Lateral (outside) hip pain has many names; trochanteric bursitis, subgluteal bursitis, gluteal tendinitis or gluteal tendinopathy. Lateral hip pain was previously thought to be caused by trochanteric bursitis (inflammation of the bursa at the side of your hip)(1-4).
Most lateral hip pain now falls under the umbrella term “greater trochanteric pain syndrome” (GTPS) – it was discovered that it is the muscles and their tendons, rather than inflammation of the bursa, that is the cause of the condition (in fact inflammation is often not involved)(1-5).
GTPS is characterised by pain over the greater trochanter (the bony prominence on the outside of your leg at the top of your thigh) that may radiate down the side of your thigh (1). It is normally tender to touch and the pain is often aggravated by weight-bearing activity such as running, walking, climbing stairs, as well as sitting cross-legged and lying on the sore hip (1, 2, 6).
Anatomy
The greater trochanter is the bony prominence on the outside of your femur (thigh bone). It is the attachment point for several muscles (Figure 1).
The gluteus medius and gluteus minimus muscles are muscles in your bottom, underneath your gluteus maximus muscle (Figure 2). They originate from the top of your pelvis bone at the back (your ilium) and attach (via tendons) to your greater trochanter (tendons attach muscle to bone). The muscles play an important role in stabilising your pelvis. They also act to take your leg out sideways (abduction) and rotate your thigh bone.
Around where the gluteal tendons insert onto the greater trochanter, there are a number of bursae. These are fluid-filled sacs that provide cushioning for the gluteal tendons and decrease friction between the tendons and the bone. There are multiple bursae around the greater trochanter. The three main bursae are the trochanteric or subgluteus maximus bursa, the subgluteus medius bursa and the subgluteus minimus bursa.
Figure 2: Muscle Anatomy – The Gluteal Muscles
1. Gluteus Medius (cut)
2. Gluteus Minimus
3. Gluteus Minimus
4. Gluteus Medius
—
What Causes GTPS?
The most common cause of GTPS is an overuse of the gluteus medius or gluteus minimus muscle (or both) at their attachment (tendon insertion) onto the greater trochanter (4, 6). This
is known as gluteus medius or gluteus minimus tendinopathy. Tendinopathy is defined as a tendon overuse injury, where the cells that make up the tendon change and become disorganised in response to the tendon being overloaded. Tendon inflammation (tendinitis) is not a major feature of GTPS (1,6).
Bursitis is not the most common cause of GTPS (6). In most cases, the bursae are not inflamed (there is no bursitis) or the cause of the person’s symptoms (6) If bursitis is present, it is thought to be secondary to the gluteal tendinopathy and not the primary cause of symptoms (3, 6). A study found that in 877 people with GTPS, nearly 80% did not have bursitis and only 8% of participants had “true bursitis”, where the bursitis was the cause of their lateral hip pain and there was no gluteal tendon abnormality (3). However, it is not always possible to differentiate between gluteal tendinopathy and trochanteric bursitis and the conditions can co-exist.
Risk Factors and Causes
GTPS is estimated to affect 10-25% of the population. There is a higher incidence in women, most commonly those aged 40-60 (4, 5, 7). It is experienced by up to 1 in 4 women over the age of 50 (4, 5, 7). It is thought to be more common in women due to the different size, shape and orientation of the pelvis (2, 4, 5).
__There is a higher incidence of GTPS in those with the following co-morbidities:__
– Low back pain
– Osteoarthritis (knee or hip)
– Iliotibial band tenderness
– Knee pain
– Leg length discrepancies
– Obesity (2, 4, 5)
It is thought these comorbidities predispose people to GTPS as they may change the way we move (they alter our biomechanics)(2, 4). Obesity is a risk factor in GTPS as it increases the stress on the hip joint and increases the risk of hip and knee osteoarthritis and low back pain (2).
One of the most frequent causes of GTPS is overuse or repetitive activity (2). Overuse can occur in several ways, most commonly from doing too much, too soon. An example of this is if you always walk around the lake every morning and then decide to walk up Mount Painter every morning instead. Your body is accustomed to walking along flat ground, and when you walk uphill, you require different muscles (such as your gluteus medius) to do more work. If you do this every day for a week, the gluteus medius and minimus tendons can become overloaded.
