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Imaging and management of greater trochanteric pain syndrome
Abstract
Greater trochanteric pain syndrome (GTPS) is a commonly diagnosed regional pain syndrome with a wide spectrum of aetiologies, reflecting the anatomy of the structures outside the hip joint capsule. There are five muscle tendons that insert on to the greater trochanter and three bursae in the region of the greater trochanter. The term GTPS includes tendinopathies, tendinous tears, bursal inflammation and effusion. There are a range of treatments and therapies depending on the specific diagnosis and severity of the condition. Many patients with GTPS can be successfully managed conservatively with weight loss and non-steroidal anti-inflammatory drugs. Patients suffering from more chronic pain can receive varying degrees of symptomatic relief with lateral hip corticosteroid and local anaesthetic injections. More severe refractory cases of GTPS can be treated with surgical intervention. It is therefore important to make the correct diagnosis to ensure that appropriate management can be implemented. The clinical features of GTPS however are often non-specific because common conditions such as lumbar radicular pain and hip joint osteoarthritis can present with an almost identical form of lateral hip pain. The various diagnostic imaging modalities have particular strengths and weaknesses with ultrasound being the best first-line investigation due to its availability, low cost, dynamic nature and ability to guide treatments such as steroid injections. MRI can be very helpful in the further investigation of patients in whom there is diagnostic uncertainty as to the cause of lateral hip pain and in whom specialist orthopaedic referral is being considered.
... A precise medical history and examination are often sufficient for diagnosing GTPS [22]. The physical examination includes the jump sign [1] and the single leg stance test [23], which are highly sensitive and have a strong positive predictive value for confirming MRI findings related to GTPS [24]. Additional tests include flexion, abduction and external rotation (FABER) test, adduction test (ADD) test, flexion, adduction and external rotation (FADER) test, positive Trendelenburg test, positive Ober's test and a positive step-up and -down test. ...
... When the clinical diagnosis is uncertain, imaging techniques such as ultrasound and MRI are very helpful [24]. Ultrasound is particularly effective with a high positive predictive value (PPV) and can reveal tears in the gluteus medius or minimus tendons [24], inflammatory changes, or a fluid-filled thickened trochanteric bursa. ...
... When the clinical diagnosis is uncertain, imaging techniques such as ultrasound and MRI are very helpful [24]. Ultrasound is particularly effective with a high positive predictive value (PPV) and can reveal tears in the gluteus medius or minimus tendons [24], inflammatory changes, or a fluid-filled thickened trochanteric bursa. ...
Greater trochanteric pain syndrome (GTPS) is one of the most prevalent causes of lateral hip pain. The incidence rate is as high as 1.8 patients per 1000 annually, with females predominantly affected. We compared and analysed the effectiveness of platelet-rich plasma (PRP) injections in treating GTPS.
Literature search was carried out on PubMed, Embase and Cochrane by two independent reviewers using the terms: ‘Greater Trochanteric Pain syndrome’ and ‘Platelet-rich plasma'. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the Cochrane risk of bias tool and Methodological Index for Non-Randomized Studies (MINORS) tool were used to assess bias. Nine studies were shortlisted and reviewed for patient sample size, diagnostic modalities, the presence of tendinopathy or bursitis, the number of PRP injections administered, and the length of symptom relief achieved.
We analysed nine studies between 2013 to 2024 comprising of a total of 508 patients who received treatment with PRP injections for lateral hip pain. There was an improvement and sustained relief in symptoms in eight studies, while one reported no change. Many studies indicated PRP injections to be more effective than corticosteroid injections (CSI) in treating GTPS.
PRP appears to be an effective injectable treatment option for GTPS, which does not respond to conservative therapy. However, due to the limitations of the current literature, there is a need for more large-scale, high-quality randomized clinical trials to assess further the effectiveness of PRP for treating GTPS.
