for GTPS⁹ 

Tears of the GMin and GMed muscles

Tears are often the underlying cause of GTPS and are frequently overlooked during diagnosis.¹⁰ Approximately 25% of females and 10% of males in the middle-aged population suffer from gluteal muscle tears.¹⁰ A study in 2020 found that GMin tears were more frequent than GMed tears.¹¹ These tears are mostly associated with the degeneration over time of tendons, ligaments, and entheses (the place where tendon or ligament joins the bone) rather than acute injury, and are usually partial – an incomplete tear.

Abnormalities of the external coxa saltans (rounded part of the femoral head) and ITB

This is also known as snapping hip syndrome and presents in 5-10% of people, most commonly in dancers and sportspeople.¹² It is usually caused by the GMax muscles or the ITB catching on the bony prominence of the greater trochanter during movement of the hip, which causes a popping sensation in your hip and a feeling of it ‘giving way’. It can also be the source of inflammation in the trochanteric bursa. These sensations are heightened when climbing stairs, hiking and running.¹³

Diagnosis

The diagnosis of GTPS is based on differential diagnosis through a series of interviews, physical examinations and medical imaging:¹⁴

1. Interview about your symptoms: your physician will ask you questions concerning your symptoms in order to obtain diagnostic information, including:
   • Information about pain: the location of the pain, the nature and onset of the pain, whether and where the pain radiates, and the activities that aggravate or relieve it
   • Information about your physical activities: including your occupation, daily, and sporting activities
   • Medical history: your physician will inquire about any recent or past trauma, hip-related conditions, and medication use, particularly corticosteroids
2. Neuromusculoskeletal examination including: 
   • Palpation of the greater trochanteric region: this will be tender and painful to the touch
   • Assessment for abnormal gait (walking pattern) which includes:
     • Antalgic gait: a shortened stance on the affected leg, less time is spent weight bearing on that leg, which affects your walking pattern
     • Trendelenburg gait: a lean to the midline away from the weight-bearing  leg while standing or walking 
   • Other observations: there is often resistance in movements such as hip abductions, and internal and external hip rotations. Several orthopaedic tests can be done to examine this and results deduced from their combination:
     • Trendelenburg's Test
     • Single Leg Stance 
     • Hip Flexion, Abduction, External Rotation (FABER Test)
     • Hip Flexion, Adduction, External Rotation (FADER Test)
     • Resisted Internal Rotation   
     • Resisted External Rotation
3. Medical Imaging: is used to rule out other diseases and conditions presenting with similar symptoms, such as: lumbar spine conditions, hip osteoarthritis an impingement, rheumatoid arthritis, fibromyalgia, and infection of the bursae. Techniques such as radiography, ultrasound and MRI can be used. Ultrasound is most accurate for detecting problems with the tendon, whereas MRI is better for overall differential diagnosis.¹⁶

Treatment and management

GTPS can be managed with some postural techniques and lifestyle changes:

• Improve your seated posture: avoid sitting with your legs crossed, try not to sit with your knees too wide apart or too close together. Avoid very low chairs
• Improve your standing posture: try not to put all your body weight on one leg and not to push one hip out to the side
• Improve your sleeping position: do not lay on the painful side or with your weight on the painful leg. If you lie on your good side do not let the affected leg come lower than your midline, so keep pillows between your knees and legs in a parallel arrangement. Alternatively, lay on your back with a pillow under your knees
• Improve your posture when climbing stairs: use the handrail if needed. Use your good leg to climb up each step and your sore leg to go down each step. 

Exercise

It is important to keep active, but avoid overdoing it! Exercise can help strengthen the affected muscles and will reduce the pain over time. Physiotherapists will recommend exercises such as:

• Isometric abduction
• Single leg stand
• Side-lying hip abduction
• Pelvic dips
• Bridge 

Pain management

Pain can be managed by:¹⁶

• Cold or neat wraps
• Extracorporeal shockwave therapy (ESWT): otherwise known as shock wave therapy, is a non-surgical treatment which uses pulses of energy to target damaged tissues, increasing blood flow to the affected area, improving cell regeneration and healing, and decreasing local pain
• Pain medication: painkillers and anti-inflammatories can be used as advised by your pharmacist or GP. Pain medication is most useful in the acute phase of GTPS, however, as it progresses the effect of medication diminishes
• Corticosteroid Injections: can be helpful for pain management but the effects are short term (3 - 4 months) and are not the first choice of treatment 
• Platelet-Rich Plasma Injections: the patient’s blood is extracted to collect platelets and plasma, which are then injected into the injured tissue to promote healing 
• Dry needling/Acupuncture: can potentially provide some pain relief¹⁹

Surgery

Surgery is usually the last resort and is only done if pain management/therapy has failed or when there is a significant tendon tear:¹⁶

• Bursectomy: is either done via open surgery or arthroscopically (keyhole surgery). This surgery removes one or more bursa in order to treat bursitis when other methods haven’t worked
• Iliotibial band surgery: three types of surgery can be done: iliotibial tract (ITT) release, ITT bursectomy and lateral synovial recess resection
• Reduction-osteotomy of the greater trochanter: is also known as hip reduction or hip resurfacing surgery. This surgical method allows for better movement by reducing the width of the hip
• Reconstruction/repair of the abductor tendon: aims to repair torn tendons or reconstruct them using a synthetic ligament (augmented repair)

Outlook

Around 90% of GTPS patients recover fully with non-surgical treatment such as rest, pain relief, physiotherapy, or corticosteroid injections.¹⁷ On average it can take 6  to 9 months and, in some cases, longer for your symptoms to improve.¹⁸

Summary

Since GTPS is often underdiagnosed, so using comprehensive differential diagnosis methods is important in the initial phases. Subsequently, after diagnosis, focusing on conservative treatment is the better option for managing GTPS because surgery can often produce complications – exercise is the best option for recovery. However, it is important to remember that since GTPS is often caused by over-exercising and abnormal hip loading, the intensity of these exercises needs to be gradually increased to avoid overloading the hip and making your symptoms worse. Therefore, it is appropriate to have a programme devised and monitored by a registered health professional.