Greater Trochanteric Pain Syndrome
Greater Trochanteric Pain Syndrome is a relatively common condition affecting the outside of the hip. Historically this has been a stubborn to treat but we now understand this condition much better. Recently as a team, Greater Trochanteric Hip Pain was the subject of our study day. So here is the first instalment in our series – what exactly is Greater Trochanteric Hip Pain, what are the symptoms and what can be done about it?
What is Greater Trochanteric Pain Syndrome?
Greater Trochanteric Pain Syndrome (or GTPS for short) is an umbrella term that refers to pain on the outer aspect of the hip. The pain is caused by irritation of one or more of the soft tissue structures in this region. Previously, it was thought that the primary cause of GTPS was trochanteric bursitis. But we now know it is most often the result of gluteus medius and/or gluteus minimus tendon.
Patients often come into the clinic concerned that they have arthritis and are worried that they need a new hip. Be assured that this is not the case, GTPS affects the soft tissues of the hip (i.e. tendons and bursae), not the joint. Although it can be a challenging condition to manage, it is very treatable.
What is gluteal tendinopathy?
Tendon tissue is the structure that anchors muscle to bone. In the case of Greater Trochanteric Pain Syndrome, the gluteal tendons attach the gluteal (bottom) muscles to the femur (thigh).
Tendinopathy is the present day term for what was formerly tendonitis. The term literally means tendon pathology. It was previously thought that inflammation was to blame for tendon related pain, however more current research tells us that tendons become irritable as a result of a breakdown in their cellular structure. This can lead to them becoming less tolerant of loading and compressive forces, subsequently resulting in pain and reduced function. If tendon tissue is repeatedly overloaded as it attempts to heal, the tendinopathy can become chronic.
What is bursitis?
Bursitis is the name we give to an inflamed bursa. Bursae are slippery fluid filled sacs which prevent friction between tendons and the bony surface beneath them. Often the inflammation is not visible, but in some cases, the swelling can be visible on the outside of the hip.
Who does Greater Trochanteric Pain Syndrome affect?
GTPS can occur at any age, but it is most common between 40 and 70. It affects women in far greater numbers than men with reported ratios of 3-4:1. There is a higher prevalence in post menopausal women and this may be due to the effect that low oestrogen levels have on tendon health. It often occurs in people with pre-existing low back pain and is more common in people who are obese. Often there can be either a sudden change to loading (e.g. a rapid increase in running/walking mileage) or a chronic history of ‘over use’.
What are the symptoms?
Greater Trochanteric Pain Syndrome is characterised by pain on the outer aspect of the hip. It can sometimes radiate down the outside of the leg towards the knee. The pain typically occurs during weight bearing activities such as walking or climbing stairs. It often also occurs when the outside of the hip is compressed, for example by lying on your side or crossing your legs.
Do I need a scan?
Not initially – an experienced physiotherapist will be able to make a diagnosis of Greater Trochanteric Pain Syndrome simply by listening to a patient’s history, and by performing a few physical tests. If the condition is not improving as expected, then an ultrasound scan may be helpful to inform what the best next treatment option is.
Treatment of Greater Trochanteric Pain Syndrome
1) Reduce load
Initially, the most important step is to reduce as many aggravating factors as possible to a level that doesn’t provoke your symptoms. This may involve reducing your walking/running accordingly, or making simple changes such as taking the lift instead of the stairs.
You also need to minimise/avoid compressive load. Avoiding lying on the symptomatic side is very important. If you sleep on your opposite side, sleeping with a pillow between your knees is advised as it stops the top leg drifting across the midline of the body. Sitting with your legs crossed is also discouraged.
The image below shows other positions that cause compression of the soft tissues of the outer hip. These should be avoided as much as possible until your symptoms have resolved.
2) Strengthening
At the same time as minimising aggravation, a graded strengthening programme targeting specific muscles of the hip and pelvis is the primary treatment. Strengthening may also target the other major muscle groups of the lower limb and trunk, with a lot of focus on single leg stability. A physiotherapist can guide you through this.
3) Shockwave Therapy and injections
Should Greater Trochanteric Pain Syndrome not respond to exercise alone, or if it is too irritable, then other options such as shockwave therapy, or injection therapy may be appropriate. If you are overweight, reducing your weight is likely to be helpful.
A more detailed overview of the treatment options can be found here.
Does Greater Trochanteric Pain Syndrome get better?
Although GTPS can be a challenging condition to treat, it has the potential to be fully cured. Be prepared for improvements being slow! Rehabilitation takes months, as opposed to weeks. It’s not unusual for it to take anything between 6 and 18 months to resolve.
Conclusion
Greater Trochanteric Pain Syndrome is a commonly encountered condition which affects the tendon and bursa of the outer hip. Treatment primarily involves minimising irritation combined with a graded strengthening exercises. It is a treatable, curable condition albeit a somewhat stubborn one! Injection and shockwave therapy may be treatment options if it is not responding to strengthening alone.
Ultimately, physiotherapy is the primary treatment. If you think you may have GTPS, book an appointment today with one of our experienced physiotherapists to get on the road to recovery.