... Os músculos glúteos médio e mínimo são os músculos abdutores primários da anca, situando-se profundamente à subglútea máxima (bursa trocantérica), e são também rotadores internos através das suas fibras anteriores, e rotadores externos pelas suas fibras posteriores. 5 A síndrome trocantérica dolorosa é geralmente atribuída a tendinopatia e/ou bursite dos tendões dos músculos glúteos médios e mínimo). 6,7 ...
... As calcificações adjacentes ao grande trocânter podem estar presentes em até 40% dos doentes com síndrome trocantérica. 5 Todavia, estas são consideradas achados inespecíficos, visto que não é claro se estas se localizam na inserção dos tendões dos músculos glúteos ou dentro da bursa. 22 Ecograficamente a tendinopatia caracteriza-se pela perda da arquitetura fibrilhar e pela hipoecogenicidade e espessamento dentro dos tendões glúteos. ...
... 24 O aumento do fluxo doppler compatível com a neovascularização inflamatória não é comum e as ruturas parciais podem detetar-se por focos intratendinosos hipoecóicos ou mesmo anecóicos, ou por defeitos no contorno do tendão. 2, 5 A ressonância tem alta sensibilidade e baixa especificidade, detetando frequentemente doentes assintomáticos. 25 As manifestações precoces da tendinopatia podem ser detetadas como paratendinopatias, que se caracterizam pela presença de sinal hiperintenso na sequência T2 à volta do tendão normal hipointenso, devido ao edema do tecido mole paratendinoso. ...
Pain around the greater trochanter is a frequent clinical problem that may be secondary to a variety of either intra-articular or periarticular pathologies. Medium and minimum gluteal tendon pathologies are one of the primary causes of trochanteric pain, despite being still underrecognized. It is usual in athletes, especially runners. The diagnosis requires a high suspicion degree, as well as an adequate anamnesis, objective examination, and complementary investigation. Tendinopathy as a clinical syndrome and tendon disfunction, is often a chronical condition and an enigma. Treatment is a challenge, since there isn´t a consensus founded on available evidence.
... athletes, and individuals with hip osteoarthritis or low back pain [3,8,9]. ...
... Diagnosis relies on clinical findings of insidious lateral hip pain, occasionally intermittent and radiating laterally and posteriorly, exacerbated by sleeping on the affected side or bearing weight ipsilaterally [3,5,8]. Physical examination reveals tenderness around the greater trochanter, accompanied by positive provocative manoeuvres which are the Faber test, the resisted external derotation test, or resisted hip abduction [3,5,8,10]. ...
... Diagnosis relies on clinical findings of insidious lateral hip pain, occasionally intermittent and radiating laterally and posteriorly, exacerbated by sleeping on the affected side or bearing weight ipsilaterally [3,5,8]. Physical examination reveals tenderness around the greater trochanter, accompanied by positive provocative manoeuvres which are the Faber test, the resisted external derotation test, or resisted hip abduction [3,5,8,10]. In some cases, imaging studies may be necessary to confirm the diagnosis and exclude other conditions. ...
Background: Greater trochanteric pain syndrome (GTPS) is a prevalent cause of lateral hip pain that often leads to significant functional limitations. Conservative treatment options include physical therapy, pharmacological treatment, and more invasive techniques such as corticosteroid injections. However, despite the high success rates reported with corticosteroid injections, a significant number of patients have their symptoms persist or recur.
Objectives: In this case series, we present the outcomes of nine patients with GTPS who underwent ultrasound-guided bipolar pulsed radiofrequency targeting the trochanteric branches of the femoral nerve. We aim to discuss the effectiveness and safety of this approach.
Material and methods: Eligible patients referred to our centre underwent ultrasound-guided bipolar pulsed radiofrequency aimed at the trochanteric branches of the femoral nerve. The procedure consisted of one cycle at 42°C for six minutes, followed by the injection of ropivacaine (0.2%, 3 mL) and dexamethasone (12 mg). The Brief Pain Inventory - Short Form (BPI-sf) and Lequesne Algofunctional Index (LAI) were used before the procedure and at the third and sixth months post-procedure. We monitored immediate and late complications, as well as adverse effects.
