What are the symptoms and treatment options for greater trochanteric pain syndrome?

Symptoms of Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome (GTPS) is characterized by persistent pain and tenderness over the lateral aspect of the hip, often radiating along the lateral thigh to the knee and occasionally to the buttock. 1

Clinical Presentation

• Pain is typically located over the lateral aspect of the hip, with point tenderness in the posterolateral area of the greater trochanter 1
• Pain may radiate along the lateral aspect of the thigh to the knee and sometimes below the knee or to the buttock 1
• Symptoms are exacerbated by activities such as navigating stairs, prolonged sitting, and repetitive loading of the affected area 2
• Soft tissue clicking over the greater trochanter is often associated with abductor tendon abnormalities 3
• Pain is commonly worsened with weight-bearing activities and lying on the affected side 4

Physical Examination Findings

• Point tenderness over the posterolateral area of the greater trochanter is a hallmark finding 1
• Decline squat test often reproduces the patient's pain by placing increased load on the affected tendons 2
• Pain may be elicited with resisted leg extension with the leg fully extended 2
• Anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation should be assessed as they may contribute to the condition 2

Diagnostic Considerations

• GTPS encompasses a spectrum of conditions including trochanteric bursitis, abductor tendinopathy, and external coxa saltans 4
• Radiographs should be obtained first to rule out other causes of hip pain, such as arthritis or bone tumors 3, 5
• Radiographs showing >2 mm surface irregularities of the greater trochanter have been associated with abductor tendon abnormalities 3
• MRI can assess peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 5, 6
• Ultrasound can effectively detect trochanteric bursitis and differentiate it from other conditions, though it may be difficult to distinguish from gluteus medius tendinosis 5
• Diagnostic injection with lidocaine alone or in combination with corticosteroids can help confirm GTPS as the source of pain 6

Treatment Options

First-Line Conservative Measures

• NSAIDs are recommended for pain relief and anti-inflammatory effects 5
• Physical therapy, including stretching exercises for the iliotibial band and strengthening of hip abductor muscles, is beneficial 5
• Activity modification to reduce pressure on the affected area can help alleviate symptoms 5
• Cryotherapy, such as applying ice for 10-minute periods through a wet towel, can provide acute pain relief 5
• Eccentric strengthening exercises are particularly effective for tendon healing and pain reduction 2, 5

Second-Line Interventions

• Corticosteroid injection into the trochanteric bursa can provide both diagnostic information and therapeutic benefit, though pain relief may not persist long-term 5
• Ultrasound guidance improves the accuracy of corticosteroid injections 5
• Extracorporeal shock wave therapy has shown promising results for chronic cases, with one study demonstrating a 68.3% improvement in pain scores 7
• Orthotics and bracing may be used to reduce tension on the affected tendon during the healing process 5

Advanced Treatment Options

• Platelet-rich plasma (PRP) injections have shown potential in treating GTPS that doesn't respond to conservative therapy, though evidence remains inconclusive 8
• Surgical intervention should only be considered after failure of 3-6 months of comprehensive conservative treatment 5
• Various surgical techniques, both open and endoscopic, are available and should be guided by the specific etiology of pain 4

Common Pitfalls and Caveats

• Differentiation between trochanteric bursitis and gluteus medius tendinosis can be difficult, and the two conditions frequently coexist 5, 6
• GTPS often mimics pain generated from other sources, including myofascial pain, degenerative joint disease, and spinal pathology 1
• In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 5
• Corticosteroid injections should be ultrasound-guided to ensure proper placement 5
• Peritendinous injections are preferred over intratendinous injections, as injections directly into the tendon substance may have deleterious effects 5