Introduction

For many years, trochanteric bursitis, a condition characterised by long-standing, intermittent pain around the outermost (lateral) aspect of the hip, buttock and thigh, was thought to be due to inflammation of the trochanteric bursa. A bursa is a “cushion” of tissue that protects muscles and tendons from rubbing on the surface of adjacent bones. The greater trochanter is a bony prominence at the junction between the shaft and the neck of the femur. It can be palpated by pressing over the outermost aspect of the hip.

Reevaluating the cause of pain

Traditionally, pain on palpation of the greater trochanter supported the diagnosis of bursitis. However, inflammation requires not only pain but also swelling and redness, features typically absent in this condition. 

Modern imaging, particularly MRI, has revealed that the pain in many cases is due to gluteus medius and minimus tendinopathy or tears, inflammation of the bursae, irritation of the iliotibial band (fibrous tissue extending from the hip to the knee), or coxa saltans (snapping hip syndrome).¹ 

For this reason, the term trochanteric bursitis has been largely replaced with the term greater trochanteric pain syndrome (GTPS) which better reflects the spectrum of causes and will be used in this article.

Anatomical complexity of the trochanteric region

The term “trochanteric bursa” is a simplification. In reality, up to 20 bursae may be present in the greater trochanteric region, varying between individuals. However, three are consistently found and most likely to be involved in GTPS:

• The gluteus minimus bursa
• The subgluteus medius bursa
• The subgluteus maximus bursa (historically labelled the trochanteric bursa)²

Importance of clinical evaluation

Because pain in the region of the hip is a very common clinical problem, with multiple causes, a knowledge of the physical examination findings is important in distinguishing GTPS from the other important causes of hip pain, most notably, osteoarthritis of the hip joint and pain referred to the hip, thigh and buttock from problems with the lumbar spine. Whilst ultrasound scanning and MRI scans can provide useful information, the diagnosis of GTPS is largely made on a clinical basis through the history and examination findings alone and MRI scans can often show signs of disease in patients without any clinical symptoms.^3,4

Clinical history in GTPS

GTPS is often chronic, with patients typically reporting symptoms for months or even years. Pain is usually localised to the greater trochanter but may radiate down the lateral thigh or into the buttock. Aggravating factors include lying on the affected side, walking, running, prolonged sitting, and side-bending. Painful movements include:

• Abduction (moving the leg away from the midline)
• Adduction (moving the leg towards the midline)
• Rotation of the hip

Unlike hip osteoarthritis, GTPS rarely impairs the ability to put on shoes or socks. Features pointing to spinal pathology include lower back pain, stiffness, and neurological symptoms such as numbness. GTPS tends to be aggravated by crossing the legs or getting in and out of a car, movements less problematic in spinal disorders.^4,5

Physical examination findings in GTPS

General examination and examining the hip whilst standing and walking

As the incidence of GTPS is higher in people with a high body mass index, the patient’s height and weight should be recorded. GTPS is also more common in people assigned female at birth, owing to the pelvic structure and hormonal effects.⁶ 

An overall observation of the patient's stance and leg musculature may reveal clues as to other causes of pain such as lumbar back pain in which the hips may be flexed or muscle wasting may occur. If the hip is held in a flexed, abducted (leg moved away from the body) and externally rotated position, this may indicate fluid within the hip joint due to inflammation or infection.⁶

Observing the person walking (examination of gait) can yield important information. A Trendelenberg gait occurs when there is weakness of the muscles that abduct the leg at the hip. This is evident as the pelvis drops on the non-weight bearing side during the stance (when standing on one leg) phase of walking. Try it yourself - if you stand on one leg the pelvis on the opposite side normally rises. This is termed a Trendelenberg-positive gait. Whilst a Trendelenberg positive gait can be found in GTPS, it is not specific for GTPS and can be found in many other hip pathologies and nervous system conditions that affect the nerve supply to the hip abductor muscles.^4,6

A test which can be quickly performed in the GP surgery or emergency department is to have the patient stand on one leg on the affected side for 30 seconds - the single-leg stance test. If this induces or worsens the person’s pain it is considered positive. MRI scans of patients with GTPS have shown that this test has a very high sensitivity for detecting GTPS (although like observing Trendelenberg gait, it can be found in many conditions, so is not particularly specific). 

