Greater trochanteric pain syndrome

Greater trochanteric pain syndrome (GTPS), also known as trochanteric bursitis, is characterised by inflammation of the trochanteric bursa, located at the top, outer side of the femur. This bursa lies between the insertion of the gluteus medius and gluteus minimus muscles into the greater trochanter of the femur and the femoral shaft. The bursa functions as a shock absorber and lubricates the movement of adjacent muscles.

Aetiology

GTPS can result from a variety of causes, including injury often due to twisting motions or overuse, though it may also arise without a clearly definable cause. More commonly, lateral hip pain is due to disease of the gluteal tendons, which secondarily inflames the bursa. Contributing factors include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles. This condition predominantly affects middle-aged women and can be chronic and debilitating, often not responding to conservative treatments.

Signs and Symptoms

The primary symptom of GTPS is hip pain, particularly on the outer (lateral) side of the joint. This pain often appears when the affected person is walking or lying down on the affected side.

Diagnosis

A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpation of the hip and leg may reveal the location of pain, and range-of-motion tests can help to identify its source.

Diagnostic imaging such as X-rays, ultrasound, and magnetic resonance imaging (MRI) may reveal tears or swelling, although these tests often do not show any obvious abnormality in patients with GTPS.

Prevention

Preventive measures for GTPS focus on reducing wear on the hip joint and supporting structures. Proper fitting shoes with adequate support are very important, especially for individuals with flat feet, who should also consider wearing orthotic inserts. Strengthening the core and leg muscles is essential for maintaining good posture. Physical training can help prevent GTPS, but it is essential to avoid exercises that may damage the hip.

Treatment

Conservative treatments for GTPS have a 90% success rate and include pain relief medication, non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, shockwave therapy (SWT), and corticosteroid injections. In cases where conservative treatments are unsuccessful, surgery may be necessary. Surgical options include bursectomy, iliotibial band (ITB) release, trochanteric reduction osteotomy, or gluteal tendon repair. Traditional nonoperative treatments benefit most patients, and low-energy SWT is a viable alternative. Surgery is effective in refractory cases and is superior to corticosteroid therapy and physical therapy.

The primary treatment for GTPS is rest, avoiding actions that aggravate the pain. Icing the joint may help, and NSAIDs can relieve pain and reduce inflammation. If conservative measures fail, a steroid injection into the inflamed area may be necessary.

Physical therapy aims to strengthen the hip muscles and stretch the iliotibial band to relieve tension and reduce friction. Point ultrasound therapy may also be beneficial and is undergoing clinical trials. In extreme cases, where pain persists despite conservative treatments, surgical intervention such as bursectomy may be required. The procedure involves removing the inflamed bursa and repairing any muscle tears or removing loose material from arthritic degeneration of the hip.

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Self-assessment MCQs (single best answer)

Which of the following best describes Greater Trochanteric Pain Syndrome (GTPS)?

What is the primary symptom of GTPS?

Which of the following is NOT listed as a contributing factor to GTPS?

Which demographic is predominantly affected by GTPS?

What type of imaging is often used to diagnose GTPS, even though it may not show obvious abnormalities?

Which conservative treatment has a 90% success rate for GTPS?

What is the primary goal of physical therapy in the treatment of GTPS?

What surgical procedure is mentioned as a treatment for extreme cases of GTPS where conservative methods fail?

What is the function of the trochanteric bursa?

Which of the following is NOT a suggested preventive measure for GTPS?