Other ways we can cause GTPS include repetitive activity, such as always running on one side of the road or walking one way along the beach (2). This can cause us to overload our gluteus medius or gluteus minimus muscle, as we are always walking across a slight slope, with one leg slightly lower than the other. Over time, this repetitive activity and overuse of the
gluteus medius/gluteus minimus muscle can lead to GTPS. Other forms of repetitive activity can include more sedentary things, such as always sitting cross-legged.
Occasionally, GTPS can result from trauma, such as a fall (2).
Signs and symptoms
Most people with GTPS will report chronic, persistent pain and tenderness at the lateral aspect (outside) of the hip (2, 4, 6). Approximately 50% of people will report pain that may radiate along the outside of the thigh to the knee, and occasionally below the knee and/or into the buttock (2-4). The onset of symptoms may be acute or insidious (building up over time)(2, 4). Symptoms will typically be unilateral (on one side) although degenerative findings may be seen bilaterally (on both sides).
People will describe pain with activity such as walking, climbing stairs and sleeping (in particular, sleeping on the affected side) (1, 2, 4, 6). Pain can also be experienced with prolonged standing, standing on one leg, standing up from a seated position, sitting with the affected leg crossed over, running and other high impact activities (2, 4).
People with GTPS will often display a Trendelenburg sign when walking and when standing on one leg – their pelvis will drop on the non-painful side when weight-bearing on the affected leg (Figure 3) (1, 4). They will also experience pain with hitching (lifting) their hip up and down (1, 4). Those with GTPS will typically have normal hip joint range of motion – they can still move it fully (there is no stiffness restricting movement), although there may be pain with movement.
IMPORTANT!
This image needs to be cited (Refer below)
Figure 3: The Trendelenburg sign shown during walking
a) Inadequate pelvic stability
b) Adequate pelvic stability
“Trendelenburg gait – inadequate pelvic stability and right, normal gait – adequate pelvic stability (19DYp13)” by sportEX journals is licensed with CC BY-ND 2.0. To view a copy of this license, visit https://creativecommons.org/licenses/by-nd/2.0/
Diagnosis
GTPS is diagnosed via a clinical examination by your physiotherapist. To determine if you have GTPS, your physiotherapist will first talk with you to determine your injury history.
Your physiotherapist will then use a number of tests to assess if you have GTPS.
They will rule out other causes of lateral hip pain, such as hip joint conditions (e.g. hip osteoarthritis) and lower back conditions (e.g. lumbar radiculopathy)(1, 2, 3, 6).
Your physiotherapist may observe you performing a number of activities such as walking, climbing stairs, standing on one leg and possibly even running. They will use palpation, assess the range of motion of your hip and assess the strength of the muscles around your hip (including your gluteus medius/minimus muscles).
Through this examination, your physiotherapist will be able to determine if you have GTPS. It is not always possible through a clinical examination to differentiate between a gluteal tendinopathy and bursitis, as the conditions can co-exist (6).
Imaging (usually ultrasound but occasionally MRI) can be used to confirm a diagnosis of GTPS (1, 6). Imaging can give specific information as to which muscle is affected (gluteus medius or gluteus minimus) and if bursitis is present. However, imaging is not always necessary to diagnose GTPS (1, 6). Your physiotherapist will discuss with you if they think imaging is required and they can provide you with a referral if indicated.
Management of GTPS
First-line treatment for GTPS includes physiotherapy to address the underlying gluteal tendon condition and relative rest (4-6). Your physiotherapist will work with you to determine the most appropriate treatment plan for you.
Physiotherapy interventions include strengthening of the hip, pelvic and gluteal muscles, addressing any biomechanical issues through gait correction and motor-control retraining (including hip/pelvic/gluteal control) and maintaining normal hip range of motion (1, 4).
