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Greater Trochanteric Pain Syndrome

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(Redirected from Trochanteric Bursitis)

Other Names

  • Greater Trochanteric Pain Syndrome (GTPS)
  • Trochanter Pain Syndrome
  • Gluteal Tendinopathy
  • Greater Trochanteric Bursitis
  • Troch Bursitis
  • Trochanteric Bursitis

Background

  • This page refers to Greater Trochanteric Pain Syndrome (GTPS), formerly called Trochanteric bursitis

History

  • Needs to be updated

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]

Introduction

Illustration of the trochanteric bursa[6]
The greater trochanter and bursa[7]

General

  • 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
  • One of the most common causes of lateral hip pain, especially in middle aged women
  • Treatment is generally conservative, rarely requiring surgical intervention
  • Can be diagnostically challenging, clinical syndrome overlaps with other common conditions

Etiology

  • Gluteus medius and minimus tendinopathy, which can include a partial tear, enthesopathy
    • 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
  • Repetitive friction between greater trochanter, IT band associated with hip flexion and extension

Associated Conditions

Anatomy of the Greater Trochanter

Anatomy of the Iliotibial Band

  • Reinforcement of the deep fascia that extends from the iliac crest to Gerdys Tubercle on the lateral tibia
  • Proximally, the iliotibial tract is tightly apposed to the greater trochanter
  • Contracture of the iliotibial tract may contribute to GTPS by compressing the enthesis of the gluteus medius and gluteus minimus muscles

Risk Factors

  • Female gender
  • Obesity
  • Greater waist girth
  • Psychosocial[11]
    • Psychological distress
    • Poorer quality of life
  • Rheumatoid Arthritis

Orthopedic

Sport Related

  • Poor running surface[12]

Differential Diagnosis

Differential Diagnosis Greater Trochanteric Pain Syndrome

Differential Diagnosis Hip Pain

Clinical Features

Demonstration of the Jump Sign[7]

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, climbing stairs, running
  • 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[13]

Physical Exam: Physical Exam Hip

  • Observe the patients gait
    • Antalgic limp may suggest hip etiology
    • Trendelenburg Sign can be positive in GTPS and hip etiologies
  • Trochanteric Tendernes Sign: Pain to palpation of greater trochanter
    • Systematic review and meta analysis: Sensitivity 84%, specificity 66%[14]
  • Comparison should be made to contralateral side

Special Tests

Evaluation

Homogeneous oval-shaped calcifications overlying the gluteal insertion into the greater trochanter bilaterally, although larger on the left. [15]
Coronal view of STIR sequence showing free fluid within the trochanteric bursa, between the glute medius and glute minimus tendons[16]
Ultrasound finding in greater trochanter pain syndrome. A. Gluteus medius tendinopathy. Transverse ultrasound images of lateral facet of greater trochanter show thick and hypoechoic gluteus medius tendon (arrows) with loss of normal fibrillar pattern. B. Trochanteric bursitis. Transverse ultrasound images shows fluid collection (arrows) in the trochanteric bursa. C. Enthesopathy. Transverse ultrasound images show cortical irregularity (arrows) with echogenic calcifications (open arrowhead) where gluteus medius inserts onto the lateral facet of greater trochanter. D. Partial tear of the gluteus medius tendon. Transverse ultrasound images show a small anechoic focus (between asterisks) in the anterior fibers of gluteus medius. E. Fullthickness tears of gluteus medius and minimus. Transverse ultrasound images shows a large defect (between asterisks) where gluteus medius (open arrowhead) and minimus (arrows) normally insert corresponding to a large tear involving both tendons.[17]

Diagnostic Criteria

  • Primarily a clinical diagnosis, however imaging useful in mixed or unclear clinical picture
  • There is no widely accepted diagnostic criteria
  • Typically involves the presence of:
    • Lateral hip pain
    • Local tenderness to palpation of the greater trochanter, most marked at its superoposterior facet (posterior corner)

Radiographs

  • Standard Radiographs Hip
    • Screening tool, often normal
    • Useful to evaluate for other conditions
  • Potential findings
    • Enthesopathy at greater trochanter
    • Calcific tendinopathy of glute medius or minimus

