Greater Trochanter Pain Syndrome

Have you been experiencing pain on the outer side of your hip? Does it hurt to lay on your side? Do you feel pain in your hip when you walk, climb stairs or run. If you answered yes to one of these questions, you may be dealing with a pain condition that used to be called trochanteric bursitis, but is properly referred to as Greater Trochanteric Pain Syndrome (GTPS). This is the best term to define the spectrum of painful conditions arising from your lateral hip involving tendons or bursae.

Outer Hip Anatomy

Your greater trochanter is the bony knob at the wide part of your thigh bone (femur) where your upper thigh curves outward. It serves as an important attachment point for several large hip muscles including your gluteus maximus, gluteus medius, gluteus minimus, tensor fascia lata (TFL), piriformis, and several other of your hip rotators. Evidence has shown that most cases of outer hip pain demonstrate gluteal tendinopathy involving gluteus medius or minimus as the primary local source of greater trochanteric pain syndrome. Gluteus medius involvement is much more prevalent than gluteus minimus.

Your Gluteal Muscles

Anatomically, your gluteal region is made up of your gluteus maximus, gluteus medius, gluteus minimus and TFL.

Your gluteus maximus is your most superficial gluteal muscle that forms the prominence of your gluteal region. It extends from your pelvis to the gluteal tuberosity of your femur.

Gluteus medius is located on the outer aspect of the upper buttock and is attached to the posterior part of your greater trochanter of your femur.

Gluteus minimus is the smallest muscle of gluteal muscles and lies deep to gluteus medius. It arises from exterior surface of Ilium (Pelvic bone) and attaches to anterolateral surface of greater trochanter of femur (thigh bone).

Your TFL, with its insertion on the iliotibial band, overlies your gluteus medius and minimus muscles. It spans from the front of Iliac crest (pelvic bone) to the tibia, onto which it inserts via the iliotibial tract. The TFL can become tight through its attachment to the IT band causing friction between bony prominences especially in situations of prolonged static shortening, such as in a seated position. 

The Role of Your Gluteal Muscles

When you lift your leg off the ground, your pelvis on the the opposite side will tend to drop through loss of support from below. Gluteus medius and gluteus minimus form part of abductor hip mechanism and  have an important role in walking, running and single-leg weight-bearing because they prevent this hip drop from occurring. This allows your other leg to easily swing forward for your next step.

What Causes GTPS ?

The primary pathology may arise from either too much or insufficient tensile loading and/ or excessive compressive loading of gluteal tendons. This can happen secondary to several factors:

1. Compression of your gluteal tendons due to increased adduction caused by compressive forces of your ITB in static positions. For instance assuming standing while poking your hip to one side, sitting with your legs crossed, or sitting with your knees together will increase excessive compressive loading on your gluteal muscles.
2. Weakness of your gluteus medius and gluteus minimus or increased compression from ITB tensioners (gluteus maximus, TFL, vastus lateralis) from overdevelopment may increase the compression of your gluteal tendons.
3. Compression due to increased adduction during functional loading. This can occur when you're running with a midline or cross-midline foot-ground contact pattern
4.  Altered tendon loading due to reduced neck/shaft angle (Coxa Vara)

Who is at risk of developing GTPS?

The peak incidence of GTPS is between 40 and 60 years of age. Women are at higher risk of developing GTPS  secondary to differences in pelvic biomechanics, hormonal effects, or activity between the populations. Recent changes in physical activity type, intensity, or duration may predispose to GTPS. For Instance, In athletes, running on an asymmetric surface, such as a crowned road, has been described as a risk factor. Other factors to consider in athletes include asymmetric shoe wear, iliotibial band tightness, and training errors

What are the Symptoms of GTPS ?

• Pain over the outer side of your hip that gradually worsens overtime with different loads and tasks
• Pain over the hip when lying on your painful side
• Pain can also occur when lying on your non-painful side if your painful hip falls into adduction
• Pain with activities such as walking, climbing stairs, standing and running
• Pain with prolonged sitting, especially sitting with your crossed legs
• Pain may refer to lateral thigh and knee (Pseudo-radiculopathy)
• Your lateral hip may be tender, red or warm if there is inflammation involved.
• Sitting with crossed legs increases pain

How Can I Manage My Hip Pain ?

The first line of management of GTPS include icing, relative rest, modification of activities and positions that can increase compressive load on your gluteal tendon. You can start initial treatment at home by making simple lifestyle changes such as:

1. Avoid standing while poking your hip to the side
2. Avoid sitting with your legs crossed
3. Stop adduction stretching exercises (for glutes and ITB) to limit compression of your gluteal tendons
4. Avoid sitting with your knees together
5. Avoid standing with legs crossed into adduction
6. Avoid side lying on the affected side
7. Place a pillow between their knees and shins when lying on the unaffected side to limit adduction of the affected hip
8. Sleep on your back with pillow under knees to prevent any compression on your hip
9. To reduce tensile loads, running over long distances, plyometric training and hill running should be stopped temporarily.
10. Avoid quick changes in training intensity or training volume. 
11. For the elderly, small changes like reducing walking distances, avoiding hills when walking and avoiding stairs may be sufficient in reducing the load on the gluteal tendons

Should I see a Physiotherapist?

Research has shown significant improvement in pain with guided exercises program. It is crucial to identify the cause of gluteal compression in establishing right efficient rehabilitation program. Your physiotherapist can help you identify the severity of your condition and introduce optimal tendon loading program tailored to the stage of recovery. Treatment in the initial stages encompasses a range of conservative interventions including various manual mobilizations,  soft tissue intervention, dry needling, shockwave therapy (SWT), and activity modification. Most cases resolve with conservative measures with success rates of over 90%. Gluteal strengthening exercises combined with hip and core stabilization program is vital to prevent a recurrence.

References:

1. Reid, D. The management of greater trochanteric pain syndrome: A systematic literature review. Journal of Orthopaedics. 2016; 13: 15-28.
2. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):910-22.
3. Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine. 2015 Aug 1;45(8):1107-19.
4. Lin CY, Fredericson M. Greater Trochanteric Pain Syndrome: An Update on Diagnosis and Management. Curr Phys Med Rehabil Rep. 2015;3(1);60-66.