Greater Trochanteric Pain Syndrome Diagnosis and Treatment

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Key points

  • Greater trochanteric pain syndrome (GTPS) is a relatively common condition causing lateral lower limb pain in a diverse group of patients.

  • GTPS can be effectively evaluated by ultrasound, and this can also provide guidance for treatment options.

  • There are many treatment options for GTPS; however, comparative effectiveness research is needed.

Video of an injection of the greater trochanteric bursa accompanies this article at http://www.pmr.theclinics.com/

Epidemiology

Hip pain is a common complaint prompting visitation to a primary care provider or musculoskeletal medicine specialist. In a large national survey, 14.3% of individuals more than 60 years of age reported frequent hip pain.2 In the survey, women reported pain more frequently than men; in men, age was not a predictor of hip pain. In a large observational study by Segal and colleagues,3 unilateral GTPS was noted to have a prevalence of 8.5% in women and 6.6% in men. In patients referred to a spine

Associated conditions and factors

Because the buttock and hip can be a common site of referred pain from the spine and other structures, as well as the biomechanical loads placed on structures in this region, there are a host of conditions that may coexist with GTPS. Iliotibial band (ITB) tenderness, knee osteoarthritis, and low back pain were positively related to the occurrence of GTPS in an observational study.3 Body mass index was not found to be associated with GTPS. In a prospective study, GTPS was found in 18% to 45% of

Anatomy

Several muscles insert on or near the greater trochanter of the femur, the gluteus medius and minimus, piriformis, obturator externus, and obturator internus. The most superficial gluteal muscle, the gluteus maximus, has a broad origin including fibers from the ilium and sacrum and inserts onto the gluteal tuberosity of the femur and the iliotibial tract. Deep to this muscle lies the gluteus medius, a smaller muscle in surface area, which originates from the ilium and inserts onto the greater

Presentation

Patients with GTPS will present with hip pain, but this verbal symptom must be carefully discussed and a full history taken. Patients should be asked about the associated presence of low back pain, groin pain, as well as more distal complaints of knee or ankle pain. Recent increases or decreases in activity should be discussed as well as questions about recent or past trauma. Groin pain often points one in the direction of hip osteoarthritis or perhaps lumbar spine disorders, whereas pain felt

Differential diagnosis

Various disorders and clinical entities can cause lateral hip pain. A comprehensive differential diagnosis is presented here10:

  • GTPS

    • Gluteus medius dysfunction, gluteus medius or gluteus minimus tendinopathy

    • Piriformis tendinopathy

    • Iliotibial tract friction syndrome

    • Trochanteric bursitis

  • Traction enthesopathy

  • Piriformis syndrome

  • Other snapping hip syndrome

  • Meralgia paresthetica

  • Other peripheral compressive neuropathy

  • Hip (femoroacetabular) osteoarthrosis

  • Slipped capital femoral epiphysis

  • Femoroacetabular

Examination

A complete neuromusculoskeletal examination should be performed, including observation of swelling or skin breakdown and gait observation. Proper manual muscle testing cannot be overemphasized because neurologic conditions, such as lumbar radiculopathy, can present as lateral hip pain. It is important to identify any weakness, sensory loss, and or diminished reflexes because these findings may direct the clinician to an alternative workup. Gluteus medius weakness, however, is often present with

Radiography

Plain radiography can depict greater trochanteric enthesopathy as manifested by surface irregularities of the greater trochanter and/or tendon calcifications.12 Radiography can also identify other causes of hip pain, such as osteoarthritis or fractures. The limitation of radiography is the inadequate imaging of soft tissue.

MRI

MRI is considered by many to be the imaging gold standard for GTPS because it can depict both osseous and soft tissue pathology. Blankenbaker and colleagues13 reported that

Conservative treatment

Patients should be initially managed with relative rest, ice, and antiinflammatory medication if deemed necessary for pain control and/or in acute cases. Most patients improve with conservative measures.19 As noted earlier, most GTPS cases are unlikely to be the result of inflammation; therefore, nonsteroidal antiinflammatory drugs may not be beneficial beyond their analgesic effects. Activity modification is important to avoid potentially injurious hip motions, such as lying on that hip or

Sonographically guided treatments

Although GTPS is not caused by bursitis, most patients feel intermediate-term relief from the injection of corticosteroids and local anesthetic into the greater trochanteric bursa (Video 1).22

When symptoms recur, repeat injections can be performed.23 Greater trochanteric bursal injections are usually done using landmarks and without image guidance. In patients with a large body habitus or in whom non–image-guided injections were unsuccessful, image guidance can confirm accurate placement of the

Surgical treatment

GTPS that is refractory to many of the aforementioned measures is, at times, managed surgically with various techniques,28 including new endoscopic approaches.29 In certain patients, surgical intervention may be superior to conservative care19; however, the results of surgical studies are challenging to evaluate given their small sample size.

Summary

GTPS is a complex clinical entity. Once thought to be primarily caused by bursal inflammation, current evidence and experience points to tendinopathy as the primary cause of pain. Therefore, antiinflammatory medications may be of limited utility. Other treatments, such as exercise, and modalities surely play a role. For cases recalcitrant to initial conservative measures, injection therapy should be considered. More recently, sonographic imaging can provide anatomic abnormalities and/or provide

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    Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction

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    Funding Sources: None.

    Conflict of Interest: Dr M. Mallow: None; Dr L.N. Nazarian: Editor-in-Chief, Journal of Ultrasound in Medicine.

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