MRI

  • Current gold standard, provides greatest detail
  • 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
    • Thickening of the iliotibial band

Classification

  • Not applicable

Management

General

  • Considered a self limited condition in most patients
  • The vast majority of patients will improve with nonoperative management
  • Initial management
    • Exercise and activity modification
    • NSAIDS, possible corticosteroid injection
    • Treatment of associated comorbidities

Nonoperative

  • 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
  • Structured Exercise
    • Mellor et al: At 8 weeks, exercise + education was superior to corticosteroid injection or placebo for global improvement, pain reduction[18]
    • Improves functional outcomes, did not reduce hip pain[19]
  • Physical Therapy
    • Goals: manage load, compressive forces across greater trochanter, strengthen gluteal muscles
    • Optimization of biomechanics
    • Improved lumbopelvic postural control
  • Medications
  • Ice
  • Weight Loss

Procedures

  • Trochanteric Bursa 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[18]
    • They also found that exercise group had 80% relief at 15 months whole CSI group had only 48%
  • Shock Wave Therapy
    • Systematic review, meta analysis: may provide short term relief, no difference to control groups at 6 and 12 months[19]
  • Platelet Rich Plasma Injection
    • Systematic review, meta analysis: may provide short term relief, no difference to control groups at 6 and 12 months[19]

Operative

  • Indications
    • Failure of conservative measure for an undefined number of 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

Prognosis and Complications

Prognosis

  • Early diagnosis is important
    • Delay in management or mismanagement can worse prognosis due to recalcitrant symptoms

Complications

  • Chronic pain
  • Inability to return to sport

See Also

Internal

External

References

  1. ↑ 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.
  2. ↑ Chowdhury R, Naaseri S, Lee J, Rajeswaran G. Imaging and management of greater trochanteric pain syndrome. Postgrad Med J. 2014;90(1068):576–581
  3. ↑ Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88:988–992.
  4. ↑ 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
  5. ↑ Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Arch Phys Med Rehabil. 1986;67:815–817.
  6. ↑ image courtesy of orthoinfo.aaos.org
  7. ↑ 7.0 7.1 Kaplan, A. H. "Musculoskeletal Sports and Spine Disorders." Musculoskelet Sport Spine Disord (2017): 33-7.
  8. ↑ 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.
  9. ↑ Woodley, Stephanie J., et al. "Lateral hip pain: findings from magnetic resonance imaging and clinical examination." journal of orthopaedic & sports physical therapy 38.6 (2008): 313-328.
  10. ↑ Kimpel, Diane M., et al. "Greater trochanteric hip pain." Orthopaedic Nursing 33.2 (2014): 95-99.
  11. ↑ 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.
  12. ↑ Nuccion S, Hunter DM, Finerman GAM. Hip and pelvis. In: DeLee JC, Drez DJ, eds. DeLee and Drez’s Orthopaedic Sports Medicine. 2nd ed. Philadelphia, PA: Saunders; 2003
  13. ↑ Brukner P, Khan K. Brukner and Khan’s clinical sports medicine. North Ryde, NSW: McGraw-Hill; 2012.
  14. ↑ Kinsella, Rita, et al. "Diagnostic accuracy of clinical tests for assessing greater trochanteric pain syndrome: a systematic review with meta-analysis." Journal of Orthopaedic & Sports Physical Therapy 54.1 (2024): 26-49.
  15. ↑ Case courtesy of Henry Knipe, Radiopaedia.org, rID: 63321
  16. ↑ https://radiopaedia.org/cases/greater-trochanter-pain-syndrome?lang=us
  17. ↑ Park, Ki Deok, et al. "Factors associated with the outcome of ultrasound-guided trochanteric bursa injection in greater trochanteric pain syndrome: a retrospective cohort study." Pain Physician 19.4 (2016): E547.
  18. ↑ 18.0 18.1 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.
  19. ↑ 19.0 19.1 19.2 Gazendam, Aaron, et al. "Comparative efficacy of nonoperative treatments for greater trochanteric pain syndrome: a systematic review and network meta-analysis of randomized controlled trials." Clinical Journal of Sport Medicine 32.4 (2022): 427-432.
Created by:
John Kiel on 10 June 2019 17:08:04
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Last edited:
11 January 2026 14:10:18
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