Greater Trochanteric Pain Syndrome

We're back from hiatus to discuss diagnosis and treatment of greater trochanteric pain syndrome. Hint: it's probably not bursitis.

Articles referenced:
Consensus statement: https://pubmed.ncbi.nlm.nih.gov/37275836/
Classification system: https://pubmed.ncbi.nlm.nih.gov/35391855/
ER de-rotation test: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990389/
ITB foam rolling: https://pubmed.ncbi.nlm.nih.gov/30140558/
Cadaver ITB stretch study: https://pubmed.ncbi.nlm.nih.gov/28217413/

Chapters

• 0:00 Introduction
• 2:47 Population and Pathoanatomy
• 5:14 Examination
• 9:03 Differential Diagnosis
• 10:10 Treatment
• 15:48 Practice Question

Transcript

Hello! We’re back, and we appreciate everyone’s patience over this last hiatus.  Today we’re going to take a look at greater trochanteric pain syndrome, which is sometimes referred to even more generally as extra-articular lateral hip pain. The Orthopedic Section currently does not have a clinical practice guideline for this condition, and research is relatively sparse, but this is actually a more common condition than Achilles tendinopathy, so you are certain to see it in the clinic and in some form on the exam. Fortunately, there is a brief, readable international consensus statement on GTPS that was published earlier this year, so I’m going to pull together information from that paper and a few others to help you out.

Like most “syndromes,” GTPS is not a single diagnosis. We have moved towards this label because the diagnoses that it encompasses were often misdiagnoses, and so it’s better to be general until we can be fairly certain of the root cause. Additionally, the label recognizes that individuals with lateral hip pain can have several of these conditions at the same time, so it gives us a more comprehensive clinical picture. The conditions that fit under the GTPS umbrella include: external snapping hip, proximal iliotibial band syndrome, trochanteric bursitis, gluteus medius or gluteus minimus tendinopathy, and gluteus medius or gluteus minimus tearing.

Most likely, the vast majority of patients you see with GTPS arrive at your clinic with a clinical label of trochanteric bursitis. However, trochanteric bursitis is actually relatively uncommon. Studies that compare individuals with GTPS to healthy controls find no histological differences in the trochanteric bursa. One small MRI study on individuals with GTPS found that only 8.3% had findings consistent with trochanteric bursa distention, while about 46% had findings consistent with a gluteus medius tear and about 63% had findings consistent with gluteus medius tendinitis. In other words, trochanteric bursitis is usually NOT the correct diagnosis in individuals who have lateral hip pain.

Let’s start by talking population and pathoanatomy. Greater trochanteric pain syndrome is most common in women in their fourth to sixth decade of life. Mechanically, we think the root cause involves some kind of overloading of the hip abductor muscles and/or compression from the iliotibial band on the greater trochanter, bursa, and gluteal tendons. These factors can then lead to the diagnoses we just mentioned—and possibly more than one at the same time. Patients with GTPS often demonstrate hip abductor weakness, impaired frontal plane pelvic control (think hip drop like a Trendelenberg gait), hypertrophy of the tensor fascia lata, and thickening of the iliotibial (IT) band. Let’s focus for a second on the hip abductor weakness and TFL hypertrophy. The abductor weakness could be the result of a tear or tendinopathy, and the TFL might have hypertrophied to compensate OR general abductor weakness without a tear could have led to the same compensation. Recall that the TFL attaches to the IT band, which covers the greater trochanter. If patients are using their TFL for lateral hip stability, then the IT band is being tensioned and creating additional compressive force on the greater trochanter. This compression can cause general tissue inflammation due to friction (called IT band syndrome), it can snap back and forth over the greater trochanter (which is an external snapping hip), it can irritate and inflame the trochanteric bursa (trochanteric bursitis), or it can contribute to gluteal tendinopathy or just cause an exacerbation of tendinopathy pain due to increased pressure on the tendon.

So to recap: GTPS can be caused by gluteal tendinopathies or tears, OR it can be caused by compression or friction from the IT band on the greater trochanter. Sometimes these are related, with the TFL trying to compensate for hip abductor weakness and thus creating more compression on the greater trochanter.