Results and discussion: Our results indicate a favourable outcome for most patients, with an average pain reduction of 76.51% according to their report of the BPI-sf. Additionally, eight out of nine patients experienced at least 50% relief. These findings align with a previous case series, which reported a similar average pain reduction. Before the procedure, most patients were classified as “extremely severe” in the LAI, with an average score of 18.17. Although there was only a slight reduction of 16.84% at the six-month follow-up, this suggests a potential improvement in their functional status. We did not observe any immediate complications or adverse effects after the procedure, nor were any reported at the subsequent follow-ups, which is consistent with existing literature.
Conclusions: Our study suggests that ultrasound-guided bipolar pulsed radiofrequency treatment is a promising minimally invasive technique for GPTS, especially for patients who do not respond to conservative treatments. Although our case series provides some evidence of effectiveness and safety, further controlled studies on a larger scale are necessary, particularly to compare this intervention with the use of corticosteroid injections alone.
... Greater trochanteric pain syndrome (GTPS) is a term used for chronic lateral hip pain in the region of the greater trochanter (1). Formerly, it was generally regarded as trochanteric bursitis, and was first described in 1923 by Stegman (2). ...
... In general, GTPS is around 4-times more common in women than in men (4,8). Despite the significant reported prevalence of GTPS, its diagnosis and management remains challenging (1,9). The main diagnostic modalities are ultrasound and high-resolution magnetic resonance imaging (1,10). ...
... Despite the significant reported prevalence of GTPS, its diagnosis and management remains challenging (1,9). The main diagnostic modalities are ultrasound and high-resolution magnetic resonance imaging (1,10). The GTPS is often resistant to conservative measures, but due to the lack of proper diagnostic methods it can also be challenging to treat surgically (3,(11)(12)(13). ...
Introduction
Greater trochanteric pain syndrome (GTPS) denotes several disorders around the lateral aspect of the hip. GTPS may develop in native hips as well as after total hip arthroplasty (THA). It is estimated that 5−12% of patients suffer from GTPS after primary THA. Despite the prevalence of GTPS, it is hard to diagnose and manage it properly. The VISA-G questionnaire was developed as a patient-reported outcome measurement tool for evaluation of GTPS. The aims of the present study were to evaluate the reliability of the VISA-G Slovenian and its construct and criterion validity.
Methods
After the finalization of the VISA-G Slovenian translation procedure, 59 patients with a painful trochanteric region planned for THA filled in the VISA-G Slovenian at the hospital on two occasions 5−7 days apart. On the first occasion, each patient also filled in the EQ-5D-5L questionnaire and the Harris Hip Score (HHS) was completed by the physiotherapist.
Results
The VISA-G Slovenian was found to have a test-retest reliability of ICC 0.977; 95% CI [0.96; 0.986]. Internal consistency was assessed with Cronbach’s alpha 0.79. The statistically significant, but low, correlation between the HHS and VISA-G (r=0.48) was obtained. Concurrent validity of the VISA-G with the EQ-5D-5L showed moderate to strong correlations in Mobility, Self-Care, Usual Activities, Pain, EQ-5D-5L Index and EQ VAS, but low correlation in the Anxiety subscale. No floor and ceiling effect were obtained.
Conclusions
The VISA-G Slovenian has excellent psychometric properties needed to measure gluteal tendinopathy-related disability of patients in Slovenia. Thus, we recommend using the questionnaire for measuring trochanteric hip pain.
... [1][2][3][4][5][6] Advancements in magnetic resonance imaging (MRI) as well as experience with hip arthroscopy have led to an improved understanding of peritrochanteric pain etiology and its management. [7][8][9][10][11][12] Greater trochanteric pain syndrome (GTPS) has expanded to include disorders of the peritrochanteric space encompassing trochanteric bursitis, gluteus medius and minimus tendinopathy or tears, and external coxa saltans (i.e. snapping hip). ...
... The most common imaging modalities used in the evaluation for GTPS are plain radiography, ultrasonography, and MRI, with MRI as the primary means of evaluating a patient for GTPS. 1,8,12 Surgical Technique ...
