Greater Trochanteric Pain Syndrome (GTPS)
Greater trochanteric pain syndrome (GTPS) refers to lateral hip pain localized around the femur’s greater trochanter generally involving degeneration of Gluteus medius tendon, gluteus minimus tendon, and/or associated bursitis1.
Demographics
GTPS is more common in woman >40 years old1.
Presentation
- Aching or point tenderness around the greater trochanter1
- Weak hip abduction1
- Gait deviation due to weak/painful hip abductors1
Symptoms are generally aggravated by movements involving hip abductors undergoing high forces sustained or repeated1.
- Single-leg stance
- Ascending stairs or hills
Co-existing conditions
Pathophysiology
The source of symptoms in GTPS is generally due to gluteus medius or minimus tendinopathies or bursitis
Gluteal tendinopathies
GTPS is believed to be primarily due to gluteus medius or gluteus minimus tendinopathies1
MRI evidence supports this theory since GTPS is often associated with thickening or thinning of the affected tendons as well as partial or full-thickness tears1.
In the case of tendon tears, the gluteus medius experiences tears more often due to its proximal attachment on the lateral surface of the greater trochanter1.
Due to parallels between gluteus medius and minimus tendinopathy with rotator cuff pathologies, GTPS has been nicknamed “rotator cuff pathology of the hip”1. Both the supraspinatus and gluteus medius and minimus tendons experience degneeration on the inferior aspect of the tendons as the tendons rub against the underlying bone1. Excessive force or tension through the gluteal medius or minimus can cause compression of the tendon against the underlying bone1.
In addition, excessive tension of the fascia latae can cause force the gluteus medius and minimus tendons into the underlying bone as well1. Using this hypothesis, situations where the gluteus minimus and medius are abnormally weak, the TFL could compensate, resulting in increased tension on the fascia latae which would compress the gluteus minimus and medius tendons against the underyling bone resulting in respective tendinopathies1.
Bursitis
Bursitis is the other cause of GTPS, making up ~20% of cases1. The bursa over the posterior-inferior aspect of the greater trochanter is most commonly affected, followed by the bursa underneath the gluteus medius and minimus insertions1.
Management
Conservative
Conservative management of GTPS has demonstrated good results. Some of the most successful treatments include:
- Corticosteroid injection
- Shockwave therapy
- Exercise
Surgical management
Patients who have poor response to conservative management can be candidates for surgical management.
Here are the following procedures commonly given to treat GTPS:
- Gluteal Tendon Repair
- ITB release/lengthening surgery
- Trochanteric Osteotomy
Treatments
Corticosteroid injection
Corticosteroid injection has been shown to decrease inflammatory pain, allowing for improved activity tolerance2.
Shockwave Therapy
- Extracorporeal shockwave therapy + exercise demonstrated an 87% success rates within 2months2
Manual Therapy
Soft-Tissue Mobilization
STM is indicated for patients with tissue-hypomobility or pain control2.
Due to the compressive etiology, caution is advised for symptomatic tissues since STM can add more irritating stimuli2.
Joint Mobilizations
Joint mobilizations are indicated if concurrent joint hypomobility is present2.
Exercise
Exercises
Stretching
Stretching has traditionally been prescribed in the management of GTPS, specifically of the ITB-complex2. Stretching the ITB can be unproductive and even aggravating since ITB tensile forces can indirectly result in compression of the gluteal tendons2.
As a result, clinicians should only perform stretching to restore tissue length if it is hindering optimum function2. In these scenarios, stretching should be dosed per patient tolerance2.
Patient Education
- Self-modifying activities and positions to decrease load/compressive forces
Modification
Sleeping
Sleeping positions are important to consider since these are static positions maintained for extended periods of time.
Recommended position: Supine with legs in slight abduction is best for patients with severe symptoms since it minimizes compression of gluteal tendons2.
Sidelying with affected leg on top and adducted creates excessive compression on the trochanteric region and should be modified to include a pillow between the knees to decrease adduction2.
Sports
Running
- Avoid banked tracks2
- Avoid running altogether if possible if aggravating
Cycling
- Minimizing cycling on roads/tracks with excessive camber2