What is Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)?
Patients dealing with pain on the outer side of their hip are often diagnosed with trochanteric bursitis. This condition is usually treated with anti-inflammatory medications, corticosteroid injections, and physical therapy. These methods bring relief to many patients, but some still experience ongoing discomfort and limited ability to move. Recent advancements in medical understanding have led to a more precise way of naming this condition: greater trochanteric pain syndrome (GTPS). This term includes trochanteric bursitis, as well as a snapping hip and tendon inflammation.
Trochanteric bursitis is the main cause of GTPS and involves inflammation of the greater trochanteric bursa, a cushion-like sac located between the outer hip bone and a band of tissue that runs down the side of the thigh called the iliotibial band. This inflammation often results from repetitive stress and injury. The condition tends to cause pain in the outer thigh, which can get worse when sitting for too long, climbing stairs, or doing high-impact exercises. Since the hip joint takes on quite a lot of our body weight during regular activities, it can easily wear down and tear.
When diagnosing GTPS, doctors often rely on physical signs and symptoms, and use medical imaging to differentiate from other possible conditions. To effectively manage resistant cases, good understanding of the relevant body structures, examination findings, and imaging results is necessary. Standard treatment methods include anti-inflammatory medications, physical therapy, and stretching exercises. If these methods don’t work, surgery might be considered.
Possible sources of GTPS can be found in any junction in the relevant anatomical structures. The crucial area around the greater trochanter comprises of several critical body structures ensuring that the hip can move flexibly and stay stable. One of these structures is the subgluteus maximus bursa, also called the trochanteric bursa. This sac acts like a cushion, easing movements of overlying tendons, the iliotibial band, and a muscle known as the tensor fascia lata. This area is covered by a sheath comprising of the gluteus maximus muscle, tensor fascia lata, and iliotibial band. Underneath this sheath, lie muscles that stabilize the hip. These include the gluteus minimus, which ensures the femoral head (the ball-like part of the thigh bone) stays in place, and originates from the pelvis and attaches at the outer hip bone. The gluteus medius which also attaches at the outer hip bone helps move the hip outward and stabilizes the femoral head as well. Lastly, the tensor fascia lata is the main muscle that moves the hip outward. When all these structures function properly, weight gets transferred from the hip towards the side while walking causing no pain.
What Causes Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)?
GTPS (Greater Trochanteric Pain Syndrome) involves conditions like bursitis (inflammation of a small fluid-filled sac called a bursa), gluteal tears (tears in the buttock muscles), and external snapping hip (a condition where a part of the hip snaps over the joint). It’s important to correctly identify what’s causing the pain to be able to treat it effectively. However, many patients can have more than one condition at the same time.
In the past, the main cause of pain at the side of the hip was thought to be inflammation of the bursa near the hip. This was believed to come from repeated minor injury and excessive load between the hip and the iliotibial band (a tough group of fibers that run down the outside of the thigh), mainly due to overuse, injury, or unusual walking patterns. But now, with more advanced imaging studies, we more often see conditions like abductor muscle tears (tears in the hip muscles responsible for moving your leg away from your body), tendinosis (damage to a tendon at a cellular level), and a thicker iliotibial band, rather than the inflammation of the bursa, as the main causes of pain.
New technology, like advanced MRI and endoscope methods, has made it easier to diagnose tears in the gluteus medius and minimus muscles (muscles of the buttock). The way these muscles get injured and deteriorate is similar to rotator cuff injuries (injuries to the group of muscles and tendons that hold the shoulder joint together). Tear in the gluteus medius muscle can range from partially torn to completely torn because of changes in how the cells heal and reduced capacity to self-heal. Furthermore, complete tears of the gluteus medius muscle can be recognized clinically by weakness when moving your leg away from your body or a Trendelenburg gait (a type of limp where your hip drops to the side you’re not standing on).
Snapping hip, also known as External coxa saltans, is identified when the iliotibial band “snaps” over the protruding part of the hip as the hip flexes after being straight, usually creating audible and painful sensations. This repeated snapping can lead to a thickened iliotibial band and further inflammation of the bursa. While snapping may not always be accompanied by symptoms, especially in athletes, it can sometimes lead to discomfort.
Risk Factors and Frequency for Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
GTPS is a condition that includes trochanteric bursitis, abductor tendinopathy, and snapping hip, and affects individuals across all age groups. Roughly 15% of women and 8% of men deal with GTPS. Some interesting patterns have been noted across genders, age groups, and geographical locations.
- GTPS affects about 1.8 out of 1000 patients every year.
- It is more common in women, with studies from the US, Korea, and Finland showing that women have a 2-5 times higher risk compared to men.
- The people most affected by GTPS are those aged 40-60.
- The highest incidence of GTPS usually occurs between 40 to 50 years of age. This trend is consistent across the US, Europe, and Asia.
