Greater Trochanteric Pain Syndrome (GTPS)
Based on the clinical presentation of lateral hip pain with radiation down the lateral thigh to the lower leg, tenderness over the lateral hip, and absence of neurological deficits or spine pathology, the most likely diagnosis is Greater Trochanteric Pain Syndrome (GTPS).
Clinical Reasoning
The patient's presentation is classic for GTPS with several key features:
- Lateral hip pain with characteristic radiation pattern down the lateral thigh into the lower leg, which is the hallmark symptom of GTPS 1, 2
- Tenderness over the lateral hip region (greater trochanter area) on examination 1, 3
- Gradual onset without clear trauma, which is typical for this condition 1
- Pain severe enough to interfere with sedentary work, indicating significant functional impact 1
- Normal strength and limited sensory changes, which helps exclude radiculopathy 1, 2
Why Not Other Diagnoses?
Meralgia paresthetica would present with isolated anterolateral thigh numbness and burning without significant hip tenderness 2. Piriformis syndrome causes buttock pain radiating down the posterior leg, not lateral hip pain 2. Lumbar radiculopathy would typically show more pronounced neurological deficits, dermatomal sensory loss, and positive straight leg raise 2, 3.
Diagnostic Workup
Initial imaging should be AP pelvis and lateral hip radiographs to exclude alternative diagnoses such as osteoarthritis, fractures, or dysplasia 4, 5, 6. However, radiographs have poor diagnostic accuracy for GTPS itself, with surface irregularities >2mm showing only 24.7% positive predictive value 5.
If symptoms persist or Trendelenburg gait develops, obtain MRI of the hip without contrast to evaluate for abductor tendon tears (gluteus medius and minimus) 5, 2. MRI is superior for detecting tendinopathy, partial or complete tendon tears, and bursal effusions that comprise the spectrum of GTPS 2, 3.
Ultrasound is an excellent first-line investigation due to its availability, low cost, dynamic capability, and ability to guide therapeutic injections 2. It can effectively visualize tendon pathology and bursal inflammation 2.
Management Approach
Start with conservative management including NSAIDs, physical therapy, weight loss if applicable, and activity modification 1, 7, 3. Most cases of GTPS are self-limited with these measures 1, 8.
For persistent symptoms, add corticosteroid injection with local anesthetic into the trochanteric bursa or lateral hip region 1, 7, 3. The combination of physical therapy with corticosteroid injection is more effective for acute symptoms than physical therapy alone 7.
Targeted physiotherapy offers superior long-term outcomes compared to shock wave therapy and corticosteroid injections alone, with 60.5% of patients reporting symptom resolution at 15 months 7. However, improvements may not be immediate 7.
Consider extracorporeal shock wave therapy (ESWT) if conservative measures fail, as it has demonstrated 68.3% improvement in pain scores with low risk of adverse effects 7.
Reserve surgical intervention for refractory cases that fail conservative and medical treatments after an adequate trial of at least 6 months 1, 7, 3.
Critical Pitfalls to Avoid
Do not assume all lateral hip pain is GTPS - lumbar radicular pain and hip joint osteoarthritis can present with nearly identical lateral hip pain patterns 2, 3. Always exclude these conditions clinically and radiographically 4, 2.
Do not rely solely on radiographs for diagnosis - they are useful for excluding other pathology but have poor sensitivity and specificity for GTPS itself 5, 2.
Avoid opioids for chronic management of this condition 6.