... Recommended surgical management consists of endoscopic trochanteric bursectomy with trochanteric micropuncture. 1,4,8 Surgical Technique: Endoscopic Trochanteric Micropuncture A 70 arthroscope is used to view the peritrochanteric space through the DALA portal, and a 45 microfracture awl is introduced through the 8.25-mm cannula within the PL portal ( Fig 4A). The limb can be rotated internally and externally to provide better access to the trochanteric region. ...
Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).
... IFI and GTPS were considered confirmed only if a clinical or surgical report documented these conditions and the corresponding imaging showed signs corroborating the suspected clinical diagnosis. This was edema and/or fatty atrophy of the quadratus femoris muscle for IFI [8] respectively abductor tendinopathy and/or trochanteric bursitis for GTPS [22,23] in postoperative ultrasound or MR imaging studies. In addition, imaging studies of patients without symptomatic IFI or GTPS in this population were reviewed for radiologic signs of these diagnoses. ...
... The measured values were then compared to normative values for the ischiofemoral space established by Özdemir et al [24]. For GTPS, available postoperative ultrasound and MRI examinations were reviewed for signs of trochanteric bursitis and abductor tendinopathy as described above [22,23]. ...
Objectives
We evaluated the relationship between femoral anteversion (FA), FA change, and ischiofemoral impingement (IFI) and the relationship between FA, femoral offset (FO), and greater trochanteric pain syndrome (GTPS) after total hip arthroplasty (THA).
Materials and methods
In this retrospective study, two readers assessed FA and FO on CT images of 197 patients following primary THA with an anterior surgical approach between 2014 and 2021. FA change was calculated relative to preoperative CT, while FO change was calculated relative to preoperative radiographs and classified as decreased (≥−5 mm), increased (≥ + 5 mm), or restored (± 5 mm). Clinical and imaging data were analyzed for IFI and GTPS after surgery. Group differences were evaluated using Student’s t -test, chi-square analysis, and receiver operating characteristic (ROC) analysis.
Results
The change in FA was 3.6 ± 3.3° to a postoperative FA of 22.5 ± 6.8°, while FO increased by 1.7 ± 3.5 mm to a postoperative FO of 42.9 ± 7.1 mm. FA and FA change were higher in patients with IFI ( p ≤ 0.006), while no significant difference was observed for patients with and without GTPS ( p ≥ 0.122). IFI was more common in females ( p = 0.023). In the ROC analysis, an AUC of 0.859 was observed for FA change to predict IFI, whereas the AUC value was 0.726 for FA alone. No significant difference was found for FO change in patients with and without IFI or GTPS ( p ≥ 0.187).
Conclusion
Postoperative FA, FA change, and female sex were associated with IFI after anterior-approached THA. The change in FA was a better predictor of IFI than absolute postoperative FA alone.
Clinical relevance statement
The findings of this study suggest that preservation of the preoperative femoral anteversion may reduce postoperative ischiofemoral impingement in patients undergoing total hip arthroplasty.
Key Points
• Higher postoperative femoral anteversion and anteversion change were associated with ischiofemoral impingement.
• Femoral anteversion change was a better predictor of impingement than absolute postoperative anteversion.
• No significant association was found between femoral offset and postoperative hip pain.
... 6 Treatment of GTPS is usually conservative consisting of weight loss, optimization of biomechanics, and analgesia. 8 Local corticosteroid injection is effective in patients with chronic pain, and can be landmark or image guided. 8 When performed under ultrasound guidance, the bursa most symptomatic on sonographic palpation is targeted for injection. ...
... 8 Local corticosteroid injection is effective in patients with chronic pain, and can be landmark or image guided. 8 When performed under ultrasound guidance, the bursa most symptomatic on sonographic palpation is targeted for injection. ...