Next we will talk about examination. First we will talk about diagnosing GTPS generally, and then we will focus on the individual diagnoses that fit within the syndrome. The key symptom in GTPS is pain at the lateral hip that is worse during single leg weight bearing and when any pressure is applied to the lateral hip. So patients will report pain with activities like walking or climbing stairs or sleeping on their side at night. Activities that apply pressure to the greater trochanter by adding tension to the IT band can cause pain as well. That includes anything that involves hip adduction past neutral—things like sleeping on the unaffected side or sitting with crossed legs. Occasionally, the pain can radiate up to the buttock or down the lateral thigh. The most useful tests for GTPS appear to be palpation, resisted hip abduction, and the resisted external de-rotation test. Clinicians should be able to reproduce the chief complaint with palpation of the lateral or posterior aspect of the greater trochanter. Resisted hip abduction is likely to be painful or very weak. The external de-rotation test involves placing the patient in supine, flexing the hip and knee to 90 degrees, externally rotating the hip, and then having the patient attempt to internally rotate the hip against resistance. The idea is that this position causes a greater proportion of the gluteus medius to function as an internal rotator, so pain and/or weakness implicates the gluteus medius.

Now let’s break down the individual diagnoses and talk about some other findings you might see. As we just discussed, bursitis is probably not what is going on with your patient, but if it is, you may be able to palpate and inflamed, boggy bursa at the greater trochanter.

With glute min or med tendinopathy, you can obviously expect pain or significant weakness with resisted muscle testing—and the external re-rotation test is very useful here. The patient may also have a positive Trendelenberg sign. It is difficult to distinguish between tendinopathy and a tendon tear through clinical examination, but generally tears are going to present with much more dramatic weakness than tendinopathy.

With IT band syndrome and snapping hip, we suspect that excess tension on the IT band is the main problem. A positive Ober’s test can implicate tightness in the TFL-IT band complex, and palpation might reveal the TFL hypertrophy we mentioned earlier. The biggest difference between IT band syndrome and snapping hip is that a patient with a snapping hip will report a history of snapping of the IT band over the greater trochanter while performing some specific movement—often IR or ER. (Before we move on, I do want to briefly note that you can also have an IT band syndrome that causes lateral knee pain due to friction over the femoral epicondyle. Just recognize that that’s a different IT band syndrome, although the cause might be the same.)

Let’s move on and discuss differential diagnosis. The two main other diagnoses that can present as lateral hip pain are lumbar radiculopathy and intra-articular hip pathology—especially osteoarthritis. Lateral hip pain that changes with lumbar spine motion would suggest radiculopathy as well as myotomal weakness, dermatomal sensation changes, and diminished or absent reflexes. An intraarticular condition would be suspected with a positive scour test, a positive FABER test (with a B as in bravo; also called Patrick’s test), or a positive FADDIR test (with a D as in delta). For hip OA specifically, you’re looking for age over 50 with morning stiffness and loss of hip PROM—particularly hip IR. If the actual problem is GTPS, you should not see significant loss of PROM.

Finally, let’s talk treatment.

There is an impairment-based classification system that was published in IJSPT by Disantis and Martin in 2022 that you might want to take a look at for more detail, but I’m going to summarize the big picture from this article and a few others. In general, we are going to treat based on the patient’s irritability level and based on whether the problem is contractile (i.e., gluteal tendons) or non-contractile (i.e., bursa and inflammation).

No matter what the cause is, when patients are highly irritable, we need to work on activity modification to reduce the frequency and intensity of aggravating behaviors. This means reducing the amount of time spent in single leg stance, like encouraging the patient to put on pants while sitting instead of while standing. It may also mean sleep modification to eliminate pressure on the hip or prolonged hip adduction on the affected side, so no sleeping on the affected hip, and no sleeping on the unaffected hip without a pillow between the knees to prevent adduction past neutral. Patients should also refrain from sitting with their legs crossed.

Continuing to think about the highly irritable patient, Disantis and Martin suggest soft tissue mobilization should be performed in the gluteal and TFL muscle bellies, but not the tendon or greater trochanter to avoid contributing to tissue irritation. This appears to be based on expert opinion, so you can judge for yourself.

If the problem is contractile—either gluteal tendinopathy or tears or an over-enthusiastic TFL trying to compensate for abductor weakness—then the long term goal is to strengthen the gluteus medius and minimus. During the high irritability stage, this might involve submaximal isometrics progressing to isotonics while ensuring that TFL is not compensating for the other abductors. As irritability decreases, these exercises can be progressed toward slow, heavy load concentrics and eccentrics to facilitate tendon repair. Disantis and Martin note that closed chain hip abductor exercises produce more gluteus medius EMG activity than any open chain activity except sidelying abduction, so we should be progressing toward closed chain exercises when the patient is able to tolerate it.