- A possible second peak in incidence might occur in younger, active people.
Research shows that being overweight (having a BMI higher than what is normal), or engaging in repetitive activities that involve hip movement (such as running or climbing stairs), increases the risk of getting GTPS. Certain biomechanical issues can also increase the risk, including differences in leg length and weak pelvic floor muscles. Systemic conditions like diabetes or inflammatory arthritis might increase the risk indirectly through their effects on inflammation and tissue health.
- Like GTPS, snapping hip syndrome is more common in women and might be connected with being overweight. This suggests that the two conditions might share some risk factors.
- Individuals with femoroacetabular impingement (FAI) and bursitis might have a 7% higher risk of chronic bursitis.
Getting a complete global picture of GTPS is challenging due to different diagnostic techniques and reporting practices used around the world. However, it seems to be more common in developed nations, possibly due to factors like inactive lifestyles and higher obesity rates. More research is needed to understand the true extent of GTPS, particularly in developing countries where healthcare access might be limited.
Signs and Symptoms of Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
If you’re experiencing lateral hip pain, it’s important for your doctor to take an in-depth look at your medical history and perform a thorough physical exam. They’ll ask you about the nature of your pain, when it began, for how long it’s persisted, and how it’s developed over time. Your doctor will want to know about anything that makes the pain worse or eases it, and any treatments you’ve tried in the past. This includes non-surgical attempts to manage the pain, such as changes in physical activity, physical therapy, and medication. Your doctor will also want to know about any injuries you’ve had, any specific characteristics of your pain, and your overall health history, including conditions such as high blood pressure, diabetes, rheumatologic disorders, and cancer.
Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain. Its typical symptoms include hip tenderness, discomfort when moving or rotating the hip, weakness during hip abduction, and positive results on the Patrick-FABER test. Patients often report pain at the back of the thigh or back that radiates down the leg, tingling sensations, and difficulty sleeping on the affected side. These symptoms can persist for weeks to years before treatment begins. Pain can be worsened by leaning to the side, sleeping on the affected side, and sitting for prolonged periods.
Patients with GTPS might have a history of trying several treatments before seeking professional help, so it’s important to document any past episodes of physical therapy, medications, injections, and previous hip surgeries, especially if they involved the hip abductors or the trochanter.
A physical exam in patients with GTPS will include basic measurements like height, weight, and body mass index (BMI). Doctors will also observe the patient’s posture, perform a gait analysis, compare the range of motion and strength between the affected and unaffected sides, and conduct a few diagnostic maneuvers like the log roll, impingement testing, FABER test, and assessments for iliopsoas tendon snapping, sciatic nerve compression, or capsular laxity.
Based on a patient’s history, examination, and systematic diagnostic evaluation, the doctor will then proceed with a full hip examination, which involves checking the patient’s standing, seated, and supine positions. This comprehensive assessment identifies any signs of GTPS or related conditions including greater trochanteric bursitis, external snapping hip syndrome, and abductor tendonitis.
Testing for Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
When diagnosing Greater Trochanteric Pain Syndrome (GTPS), a condition that causes pain in the hip area, doctors use a few main imaging techniques. These include X-rays, ultrasound, and Magnetic Resonance Imaging (MRI).
With X-rays, doctors can check for any diseases or conditions in the hip joint that could be causing your pain like arthritis, a condition that causes joint inflammation, or abnormal development of the hip joint. Although X-rays are not always able to show clear signs of GTPS, they may reveal other issues such as calcification (hardening due to the buildup of calcium) in the bursa, a small fluid-filled sac that provides cushioning between bones and tendons or muscles, or changes in the tendons or the places where tendons attach to bones. Nevertheless, X-rays play an essential role as they can help rule out other conditions. As part of the diagnosis process, a doctor might inject a mixture of anesthetic and steroid into the hip joint. If your pain vanishes, it confirms that the hip joint was the pain source.
MRI scans are the main method used to diagnose GTPS, as they provide a detailed view of the hip’s internal and external structures. An MRI can show inflammation near the spot where the thigh bone connects to the hip bone, indicating trochanteric bursitis, an inflammation of the bursa at the outer point of the hip. MRIs can also show other GTPS signs like thickening tendon or partial and complete tear. Multiple studies have shown that MRIs are highly accurate in diagnosing GTPS, confirming their findings by comparing them to physical inspections during surgery.