Magnetic resonance arthrography and 3T magnetic resonance imaging of the hip are a technique commonly performed in young, physically active patients presenting with pain relating to the hip, with the focus on assessing for the presence of labral tears and femoroacetabular impingement. Abnormal signal within the labrum can be misleading, however, as labral tears are a frequent incidental finding and have been identified in a large proportion of the asymptomatic population. A range of extralabral conditions can cause hip-related pain in young patients, including pathology related to the bones, joints, and periarticular soft tissues. It is vital that the radiologist is aware for these pathologies and examines for them even in the presence of a confirmed labral tear. In this article, we review a range of common extralabral pathologies responsible for hip pain and highlight review areas that aid in their diagnosis.
... GTPS is mainly a clinical diagnosis, based on history and physical examination, including the single leg stance test (standing for 30 seconds on the painful leg will provoke pain at the greater trochanter) [8]. Imaging of the spine and legs will exclude other pathologies [9]. MRI has a high sensitivity but a low specificity for diagnosing GTPS [1]. ...
... MRI has a high sensitivity but a low specificity for diagnosing GTPS [1]. Ultrasound examination of the hip region will generally lead to the correct diagnosis [9]. ...
Greater trochanteric pain syndrome (GTPS) is related to abnormal hip biomechanics, predisposing to gluteal tendinopathies. Often concomitant osteo-articular conditions make the diagnosis difficult. GTPS occurs mainly in women, aged 40 to 60 years, but can also be seen in geriatric patients. We describe an 84-year-old, community-dwelling woman, hospitalised for exacerbation of low back pain, irradiating to the right hip, knee, and foot. The diagnosis of GTPS was based upon a painful greater trochanteric region and painful adduction of the right hip, a positive single stance test, and ultrasound examination. The patient was successfully treated by physical therapy, focusing on positioning and muscle strengthening, combined with pain relieve.
... cause local pain symptoms due to lesions or injuries of the tissue structure attached to the greater trochanter of the femur. The main causes include inflammation or tear of the gluteus medius and gluteus minimus tendons, and bursitis around the greater trochanter [2,3]. The incidence of GTPS in the population is 10%-25%, and it mainly affects middle-aged women(40-60y) [4,5]. ...
... Conservative treatment is the first-line approach for GTPS, including correction of gait disorders, relative rest, cold and heat, stretching and strengthening, physiotherapy, drugs (e.g., NSAIDs, opioids, antidepressants, topical treatments), corticosteroid injection (CSI), extracorporeal shockwave therapy (ESWT) [6][7][8][9]. Some intractable ones require surgical treatment [2,10]. ...
Background
corticosteroid injection (CSI) has been used to treat greater trochanter pain syndrome (GTPS) for many years. However, so far, the efficacy of CSI in the treatment of GTPS is still controversial. Therefore, the aim of this review is to evaluate the effectiveness of CSI in comparison with sham intervention, nature history, usual care, platelet-rich plasma (PRP), physiotherapy/exercise therapy, dry needling, or other nonsurgical treatment for improvements in pain and function in GTPS.
Methods
PubMed (Medline), Embase, Cochrane Library were searched from their inception until April 2021. Randomized controlled trails (RCTs) comparing CSI to nonsurgical treatment were included. Data on the effect of CSI on pain and function were extracted and checked by two review authors independently. The treatment effect was analyzed in the short term, medium term, and long term.
Results
Eight RCTs (764 patients) were included. This review suggests CSI may be superior to usual care and ‘wait and see,’ ESWT, but may not be superior to exercise, PRP, dry needling, and sham intervention in short-term pain or function improvement. In terms of medium-term pain or function improvement, CSI may be superior to usual care and ‘wait and see,’ but may not be superior to PRP. In terms of long-term pain or function improvement, CSI may be inferior to PRP and ESWT, but it may be superior to usual care and ‘wait and see’ at 12 months.
Conclusions
Due to the small sample size and lack of sufficient clinical studies, current evidence is equivocal regarding the efficacy of CSI in the treatment of GTPS. Considering the limitations, more large-sample and high-quality RCTs are needed to prove the therapeutic effect of CSI on GTPS.
Trial registration
PROSPERO registration number: CRD42021247991. Registered 09 May 2021.
