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Basics ⬇

Author(s): StephenCarek, MD and Daniel C.Herman, MD, PhD, FAAPMR, FACSM, CAQSM

Description

Historically, the condition of pain and tenderness in the area of the greater trochanter had been referred to as trochanteric bursitis. Recent literature has referred to this condition as greater trochanteric pain syndrome. This change has come about owing to the recognition that the etiology of this pain can be from multiple sources, including the bursa and gluteal tendons or the iliotibial band. This includes tendinosis and tendon tears of the gluteus medius and gluteus minimus that insert on the greater trochanter (1).

Epidemiology

  • Incidence peaks between the 4th and 6th decades of life.
  • Predominant gender: female > male (4:1)
  • Common in runners

Etiology and Pathophysiology

  • Etiology of bursitis:
    • Inflammation of the bursae can come from repetitive friction between the bony structures of the trochanter and the muscle, tendon, or fascial tissue that overlies the bursae.
    • Inflammation of the bursae also can come about owing to direct trauma to the lateral hip.
  • Etiology of tendinopathy:
    • Tendon changes can come about from acute or chronic overuse of a muscle tendon unit.
    • Weakness or tightness of the muscle tendon unit contributes to this condition.

Risk-Factors

  • Ipsilateral or contralateral hip arthritis
  • Degenerative changes of the lumbar spine
  • Degenerative changes of the knees
  • Leg-length discrepancy
  • Total hip arthroplasty
  • Obesity
  • Fibromyalgia
  • Iliotibial band syndrome
  • Weakness of hip abductors and/or external rotators of the hip
  • Pes planus
  • Excessive or rapidly increased activity
  • Training on hard or banked surfaces
  • Poorly cushioned shoes
  • Limitation of internal rotation of the hip
  • Local trauma

Genetics

No genetic predisposition is known.

General Prevention

  • Strengthening of hip external rotators and hip abductors
  • Stretching of muscles around the hip
  • Avoid sudden increase in activity (including intensity, duration, or pace).
  • Avoid exercise on banked surfaces.
  • Proper shoe wear
  • Avoid direct trauma (use protection when appropriate).
  • Weight loss (if appropriate)

Commonly Associated Conditions

See “Risk Factors.”

Diagnosis ⬆ ⬇

History

  • Pain localized to the area of the lateral hip is the key historical finding. This pain may radiate down the lateral thigh or into the groin.
  • Pain is often aggravated by:
    • Prolonged walking.
    • Rising after sitting.
    • Lying on affected side.
    • Squatting.
    • Climbing.
  • Patient also may report other related conditions as seen in “Risk Factors.”

Physical Exam

  • Tenderness over the greater trochanter is the key diagnostic finding.
  • Pain reported within 30 sec of standing on the affected limb (LR = 12) (2)
  • Other exam tests may be positive but are less specific and lack sensitivity:
    • Pain with extremes of passive rotation, abduction, or adduction
    • Pain with resisted hip abduction and external or internal rotation
    • Positive Trendelenburg sign
  • Other testing to evaluate for associated conditions:
    • Positive Patrick-FABERE (flexion, abduction, external rotation, extension) testing for sacroiliac joint dysfunction or hip joint pathology
    • Ober test for iliotibial band flexibility
    • Flexion and extension of hip for hip joint pathology
    • Leg-length measurement for leg-length discrepancy
    • Foot inspection for pes planus or overpronation
    • Lower extremity neurologic assessment for lumbar radiculopathy or neuromuscular disorders

Differential Diagnosis

A wide variety of conditions should be considered:

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Blood tests are not altered by this condition.
  • Imaging is not essential for the diagnosis.
  • If radiography is done, it should include anteroposterior view and frog-leg lateral view of the affected hip.
  • Radiographs typically are normal but can show irregular bone formation or bony spurring at the greater trochanter owing to chronic bursitis or chronic tendinopathy.
  • Radiographs also may show associated degenerative disease of the hip joint or the lumbar spine.

Diagnostic Procedures/Other

  • Advanced imaging is rarely necessary.
  • Detection of abnormalities on magnetic resonance imaging (MRI) is a poor predictor of clinical syndrome.
  • Ultrasound can be used to aid in diagnosis and management of gluteal tendon tears and may be more accurate than MRI (3)[A].

Treatment ⬆ ⬇

General Measures

  • Multimodal conservative approach including (4)[A]:
    • Ice
    • Analgesics
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Minimize aggravating activities such as running or prolonged standing or walking.
    • Avoid lying on affected side and consider placing a pillow between knees while sleeping.
  • Physical therapy or home exercises program focusing on (5)[A]:
    • Strengthening (including hip abductors and external rotators of the hip)
    • Stretching (including the piriformis and iliotibial band)
    • Address flexibility of hip and low back.
  • Corticosteroid injection (5)[A]:
    • Ultrasound-guided injection may be helpful for patient with large body habitus.
  • Extracorporeal shock wave therapy
  • Platelet-rich plasma (PRP) injections for refractory cases (4,6)[C]
  • Deep friction massage of greater trochanteric, gluteal, and iliotibial band areas
  • Weight loss (if applicable)
  • Address leg-length discrepancy (if applicable).
  • Address pes planus or overpronation (if applicable).

Medication

  • Analgesics:
  • NSAIDs:
  • Injectable corticosteroids:
  • Anesthetics:
    • Injection of anesthetic alone can be diagnostic.
    • Should be used along with corticosteroids during injection
    • 5 mL of 1% lidocaine, 5 mL of 0.5% bupivacaine, or a combination of both can be used.

Issues for Referral

  • Recalcitrant pain and failure of conservative treatments
  • Septic bursitis

Surgery/Other Procedures

  • Surgery is rarely needed and should be reserved for recalcitrant cases that have failed conservative measures.
  • Various surgical procedures have been described. They include:
    • Open surgery with fenestration or release of the iliotibial band and excision of the subgluteal bursae.
    • Arthroscopic bursectomy.
    • Gluteal tendon repair.

Ongoing Care ⬆ ⬇

Complications

  • Bursal thickening and fibrosis
  • Tendon thickening, fibrosis, or tearing

Additional Reading ⬆ ⬇

  • Korakakis V, Whiteley R, Tzavara A, et al. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018;52(6):387–407.
  • Paluska SA. An overview of hip injuries in running. Sports Med. 2005;35(11):991–1014.
  • Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662–1670.

References ⬆ ⬇

  1. Redmond JM, Chen AW, Domb BG. Greater trochanteric pain syndrome. J Am Acad Orthop Surg. 2016;24(4):231–240.
  2. Grimaldi A, Mellor R, Nicolson P, et al. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med. 2017;51(6):519–524.
  3. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med. 2015;45(8):1107–1119.
  4. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013;5(3):169–175.
  5. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447–453.
  6. Fitzpatrick J, Bulsara MK, O’Donnell J, et al. The effectiveness of platelet-rich plasma injections in gluteal tendinopathy: a randomized, double-blind controlled trial comparing a single platelet-rich plasma injection with a single corticosteroid injection. Am J Sports Med. 2018;46(4):933–939.

Clinical Pearls ⬆

  • Trochanteric bursitis, also referred to as greater trochanteric pain syndrome, is best diagnosed with tenderness of the lateral hip and reproduced pain with single leg stance.
  • Treatment modalities including ice, analgesics, anti-inflammatories, physical therapy, and steroid injections are reasonable first-line interventions for pain and improved function.
  • Ultrasound is an emerging diagnostic tool and can be used to assist in guidance for injections.