Another variation of this test is to ask the person to stand on the affected leg and flex the hip and knee of the unaffected leg to 45 degrees, holding the position for 6 seconds. If the pelvis shifts downwards on the unaffected side, this is a positive test.^5,7

Examination of the hip joint and movements

Applying manual pressure over the region of the greater trochanter appears to be an extremely reliable sign in diagnosing GTPS in studies that have tried to validate clinical tests with MRI imaging of the hip joint.⁷ Sometimes called the “jump test”, owing to the degree of tenderness in this region causing the patient to “jump” when it is pressed. Skin overlying the hip joint and greater trochanter does not usually feel warm or appear red or inflamed.⁶

Raising the leg with the hip flexed and the leg straight (straight-leg raise) is usually possible in GTPS (as opposed to spinal causes of pain) and performing a “log roll” - rotating the hip externally and internally (towards and away from the midline) with the hip flexed at 90 degrees to the body is possible in GTPS (however may be difficult in arthritis of the hip).⁶

Specific manoeuvres 

In addition to generally examining the movements at the hip joint, specific manoeuvres can be performed which may suggest the presence of GTPS. These tests put strain on the gluteus medius and gluteus minimus muscles which abduct the hip, so they provoke pain in the presence of muscle tears and tendinopathies in these muscles which are important causes of GTPS. 

Clinical tests 

FABER test

In the FABER test, the patient is lying flat and the leg to be tested is placed with the hip flexed, and the knee bent so that the ankle lies on the opposite leg above the knee (so that the patient’s legs resemble the number 4). Pressure is then applied to the bent knee, whilst stabilising the patient’s pelvis with the opposite hand to externally rotate the leg at the hip. 

Provocation of the patient’s usual pain is considered a positive test. A study comparing clinical tests in distinguishing osteoarthritis of the hip and GTPS, using X-rays and MRI scans to confirm the diagnosis found the FABER test to be highly sensitive and specific for GTPS.^6,7

FADER test

In the FADER test the patient again lies flat on their back and the hip is flexed to 90 degrees, the leg is then moved to the midline (adducted) and externally rotated. A positive test will be reproduction of the patient’s pain, indicating GTPS.⁶

ADD - adduction test and ADD-R (resisted adduction test)

In the ADD- adduction test, the patient is positioned on the unaffected side, with hips and knees flexed at 90 degrees. The affected leg is then straightened by the examiner, and brought into line with the pelvis. The examiner then exerts downward pressure on the leg to force the leg into an adducted (towards the midline) position. A positive test is reproduction of the patient’s pain in the region of the greater trochanter. To increase the test’s sensitivity the patient is then asked to adduct their leg (move it away from the midline) against the resistance of the examiner's hand.⁶ 

Ober’s test

In Ober’s test, the patient lies on the unaffected side with both hips and knees flexed to 90 degrees. The test leg is the adducted (brought away from the midline) and the hip is extended, so the leg is raised above the body with the knee supported. The examiner then removes the hand supporting the knee. In a positive test the leg will not fall back down to the examination couch but will remain raised.^5,6

Ober’s test is specific for tightness or inflammation of the iliotibial band, a thick band of fibrous tissue extending from the hip to the knee. Inflammation of the iliotibial band is associated with GTPS.⁶

External Coxa Saltans (or snapping hip syndrome) is a condition caused by the movement of a thickened iliotibial band over the hip as it flexes. It can either be felt, or even heard as a clicking or popping sound or sensation. This sometimes causes pain in the region of the greater trochanter.^4,6

Summary

Greater Trochanteric Pain Syndrome encompasses a range of pathologies affecting the lateral hip, including gluteal tendinopathies, bursitis, and iliotibial band irritation. While once attributed solely to bursal inflammation, current understanding recognises a multifactorial aetiology. Accurate clinical diagnosis requires careful history-taking and physical examination, supplemented by specific tests such as the FABER, FADER, single-leg stance, and Ober’s test. Distinguishing GTPS from other common causes of hip pain, such as osteoarthritis and lumbar spine disorders, is essential for appropriate management.