... GTPS must be differentially diagnosed from other common causes of hip pain like hip and knee osteoarthritis, lumbar spine pain, iliotibial band syndrome and other pelvic pathologies [8]. ...
... US can better detect calcifications than MRI and is very useful during aspiration and local injections [1]. MRI provides detailed soft tissue examination and can play an important role in differential diagnosis [1,[7][8]. ...
Purpose
The purpose of this clinical study was to evaluate and compare the effectiveness of ultrasound
(US)-guided platelet-rich plasma (PRP) injections versus US-guided corticosteroid injections
(CSI) in the treatment of greater trochanteric pain syndrome (GTPS).
Methods
Between January 2015 and December 2016, 24 patients with GTPS were enrolled and
randomized in two groups (A and B). Group A (study group) patients received US-guided PRP
injection treatment, while group B (control group) patients received US-guided CSI treatment.
Clinical outcomes in both groups were evaluated and compared using the Visual Analogue
Scale (VAS) of pain, the Harris Hip Score (HHS) and the presence or absence of complications at
4, 12, and 24 weeks post-injection. The level of significance was set at p<0.05.
Results
Both groups showed improved scores (VAS and HHS) compared to the pre-injection period, but
patients in group A had a statistically significant (p <0.05) decrease in VAS score and a
significantly increased HHS at the last follow-up (24 weeks post-injection). No complications
were reported.
Conclusions
In conclusion, patients with GTPS present better and longer-lasting clinical results when
treated with US-guided PRP injections compared to those with CSI. Further studies are needed
to optimize the technical preparation of PRP, the sample concentration, the number of
injections and the time intervals between them, in order to achieve the maximum desired
results
... To differentiate, a standing X-ray of the pelvis is taken and the hip joints are assessed. However, it may also be the case that GTPS is a complication of coxarthrosis and the X-ray will show radiological changes characteristic of coxarthrosis, and the patient will also have GTPS [8]. ...
Greater trochanter pain syndrome (GTPS) occurs in a large group of patients. This problem can affect patients of any age and is associated with a sedentary, overloading, and non-ergonomic lifestyle/work with a concomitant lack of regular physical activity. The literature to date describes the effectiveness of various therapies. Glucocorticosteroid injections and physical therapy are used. One of the new methods is injection collagen therapy using collagen type I (COL-I), a protein of porcine origin, which aims, among other things, to regenerate inflammation-changed tendon. Various repair mechanisms are activated, including the induction and proliferation of fibroblasts, as well as their migration to the pathological site. This is followed by stimulation and synthesis of COL-I, secretion, and maturation. Ultimately, a regenerative effect is achieved. This article aims to discuss the role of COL-I in the injectable treatment of GTPS as a new therapeutic approach.
... would provide more detail but should only be used in correlation with the clinical picture [60]. ...
Nearly 1 in 4 people will experience symptomatic hip osteoarthritis throughout their lifetime [1]. In middle aged and elderly patients, osteoarthritis remains the most recognised cause of hip pain, with over 10% of all adults being diagnosed with this condition [2]. However, there remains a gap in the accurate diagnosis of non-osteoarthritic conditions and appropriate referral to secondary care [3]. This narrative review will explore the sources and unusual presentations of ‘hip pain’, highlighting key diagnostic features and new evidence in the current literature, to support clinicians towards a holistic approach to the management of patients with hip pain. A case series of unusual presentations of pain around the hip has been included in the second part of this review to further highlight the differential diagnoses discussed. Literature search was performed on PubMed and Medline using terms such as “Hip pain”, “pelvic pain”, groin pain”, “thigh pain”, “Lower back pain”, “buttock pain”, “Pain around the hip”, and “non-osteoarthritic hip pain”. All types of articles related to this subject were considered, but only articles written and published in English language were considered for the review.
... In acute bursitis, hypo/anechoic bursal collections are detected overlying the tendons, whereas chronic bursitis leads to isoechoic bursal wall thickening and bursal collections. [6] Unfortunately, color Doppler ultrasonography (CDUS) is considered to have limited utility in the diagnosis and differential diagnosis of GTPS [7] ; therefore, the utilization of CDUS may vary among healthcare facilities. ...
