What is the diagnosis, treatment, and prognosis of Greater Trochanteric Pain Syndrome (GTPS)?

Diagnosis, Treatment, and Prognosis of Greater Trochanteric Pain Syndrome (GTPS)

Greater Trochanteric Pain Syndrome (GTPS) is effectively managed with a combination of conservative measures including physical therapy, weight loss, NSAIDs, and corticosteroid injections, with most patients responding well without requiring surgical intervention. 1, 2

Diagnosis

Clinical Presentation

• GTPS presents as chronic lateral hip pain that may radiate along the lateral thigh to the knee and occasionally to the buttock 2
• Point tenderness in the posterolateral area of the greater trochanter is a key physical examination finding 2
• Higher prevalence in women and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity 2

Differential Diagnosis

• GTPS must be differentiated from hip osteoarthritis, femoroacetabular impingement, and lumbar stenosis 1
• Clinical examination is essential for accurate diagnosis, as symptoms can mimic pain from other sources including myofascial pain, degenerative joint disease, and spinal pathology 2

Imaging

• Plain radiographs and MRI are not required for diagnosis but may be useful to exclude alternative pathologies 1
• Ultrasound is recommended as the best first-line investigation due to its availability, low cost, dynamic nature, and ability to guide treatments such as steroid injections 3
• MRI can be helpful in cases of diagnostic uncertainty or when specialist orthopedic referral is being considered 3

Pathophysiology

Spectrum of Disorders

• GTPS encompasses multiple diagnoses including:
  • Trochanteric bursitis
  • Gluteus medius/minimus tendinopathy or tears
  • External snapping hip (coxa saltans)/proximal iliotibial band syndrome 4
• Development of GTPS has been linked to faulty mechanics during functional activities, mainly loss of pelvic control in the frontal plane secondary to hip abductor weakness or pain 4

Treatment

Conservative Management

• Most cases of GTPS (approximately 90%) respond well to conservative measures 1, 2
• First-line treatment options include:
  • Physical therapy focusing on hip abductor strengthening 1, 4
  • Weight loss for patients with obesity 2, 3
  • Non-steroidal anti-inflammatory drugs (NSAIDs) 1, 2
  • Activity modification to reduce aggravating movements 2

Injection Therapy

• Corticosteroid and local anesthetic injections to the lateral hip/bursa provide significant symptomatic relief for patients with more chronic pain 2, 3
• Ultrasound guidance improves accuracy of injections 3

Surgical Management

• Operative management is typically indicated only in patients with chronic symptoms refractory to conservative therapy (approximately 10% of cases) 1
• Surgical options include both open and endoscopic approaches and should be guided by the specific etiology of pain 1
• Surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail 2

Rehabilitation

Physical Therapy Approach

• An impairment-based treatment classification system is recommended to better tailor conservative treatment interventions 4
• Physical therapy should focus on:
  • Hip abductor strengthening exercises 4
  • Correction of faulty movement patterns 4
  • Pelvic control exercises in the frontal plane 4
  • Range-of-motion exercises 1

Prognosis

• The majority of GTPS cases (approximately 90%) are self-limited with appropriate conservative management 1, 2
• Patients with risk factors such as obesity, coexisting low back pain, and osteoarthritis may have a more prolonged course 2
• Refractory cases requiring surgical intervention generally have good outcomes when the specific pathology is addressed 1
• Without appropriate treatment, GTPS can become chronic and significantly impact quality of life 5

Common Pitfalls and Caveats

• Misdiagnosis is common as GTPS can mimic other conditions including lumbar radiculopathy and hip osteoarthritis 3
• Focusing solely on trochanteric bursitis may lead to inadequate treatment, as gluteal tendinopathy/tears are increasingly recognized as potential causes 5
• Failure to address biomechanical factors and movement patterns may lead to symptom recurrence despite initial improvement with injections 4
• Overreliance on imaging findings without correlation to clinical symptoms may lead to inappropriate treatment 3