Greater Trochanteric Pain Syndrome (GTPS)
By Laurence Schubert APAM
Greater Trochanteric Pain Syndrome (GTPS) is a modern-day term that describes lateral hip pain, that includes trochanteric bursitis associated with tendinopathy of gluteus medius and gluteus minimus (among other muscles). Previously, this condition was referred to as trochanteric bursitis, however the new definition recognises that inflammation of the bursa typically exists due to gluteal tendinopathy and not solely due to inflammation. Some small studies have found that the bursae can be a possible source of pain for GTPS patients.
Tendinopathy encompasses any injury to the tendon, including failed healing, intracellular abnormalities, disruption of collagen fibres, and inflammation of the tendon. Tendon tears are commonly missed during the diagnosis of GTPS. According to Domb et al. (2010), up to 25% of middle-aged women can have glute medius tears, and up to 10% of middle-aged men. Majority of tears are degenerative as opposed to acute and different types of tears exist, with partial tears the most common.
The greater trochanter is a bony landmark on the lateral aspect of the hip (part of the bone that sticks out if you slide your hand down the side of your hip). This landmark is clinically significant as your glute muscles attach to this point. Secondly, there are various bursae that are located around this bony landmark, most notably the trochanteric bursa. There are three layers of the glutes; gluteus maximus, gluteus medius and gluteus minimus, each muscle respectively deeper than the previous. The glutes work together to perform movements of the hip, the maximus primarily an extensor, whereas the medius and minimus are needed for abduction and stabilisation. The iliotibial band (ITB) and tensor fascia latae (TFL) also cross over the greater trochanter.
The most common symptom is pain on the lateral aspect of your hip that may radiate down the thigh and buttocks. This typically occurs gradually, with an insidious onset. The pain will generally present as an ache but can be sharp when certain movements are performed. Symptoms include:
- Pain on palpation of the greater trochanter.
- Pain with resisted abduction or external rotation of the hip.
- Pain when the hip is in adduction – e.g. sitting cross legged.
- Pain when lying on the injured side – e.g. lying in bed.
- Difficulty and pain performing tasks that require standing on one leg – e.g. climbing stairs, walking, running.·
As GTPS encompasses multiple injuries that contribute to the pain, the exact cause of the issue varies. For tendon injuries the cause is likely due to overuse, mechanical overload and incomplete healing of the tendon. Compressive forces also contribute to the tendon injury. The combination of tensile and compressive force on the tendon is believed to cause the most disruption to normal function.
Weak hip abductors are the most significant biomechanical factor when considering GTPS. With a lack of strength and control it increases the compressive and tensile forces on the glute tendons. During adduction the hip is in a position where the ITB causes a compressive force. Therefore, with a lack of abduction control the body is placed under more stress more frequently. When the hip is placed in flexion the compression force of the ITB is increased, which may explain why pain occurs with long periods of sitting.
Gender is another factor that increases the likelihood of developing GTPS. Typically, females have increased hip width (Q angle), which increases the compressive and tensile force on the glute tendons. Secondly, there was one study that found females have a smaller insertional area to which the glute medius tendon attaches, resulting in a greater concentration of tensile forces on the insertion point.
It is important to obtain an accurate diagnosis in order to ensure treatment is effective. The most common differential diagnoses include:
Unlike GTPS, the above conditions include symptoms such as: locking/catching, pain with passive internal rotation, groin pain, thigh pain and knee pain. Other common conditions that may present similar to GTPS include:
- Lumbar spine referral.
- Inflammatory joint disease – e.g. Rheumatoid Arthritis (RA).
- Neck of femur fracture.
- Piriformis Sydnrome
Majority of GTPS cases can be managed non-surgically; conservative measures should be attempted for at least 6-8 weeks before considering surgical options. Treatment options include:
Platelet-Rich Plasma (PRP) or corticosteroid injections.
- Other pain management strategies such as extracorporeal shockwave therapy (ESWT).
During physiotherapy the focus will be to educate the patient on how to best manage the condition and improve recovery time. For example, patients should avoid any aggravating activities such those listed above under symptoms. Patients can sleep with a pillow in between their legs and should avoid stretching of the ITB and gluteal muscles.
During physio treatment your practitioner will focus on any areas that are contributing to your injury, e.g. this may include release work through ITB, lumbar spine, glutes.
Exercise will focus on correcting any biomechanical insufficiencies that have been identified as well as progressively loading the injured tendons. In order to reduce pain and improve strength isometric muscle contractions are a great way to begin early phase rehab. Isometric contractions of 45 seconds have shown to be significant in reducing pain for most tendon injuries. Strengthening should focus on the glute medius, glute minimus and other areas that contribute to hip stability such as the core and lumbo-pelvic stabilisers.
Example of phase 1 rehab exercises:
- Standing hip extensions 3 x 10 (with 3 sec holds).
- Glute bridge 3 x 10.
If non-surgical treatment fails, then considering some surgical options may be necessary.
- Bursectomy – removal of some of the inflamed bursa.
- IT band surgery – this includes release and resection of the ITB in order to release the compressive force on the glute tendons.
- Reduction osteotomy of the greater trochanter – reduction of the bone, if the above two surgical options have failed.
- Reconstruction / repair of the abduction tendon – in cases where the glute tendons have a significant tear then surgical repair is necessary.