An ultrasound, on the other hand, can be a quick and accessible supplement to an MRI. This imaging technique is particularly useful for visualizing movement, which can help diagnose issues where the outer point of the hip rubs against a thick band of tissue running down the outside of the thigh, causing snapping hip syndrome. An ultrasound can also identify the exact location of the pain. For example, tendinosis, a disease caused by overuse leading to small tears in the tissue in and around the tendon, can appear as thickened tendon with a disrupted pattern and fluid that does not reflect echoes well. Bursitis can be seen as fluid that doesn’t return any echoes distending or swelling the bursa under the gluteus muscle. Ultrasound has a high sensitivity and is reliable in detecting abnormalities in the tendon that moves the thigh away from the body. Specifically, when used on patients with GTPS, ultrasounds often reveal abnormalities in the gluteal tendon and thickening of the thick band of tissue running down the outside of the thigh, while bursitis is less common.
Treatment Options for Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
If you’re suffering from Greater Trochanteric Pain Syndrome (GTPS), the initial treatment plan usually focuses on non-surgical methods. This often involves changing day-to-day activities and doing physical therapy, including specific exercise routines to strengthen and relax the muscles around your hip. If you’re overweight, your doctor might suggest weight management strategies as well.
For pain and inflammation relief, doctors often prescribe Nonsteroidal Anti-inflammatory Drugs (NSAIDs). However, these drugs should be used carefully, especially if you have associated health risks such as bleeding disorders or potential stomach issues. For some, corticosteroid injections may also be recommended to locally reduce the inflammation and pain. If first-line treatments don’t work, doctors may consider advanced therapies like platelet-rich plasma (PRP) injections or extracorporeal shock wave therapy (ESWT), particularly when combined with exercise routines. Overall, these non-surgical treatments tend to work well, and most patients experience a relief in their symptoms.
Physical therapy is a crucial part of treating GTPS. It usually involves targeted exercises to strengthen the quadriceps muscles, stretch the iliotibial band (ITB), and other hip abduction exercises, to enhance the muscles around your hip joint. It is important for young athletes to learn proper running and jumping techniques to prevent future issues, sustain hip mobility, and aid in the treatment. Increasing muscle strength through eccentric exercises (where muscles lengthen while bearing a load) can be particularly beneficial, especially in older adults.
In some cases, corticosteroid injections may be helpful. These injections, composed of cortisone and commonly a local anesthetic, offer relief by directly reducing local inflammation. These injections are minor procedures that can be performed by orthopedic surgeons or primary care clinicians. Comforting fact is that whether you receive a corticosteroid injection or choose physical therapy, the long-term outcomes are generally comparable.
PRP is a newer treatment wherein the patient’s own blood is enriched with platelets and injected into the painful area. Although there is evidence that patients show improvement after receiving PRP therapy, it is not yet considered standard treatment for GTPS due to limited high-quality research.
ESWT works by delivering shock waves to the painful area to promote healing and is an effective treatment for GTPS. Research has shown it to be especially beneficial when combined with a specific exercise regimen.
If the symptoms persist for six to twelve months despite trying these conservative treatments, your doctor may suggest surgical intervention. The type of surgery will depend on the source of the pain. Surgery can be performed through either an open or endoscopic (using small incisions and a camera) approach.
Surgical options for stubborn greater trochanteric bursitis (a condition causing hip pain) involve debridement (cleansing of injured tissue) and removal of the inflamed tissue in the bursa, which is a small fluid-filled sac near the hip joint. Procedures often include resizing the bony bump on the hip (greater trochanter) and relieving tension in the iliotibial band (ITB) – a group of fibers that run along the outside of the hip to the knee. Both open and endoscopic approaches have reported to provide good outcomes.
When it comes to treating external snapping hip (a condition where a tight band of tissue snaps over the hip joint causing discomfort), multiple surgical techniques can be used. These can eliminate the snapping and reduce the pain. The techniques may include open and endoscopic release of the ITB, which is accompanied with the removal of the inflamed bursa. Both open and endoscopic techniques have shown to bring substantial symptom relief with a minimal need for repeat surgery.
Surgical treatment for torn hip abductors, which is similar to repairing a torn rotator cuff in the shoulder, can be done through both open and endoscopic techniques. For unrepairable tears, where the muscle or tendon has been too severely damaged, surgeons might consider muscle transfers or tissue grafts. Success rates of these procedures vary depending on the size of the tear and other factors.
What else can Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis) be?
The following conditions are some of the possible causes of lateral hip pain that doctors might think of when diagnosing Greater Trochanteric Pain Syndrome (GTPS). GTPS can be difficult to diagnose, so it’s important to consider all possible options:
Intra-articular hip conditions: These affect the hip joint itself.
- Femoroacetabular impingement
- Acetabular labral tear
- Ligamentum teres tear
- Loose body
- Synovitis
- Capsulitis
- Degenerative joint disease
- Dysplasia
Extra-articular hip conditions: These don’t affect the hip joint, but the surrounding muscles, tendons, or bursa.
