Greater Trochanteric Pain Syndrome
What is it?
Greater trochanteric pain syndrome (GTPS) refers to pain on the outside of the hip joint and thigh. The tendon of the glute medial muscle inserts on the greater trochanter of the femur. At this point you can have irritation and pain of the tendon (tendinopathy), the bone tendon junction (enthesopathy), or the overlying fluid filled sac called a bursa (bursitis). See figure 1 and 2 below. This condition is typically referred to as greater trochanteric bursitis but there has recently been a debate whether the pain originates from the tendon, the bursa or both so it is now increasingly referred to as greater trochanteric pain syndrome.
How did I get it?
Greater trochanteric pain syndrome is an overuse and degenerative injury of the bone, tendon and bursa. This commonly results in breakdown of the tendon and bone tendon junction and excessive friction on the bursa. This can occur when you have certain anatomical features, tight gluteal muscles or poor biomechanics around the pelvis. The trochanteric bursa works to allow the gluteal muscles to slide smoothly and without friction over the point of the hip. When these muscles are excessively tight, they place increased tension on the tendon and bone and pressure and friction on the bursa. This increases wear and tear on the bursa, causing microtrauma which, over time, can result in tendon break down, bursal thickening, inflammation and bursitis.
What are the symptoms?
GTPS causes pain over the outside of the hip. In some instances, this pain may radiate down the outside of the thigh as far down as the knee. This pain may be aggravated by activities involving movement of the hip such as walking, running, stair climbing, crossing your legs and getting in and out of the car. The area may be warm and tender to touch, sleeping on the affected side and pressure over the area may exacerbate the pain.
What should I do?
If you have GTPS, it is advisable to avoid activities which aggravate your pain and seek the assistance of a sports medicine professional to establish the cause. If the cause isn’t addressed, the pain may go away if you rest, only to return as soon as you re-commence activity. If you have GTPS, you shouldn’t continue with activities which aggravate your hip and make your pain worse. If you continue you will increase tension on the tendon and friction on the bursa, further irritating it, and possibly delaying recovery. In young athletes GTPS does not produce any long-term effects and usually gets better within a matter of weeks. In older people, however, in particular middle-aged women, it can cause long term and debilitating pain. This condition is better addressed early before symptoms are severe and sleep is affected.
How is a diagnosis made?
The diagnosis of GTPS is suggested by the characteristic nature of the symptoms and physical examination findings. Sometimes X-Rays, ultrasounds or other scans may be required to assist in eliminating other possible causes of pain.
What does rehab involve?
In recent years there has been a very significant shift in the treatment of GTPS. Anti-inflammatory medications in particular have fallen out of favour. Often GTPS will persist for a long time. In fact a serious injury such as a broken bone or large tendon tear will heal long before a GTPS will. It seems as though the body does not recognise GTPS as an injury and makes no attempt to repair the tissue. For this reason treatments aimed at strengthening and or irritating the tissue are considered more beneficial. Physical / exercise based therapy must always be the mainstay of treatment.
Reducing provocative activities such as running and jumping will facilitate recovery.
Pain medication tends not to be particularly effective for GTPS. A trial of anti-inflammatories or simple pain relief medication like paracetamol may however be worthwhile initially or if the symptoms are severe.
Exercise therapy, in particular strengthening exercise should be the mainstay of treatment.
An injection of cortisone, which is an anti-inflammatory steroid medication, may be given to relieve pain. Relief from a cortisone injection is usually highly effective but also only temporary. It may last as long as many months but as little as a few weeks. There is some contention regarding how many times an injection can be repeated but generally it will be considered twice before pursuing surgical options. The injection can be painful and has an extremely small risk of causing infection. One theoretical side effect of a cortisone injection is that it can weaken the tissue or tear it. The risk of this is low, approximately 1/1000.
A cortisone injection is usually used in two groups of patients. The first group have milder symptoms or can alternate their duties so they can work around the pain. In this group an injection is performed when the pain has been present for a long period of time and an extensive trial of physical therapy has failed. The second group is patients with extreme symptoms or who for some reason cannot wait for physical therapy to become effective. This group usually receives an earlier injection but must also engage in physical therapy or the pain will just return when the injection wears off.
Irritant injections such as Platelet Rich Plasma (PRP) are increasingly popular. It acts to irritate the tissue and infiltrate growth factors that promote healing. It can be quite a painful injection. It is quite different to cortisone. Cortisone works well in the short term but not in the long term whereas PRP works more slowly but long term outcomes have been shown to be better than cortisone. See figure 3 for area of injection.
Shock wave therapy
Shockwave therapy can be considered. It may offer some benefit.
Surgery is rarely required and should be avoided in the vast majority of cases.