An important principle in the management of tendon injuries (such as GTPS) is load management and a graduated return to exercise (4). Your physiotherapist will work with you to manage the load you are placing on the tendon and develop a time-frame for return to your exercise (walking, hiking, running etc.). Initially, the load on the tendon must be decreased to allow the tendon to settle (4, 6). This is known as relative rest. Relative rest involves staying as active as possible while modifying your activity to avoid any exacerbating activities (and avoid overloading the affected tendon). Exacerbating activities usually involve repetitive hip movements (2, 4, 5). For example, during a period of relative rest, you might start riding a stationary bike instead of going for a walk each morning, so you are staying active but minimising the load on the gluteal tendons.
After a period of relative rest, your physiotherapist will work with you to gradually increase the load on your tendon, allowing for the load-bearing capacity of the tendon to increase. This will involve introducing small amounts of activity, such as short walks, and then gradually increasing activity over time. It is important to note that if the load placed on the tendon is greater than the load the tendon can manage, flare-up of symptoms can occur. If this happens consistently over time, symptoms can worsen (4).
Tendinopathies are slow to resolve as tendons have a poor blood supply and return to activity must occur in a slow, graduated fashion. It can take 6 months or longer for GTPS to
resolve. Frustratingly for a lot of people, one of the last symptoms to resolve is pain at night with lying on the affected side.
Other interventions to address GTPS include weight loss, ice and soft tissue mobilisation of trigger points (2, 4, 5). The use of non-steroidal anti-inflammatory drugs (NSAIDs, e.g. voltaren/neurofen) is controversial. While they may give effective pain-relief, long-term use of NSAIDs has been shown to hamper tendon healing in the body (4). It may be beneficial in acute cases of GTPS but should be avoided in chronic cases (4).
Corticosteroid injections (CSI) are a commonly prescribed treatment for GTPS. The aim of a CSI is to decrease pain and inflammation. It can be effective in relieving the symptoms of GTPS when there is associated bursitis, as it can help relieve the inflammation in the bursa. However, we know the underlying pathology of GTPS is usually tendon-related, not bursa-related (3). Therefore, in most cases, CSI may not be indicated. It may decrease pain temporarily but the effects are usually only short-lived as they only address the symptoms of GTPS and not the cause (which is most likely biomechanical)(1). CSI may be used as an adjunct to a more comprehensive rehabilitation program but they are not a first-line treatment (4). An Australian study (the LEAP trial) of over 200 participants found that those receiving an exercise program and education had greater improvements at 8 weeks and 1 year than those who had corticosteroid injections and those who did nothing at all (7).
Very rarely, when conservative methods have been trialled for a significant period of time and failed, various surgical interventions may be considered (2-3).
Summary
– Greater trochanteric pain syndrome (GTPS) is most commonly caused by a gluteus medius or gluteus minimus tendon injury rather than bursitis – only 8% of GTPS cases are true bursitis
– More common in women aged 40-60 and people with low back pain, obesity, knee pain and arthritis
– People will report pain over the lateral hip and tenderness over the greater trochanter – Your physiotherapist will exclude other causes of lateral hip pain.
– Initial management involves physiotherapy to identify the underlying cause and address any biomechanical deficits
– Corticosteroid injections should be used with caution – they are a temporary solution and don’t address the cause
References
1. Robinson N. Does Dynamic Tape alter gait and reduce pain in women with greater trochanteric pain syndrome? A double-blind randomised controlled trial. University of Canberra Physiotherapy (Honours) Submission [First Class]. 2017 Oct.
2. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia. 2009 May 1;108(5):1662-70.
3. Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology. 2013 Nov;201(5):1083-6.7.
4. Ho GW, Howard TM. Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction. Current sports medicine reports. 2012 Sep 1;11(5):232-8.
5. Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. British medical bulletin. 2012 Jun 1;102(1).
6. Klauser AS, Martinoli C, Tagliafico A, Bellmann-Weiler R, Feuchtner GM, Wick M, Jaschke WR. Greater trochanteric pain syndrome. InSeminars in musculoskeletal radiology 2013 Feb (Vol. 17, No. 01, pp. 043-048). Thieme Medical Publishers.
7. Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. bmj. 2018 May 2;361:k1662