- Muscle strain or tear
- Adductor strain
- Iliotibial band syndrome
- Iliopsoas complex disorders
- Piriformis or hip external rotator disorders
- Hamstring complex disorders
- Snapping hip syndrome
Bone conditions:
- Stress fracture
- Dislocation
- Contusion
- Epiphysitis
- Transient osteoporosis
- Childhood disorders (eg, Legg-Calve-Perthes disease)
Ligament conditions:
- Ligament sprain
Nerve disorders:
- Nerve entrapment syndrome
- Meralgia paresthetica
- Genitofemoral nerve disorders
- Ilioinguinal nerve disorders
- Sciatic nerve disorders
Systemic and Other Conditions:
- Inflammatory disorders (eg, rheumatoid arthritis and seronegative arthropathy)
- Infection
- Metabolic disorders
- Malignancy
- Sports hernia
- Pelvic visceral pain
Outside the Hip (Referred Pain):
Axial conditions:
- Disk and facet disorders
- Lumbar strain
- Vertebral fracture
Sacroiliac conditions:
- Sacroiliac disorders
Radicular disorders:
- Spinal stenosis
- Radiculopathy
- Spondylolisthesis
What to expect with Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
Preexisting health conditions, treatment choices, and an individual patient’s own responses can greatly influence the progression of GTPS, a condition that affects the hip and thigh region. Although the outcomes are usually positive, the journey to recovery can be difficult, with a significant chance of the pain coming back even after temporary relief from medications.
A study by Lievense et al revealed that patients who also have osteoarthritis, a type of joint disease, are nearly five times more likely to still have symptoms a year after treatment. Additionally, while steroid treatments can be effective, they are associated with almost three times the likelihood of the symptoms coming back within five years.
Moreover, the effects of trochanteric bursitis, an inflammation that could be a part of GTPS, affect more than just one’s health; they can disrupt work, hobbies, sleep, and even one’s sports performance. About 34% of those with the condition report it significantly affects their job, with 25% having to miss work because of it. Sleep disturbances afflict 40% of those with the condition and over half have noted a serious decline in their sports performance, reducing their overall quality of life.
Luckily, conservative management has shown to bring quick and lasting relief to a significant portion of patients. Schapira et al observed that local steroid and anesthetic injections brought swift and ongoing pain relief to over 90% of patients. Some research even suggests that topical anti-inflammatory medications can be just as helpful as those taken orally in managing symptoms of GTPS.
Possible Complications When Diagnosed with Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
: Greater trochanteric pain syndrome (GTPS) can greatly affect your everyday life beyond simply causing hip pain. While it doesn’t typically lead to more serious health issues, the chronic pain and related physical limitations can significantly lower your quality of life. GTPS can make it more difficult for people to walk, use stairs, and move from bed.
- It might lead to less physical activity: GTPS can cause people to do less physical activity due to pain and difficulty moving. This can negatively impact their general health and level of fitness.
- Workplace challenges: The physical challenges caused by GTPS can make it harder to perform at work, leading to increased absences, and lowered work performance.
- Social isolation: As pain limits physical activity, one might end up avoiding social and recreational activities, which can lead to feelings of isolation and adversely affect mental health.
Treatments for GTPS can relieve symptoms but they can have side effects as well. For instance, Nonsteroidal Anti-inflammatory Drugs (NSAIDs) can potentially harm the stomach lining and cause bleeding, especially in patients with other health conditions or those on blood-thinning medications. Remember to watch out for signs of anemia due to the unlikely event of hidden bleeding from your stomach. An alternative treatment option, steroid injections, can help with the pain but they’re not without their own risks, which include vastly increased blood sugar levels (especially in diabetics), and complications at the injection site.
Preventing Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis)
The successful treatment of GTPS (Greater Trochanteric Pain Syndrome), a condition causing hip pain, largely depends on clear communication between doctors and patients, and setting realistic expectations for recovery. It’s important for patients to understand that non-invasive methods like physical therapy and changing daily activities may take at least 3 months to fully relieve symptoms. Sticking to these treatment plans is key to getting the best results.
Patients should also be told about the potential long-term risks, including the chance that tendons might weaken if corticosteroid injections, a treatment that reduces inflammation, are used. This will help patients make well-informed decisions about their treatment.
For young athletes, strategies to prevent GTPS such as proper stretching and training are beneficial. However, many cases of GTPS are caused by accidents or for reasons that are not clear. In these cases, it’s important to highlight that the outlook is generally good and that non-invasive treatments are effective. Early use of medicines to reduce inflammation, sometimes together with corticosteroid injections, along with clear and comforting communication, often leads to symptom relief and patients being happier with their treatment. If non-invasive treatments don’t work, surgical options could be considered for long-term or recurring GTPS.
Patients need to know that success rates can vary and there are potential risks with surgery. An open conversation and realistic expectations are crucial in helping patients manage their condition effectively.