During the low irritability stage, Disantis and Martin suggest pain-free hip abductor strengthening. (At this point, I’m going to briefly pull from some other sources to give you a more complete picture.) We are primarily interested in lateral hip stretching if we think the IT band is creating too much compression on the greater trochanter. This has led some to focus on “IT band stretching” or “IT band foam rolling.” Keep in mind that the IT band is noncontractile. Attempts to stretch the IT band in cadaver studies have demonstrated that the proximal third—you know, the third with the tensor fascia lata, which is contractile—lengthens about twice as much as the middle or distal sections of the IT band. Additionally, some have focused on foam rolling the IT band either to lengthen it or to “break up adhesions” between the IT band and the lateral quadriceps underneath. A nice little study by Hall and Smith in 2018 compared foam rolling over the IT band to foam rolling over the hip abductor muscles. They found that foam rolling the IT band only produced a 2% improvement in hip adduction PROM, but foam rolling the abductors—you know, the contractile structures—produced a 15% improvement in hip adduction PROM. This is a long way of saying, if someone has a lateral snapping hip or lateral hip pain from IT band compression, they should be focused on targeting and foam rolling the TFL and abductors, NOT the middle and distal IT band. Please, tell your runners.

But enough about that—let’s return to the matter at hand. The final component of treatment we should focus on in the low irritability stage is frontal plane control. If patients are continuing to walk with a Trendelenberg-type gait, then they are continuing to repeatedly compress that lateral hip tissue. It’s a good idea to try to minimize that to help them make a full recovery. This might include core strengthening and neuromuscular control training in addition to ongoing hip abductor strengthening.

Now if the problem is noncontractile, like trochanteric bursitis, Disantis and Martin suggest a very similar progression. The biggest difference is that there is more of a focus on reducing tissue irritation and inflammation in the high irritability phase, so anti-inflammatory modalities like ice might be considered here. We still want to strengthen the abductors, but out goal is here focused only on strengthening them to improve frontal plane motor control, not because we think there is tendinopathy and we are trying to stimulate tendon repair.

Let’s finish with a practice question.

A 48-year-old female patient presents with L lateral hip pain that started bothering her on her daily hikes about a month ago. It gradually progressed until it was bothering her at night when she tried to sleep on her affected side. The pain is a 2/10 in the morning, but it progresses to 7/10 during the day with walking activities that last longer than 10 minutes. Physical examination reveals:

• L hip passive IR 28 degrees; R hip IR 33 degrees
• L hip passive adduction 20 degrees and painful; R hip adduction 25 degrees
• Local tenderness on the posterior greater trochanter
• Hip abductor MMT 3/5 with pain on the L and 4/5 on the R

Which of the following treatments would be most appropriate for this patient at this time?
A. Ice
B. Submaximal hip abductor isometrics
C. Inferior hip mobilizations
D. Foam rolling over the mid portion of the IT band

First of all, you should recognize that this is a greater trochanteric pain syndrome case, because even though she has some PROM limitations, she is younger than is typical for OA, her ROM is not limited enough to be OA, and her pain pattern better fits greater trochanteric pain.

Next, you will want to see if there are clues about what type of GTPS she has. She has significant L abductor weakness with pain, so we suspect gluteus medius or minimus pathology is involved here.

Then look for the irritability. 7/10 pain after 10 minutes of activity is definitely on the high irritability side of things, so we will want to pick our treatment accordingly.

The correct answer is B. Sub maximal hip abductor isometric exercises. Unlike many other tendinopathies where sub maximal isometrics probably do not generate enough force to stimulate changes, the current recommendation for GTPS is to start with sub maximal isometrics when there is high tissue irritability. Ice is not contraindicated, but it’s more appropriate if bursitis or inflammatory processes are going on. Inferior hip mobilizations are similarly not going to hurt, but they aren’t going to address the main issue. And foam rolling over the IT band, as I emphasized, is not going to do much of anything for the hip.

That’s it for this episode. I will post references for a couple of the studies I mentioned in the show notes if you want to read more.