Treatment Options for Greater Trochanteric Pain Syndrome

The understanding of the etiology of lateral hip pain has evolved significantly in recent years. Previously, patients presenting with such pain were typically given a diagnosis of trochanteric bursitis, which is now part of a broader diagnosis of greater trochanteric pain syndrome (GTPS). This category also includes external coxa saltans–also known as “snapping hip”–and tendinopathy of the gluteal medius and minimus. Two or more of these disorders often co-occur in patients.¹

Though pain in the lateral hip commonly observed in runners, is often referred to as hip “bursitis,” it often involves irritation of the hip abductor muscles.

“Bursitis is inflammation of tissue that reduces friction around a tendon, but practically, this problem involves the tendon insertion, such as the gluteus medius tendon,” explained Anthony Luke MD, MPH, a professor of clinical orthopedics at the University of California, San Francisco (UCSF), and director of UCSF Primary Care Sports Medicine and the UCSF Human Performance Center.

“As such, the most effective treatment options typically include rest, ice and anti-inflammatory medications if the pain is significant and affecting one’s ability to run,” and surgery is rarely necessary, he told Clinical Pain Advisor.

Physical therapy is an essential component of treatment for this type of pain, including a course of strengthening and stretching exercises for the gluteal and hip abductor muscles, according to Dr Luke.

These may consist of stabilization exercises for the abdominals and lumbar spine that strengthen the core muscles, as well as various moves to stretch the hips, including gluteal, flexor, IT band, and hamstring stretching exercises. In addition, patients may use foam rollers to gently massage the affected area, though these should not be overused, as they can contribute to irritation.  

“In patients who are failing conservative treatment options, localized steroid injection can help reduce pain symptoms short term, though it is critical to continue all the physical therapy exercises as the long-term treatment,” said Dr Luke.

“Some sports medicine physicians will perform these injections under ultrasound guidance which is more precise,” he added. A retrospective cohort study published in Pain Physician showed significant improvement in pain and function in patients who received ultrasound-guided trochanteric bursa injections, with successful outcomes observed in approximately 80%, 65%, and 56% of patients at the 1, 3, and 6-month follow-up points, respectively.²

However, less therapeutic effect was found in patients who also presented with knee osteoarthritis or pain in the lumbar facet joint or sacroiliac joint.

In highly symptomatic patients, magnetic resonance imaging  can help to assess whether there is a significant bursitis or tear in the tendon insertion, and standard radiography can help to rule out intra-articular pathology.

Though rarely warranted, recalcitrant cases of GTPS may require surgery. In these patients, open or endoscopic techniques may be considered. Findings published in July 2016, for instance, report the following overall improvements in patients with GTPS who underwent endoscopic longitudinal vertical iliotibial band release and trochanteric bursectomy: a decrease in mean Visual Analogue Scale values from 7.8 to 2.8 (P <.001); an increase in Oxford Hip Scores from 20.4 to 37.3 ( P  <.001), and an increase in International Hip Outcome Tool (iHOT-33) scores from 23.8 to 70.2 ( P  <.001).³

Once the patient is able to resume running with minimal discomfort, gait retraining should be implemented, and “running form should be checked to ensure good core and pelvic stability and stride length, and avoiding crossing over to avoid strain to the lateral hip,” Dr Luke advised. “Good running technique is important to avoid recurrent symptoms.”

Summary and Clinical Applicability

Greater tronchanteric pain syndrome can usually be treated with rest, ice, anti-inflammatories, and physical therapy. Localized steroid injections may also be given for short-term relief, and open or endoscopic surgery may be considered in recalcitrant cases. 

Look at this video for recommended physiotherapy exercises for greater trochanteric pain syndrome:

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References

1. Redmond JM, Chen AW, Domb BG. Greater Trochanteric Pain Syndrome. J Am Acad Orthop Surg. 2016; 24(4):231-240.

2. Park KD, Lee WY, Lee J, Park MH, Ahn JK, Park Y. Factors Associated with the Outcome of Ultrasound-Guided Trochanteric Bursa Injection in Greater Trochanteric Pain Syndrome: A Retrospective Cohort Study. Pain Physician. 2016; 19(4):E547-57.

3. Drummond J, Fary C, Tran P. The outcome of endoscopy for recalcitrant greater trochanteric pain syndrome. Arch Orthop Trauma Surg. 2016; DOI 10.1007/s00402-016-2511-z