What is the initial treatment for Greater Trochanteric Pain Syndrome (GTPS)?

Initial Treatment for Greater Trochanteric Pain Syndrome (GTPS)

The initial treatment for Greater Trochanteric Pain Syndrome should focus on conservative measures including activity modification, physical therapy with targeted hip abductor strengthening exercises, and oral NSAIDs. 1, 2

Diagnosis

• Radiographs should be obtained first to rule out other causes of hip pain 1, 3
• Ultrasound can effectively detect trochanteric bursitis and differentiate it from gluteus medius tendinosis, though these conditions frequently coexist 1, 2
• MRI is appropriate when evaluating for suspected tendon or muscle injury after negative radiographs 1, 3

First-Line Treatment

Non-pharmacological Approaches

• Physical therapy with targeted exercises for hip abductor muscles shows superior long-term outcomes compared to other interventions 1, 2
  • Focus on eccentric strengthening exercises for gluteal muscles 2
  • Land-based physical therapy is preferred over aquatic therapy 1
• Activity modification to decrease repetitive loading of the damaged tendon and bursa 1, 2
• Application of ice (cryotherapy) for 10-minute periods through a wet towel can provide acute pain relief 2

Pharmacological Approaches

• NSAIDs are recommended for pain relief and anti-inflammatory effects 1, 4
• Acetaminophen should be considered for mild to moderate pain, especially in patients with contraindications to NSAIDs 1
  • Daily dosage should not exceed 4 grams per day 1

Second-Line Treatment

• Corticosteroid injection into the trochanteric bursa if first-line treatments fail after 4-6 weeks 1, 2, 5
  • Ultrasound guidance improves accuracy of injections 1, 2
  • Can provide both diagnostic information and therapeutic benefit 1, 6
  • May be more effective than oral NSAIDs for acute phase pain relief 2

Advanced Treatment Options

• Extracorporeal shock wave therapy is a safe and effective treatment for chronic cases that have failed physical therapy and NSAIDs 2, 7
• Platelet-rich plasma injections may be considered in refractory cases 4
• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 1, 2, 8

Important Clinical Considerations

• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the two conditions frequently coexist 1, 2
• GTPS affects 10-25% of people in developed countries with higher prevalence in women 4, 6
• Patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity have higher prevalence of GTPS 6

Common Pitfalls and Caveats

• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 1, 2
• Corticosteroid injections directly into the tendon substance should be avoided due to potential deleterious effects 2
• High-impact aerobic training involves rapid application of loads across joint structures and should be avoided during treatment 1