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Greater Trochanteric Pain Syndrome
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Contents
Other Names
- Greater Trochanteric Pain Syndrome (GTPS)
- Trochanter Pain Syndrome
- Gluteal Tendinopathy
- Greater Trochanteric Bursitis
- Troch Bursitis
- Trochanteric Bursitis
Background
- Previously known as greater trochanteric bursitis but now known as Greater Trochanteric Pain Syndrome
History
- Historically referred to as a bursopathy or bursitis due to location
- Now more accurately described as a tendinopathy based on surgical, histological and imaging studies
Epidemiology
- Most commonly seen in females age 40-60[1]
- Male to female ratio is 4:1 (need citation)
- Cause of up 10-20% of hip pain presenting to primary care[2]
- Prevalence of unilateral GTPS was 15% in women and 6.6% in men[3]
- 8.5% of women were bilateral, 1.9% of men were bilateral
- Incidence of around 1.8 per 1000 person-years[4]
- Up to 91.6% of patients with GTPS had other associated pathology affecting adjacent areas[5]
Pathophysiology
- Gluteus medius and minimus tendinopathy, which can include a partial tear, enthesiopathy
- Rarely bursitis alone
- Etiology not entirely understood
- Believed to be due to repetitive mechanical stress
- Provocative activities include: hip abduction and pelvic stabilization in walking, stair climbing, running, and standing on one leg
- May be mistaken for other primary causes of pain such as hip OA, lumbar back pain, pelvic pathology
- Can co-occur with these diseases as well
Etiology
- Repetitive friction between greater trochanter, IT band associated with hip flexion and extension
Associated Pathology
Pathoanatomy
- Greater Trochanter
- Site of attachment for: Obturator Internus, Obturator Externus, Gemelli, Piriformis, Gluteus Minimus, Gluteus Medius
- 'Trochanteric Bursa': Largest of the subgluteus maximus bursa
Risk Factors
- Female gender
- Obesity
- Greater waist girth
- Knee pain
- Low back pain
- Foot Pain
- Psychosocial[7]
- Psychological distress
- Poorer quality of life
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Pain which localizes to the lateral hip
- Worse with weight bearing activities, laying on affected side at night
- Worse with standing for long periods, sitting cross legged
- May or may not radiate down to knee
- Worsens over time
- Triggered by or exacerbated by change in exercise, trauma, prolonged weight bearing, sporting over-use[8]
- Physical Exam: Physical Exam Hip
- Pain to palpation of greater trochanter
- Comparison should be made to contralateral side
- They may demonstrate an antalgic gait including Trendelenburg Gait
- Special Tests
- Single Leg Stance Test: Stand on affected limb for 30 seconds to reproduce pain
- Jump Sign: Palpation of greater trochanter reproduces pain, causes 'jump'
- FABER Test: Flexion, abduction, external rotation
- Ober Test: Often positive, not specific to GTPS
- Resisted External Derotation Test: hip and knee flexed to 90°, hip is externally rotate, patient brings back to neutral against resistance
- Passive Adduction With Resisted Abduction: Abduct or adduct limb and then ask patient to abduct further against resistance
- Resisted Internal Rotation: Knee, hip flexed to 90°, add 10° hip external rotation, internally rotate against resistance
Evaluation
- Primarily a clinical diagnosis, however imaging useful in mixed or unclear clinical picture
Coronal view of STIR sequence showing free fluid within the trochanteric bursa, between the glute medius and glute minimus tendons[9]
Radiographs
- Standard Radiographs Hip
- Screening tool, often normal
- May show ensthesopathy at greater trochanter
- May show calcific tendinopathy of glute medius or minimus
MRI
- Findings
- Look for gluteus tendinopathy or tearing
- Enhancement within the trochanteric bursa
- Muscle atrophy, fat replacement, enthesopathy, bursal effusion
Ultrasound
- High PPV for GTPS (need citation)
- Findings
- Fluid-filled and thickened trochanteric bursa with evidence of inflammation
- Tendinopathic echogenic findings
- Tears within the gluteus medius or gluteus minimus tendons
Classification
- Not applicable
Management
Prognosis
- Early diagnosis is important
- Delay in management or mismanagement can worse prognosis due to recalcitrant symptoms
Nonoperative
- First line and primary management in most cases
- Relative rest and activity modification
- Runners should avoid banked tracks, roads with excess camber
- Minimize vertical activity such as climbing stairs, running or walking uphill
- Avoid exaggerated adduction
- Avoid crossing legs while sitting
- Sit with hips flexed above knees
- Weight bear symmetrically on both legs
- Avoid side-lying
- Exercise
- Mellor et al: At 8 weeks, exercise + education was superior to corticosteroid injection or placebo for global improvement, pain reduction[10]
- Physical Therapy
- Goals: manage load, compressive forces across greater trochanter, strengthen gluteal muscles
- Optimization of biomechanics
- Improved lumbopelvic postural control
- Medications
- Analgesics including NSAIDS
- Ice
- Weight Loss
Procedures
- Corticosteroid Injection with or without ultrasound
- Mellor et al: provides effective short term relief in 70-75% of cases, although no benefit showed at 12 months[10]
- They also found that exercise group had 80% relief at 15 months whole CSI group had only 48%
- Shock Wave Therapy
- Platelet Rich Plasma Injection
- Role is unclear at this point
Operative
- Indications
- Failure of conservative measure for ?months
- Technique
- Bursectomy
- Tenotomy
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- When athlete can run and cut without pain
Complications
- Chronic pain
- Inability to return to sport
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: a systematic review. Br J Sports Med. 2017;51(2):97–104.
- ↑ Chowdhury R, Naaseri S, Lee J, Rajeswaran G. Imaging and management of greater trochanteric pain syndrome. Postgrad Med J. 2014;90(1068):576–581
- ↑ Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88:988–992.
- ↑ Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract. 2005;55(512):199–204
- ↑ Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Arch Phys Med Rehabil. 1986;67:815–817.
- ↑ Collee G, Dijkmans BA, Vandenbroucke JP, et al. A clinical epidemiological study in low back pain. Description of two clinical syndromes. Br J Rheumatol. 1990;29:354–357.
- ↑ Plinsinga ML, Coombes BK, Mellor R, et al. Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross-sectional study. Eur J Pain. 2018;22(6):1124-1133.
- ↑ Brukner P, Khan K. Brukner and Khan’s clinical sports medicine. North Ryde, NSW: McGraw-Hill; 2012.
- ↑ https://radiopaedia.org/cases/greater-trochanter-pain-syndrome?lang=us
- ↑ 10.0 10.1 Mellor R, Bennell K, Grimaldi A, et al. 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;361:k1662. Published 2018 May 2.
Created by:
John Kiel on 10 June 2019 17:08:04
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Last edited:
5 October 2022 13:08:02
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