Greater trochanteric pain syndrome (GTPS) is a common cause of hip pain and is often associated with chronic lower back pain and lower extremity osteoarthritis. Its diagnosis is clinical; however, imaging has been shown to aid in the differential diagnosis of challenging cases. Superb microvascular imaging (SMI) is a new technique that may be more effective than power Doppler ultrasonography (PDUS) in the detection of inflammation-related vascularity in patients. In this study, we aimed to compare the diagnostic accuracies of SMI and PDUS in patients with GTPS and evaluate the usefulness of these techniques in clinical practice. We recruited 37 GTPS patients and 15 healthy volunteers for participation in this study. PDUS and SMI examinations were performed and we retrospectively reviewed the magnetic resonance imaging scans for tendinosis, tears, and edema. The PDUS and SMI were positive in 19 and 31 hips, respectively. Both techniques had low sensitivity but high specificity and positive predictive values, with SMI being slightly better. PDUS and SMI had accuracies of 75% and 82.7%, respectively, with a grade 1 vascularization threshold. Moreover, magnetic resonance imaging detected peritendinous edema with an accuracy of 60.5%, including tendinosis and partial tears but not complete tendon tears. Our study showed that PDUS is an underutilized modality in the diagnosis of GTPS and that SMI may further improve diagnostic accuracy. However, the low sensitivity of both techniques suggests that a clinical diagnosis remains essential.
... El SDTM incluye un espectro de desórdenes, tales como la bursitis trocantérica, las tendinopatías del glúteo medio y menor, y el 'snapping hip' externo Page 4 of 16 J o u r n a l P r e -p r o o f 4 [8]. La prevalencia de este síndrome es alta en pacientes con dolor lumbar coexistente, osteoartritis y obesidad, lo que sugiere una interacción compleja entre la región lumbar y la cadera en el desarrollo de la patología [9]. ...
... Several conditions should be included in the differential diagnosis with this pathology, such as lower limb dysmetria, osteoarthritis, femoroacetabular impingement (FAI), tendon degeneration, compression of lumbar nerve roots [10,11]. Pelvis and hip X-rays are often the initial investigation in primary care to rule out common differentials such as hip osteoarthritis or FAI and they may detect some calcifications in the tendon insertion area near the GT [12]. Ultrasound and MRI are second-tier imaging techniques for GTPS, which often reveal evidence of gluteal tendinopathy or musculotendinous tears [13]. ...
Background
Greater trochanteric pain syndrome (GTPS) presents challenges in clinical management due to its chronic nature and uncertain etiology. Historically attributed to greater trochanteric bursitis, current understanding implicates abductor tendinopathy as the primary cause. Diagnosis usually involves a clinical examination and additional tests such as imaging and provocative testing. Surgical intervention may be considered for cases refractory to conservative therapy, with endoscopic techniques gaining ground over open procedures.
Materials and methods
A systematic review was conducted adhering to the PRISMA guidelines. Relevant studies were searched in four databases: Pubmed, Scopus, Embase, and Medline. The selected articles were evaluated according to the criteria of levels of evidence (LoE). The Coleman methodology score (mCMS) was used to analyze the retrospective studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews.
Results
Surgical success rates ranged from 70.6–100%, significantly improving pain and function. Complications were generally mild, mainly hematomas and seromas, while recurrence rates were low. However, limitations such as the retrospective design and the absence of control groups warrant cautious interpretation of the results.
Conclusions
Endoscopic surgery emerges as a promising option for refractory GTPS, offering effective symptom relief and functional improvement. Despite limitations, these results suggest a favorable risk–benefit profile for endoscopic procedures. Further research is needed, particularly prospective randomized trials, to confirm these findings and optimize surgical techniques to improve patient outcomes.
... 6,8,9 Refractory cases may require surgical intervention. 10,11 Despite various conservative and operative treatments being available to alleviate GTPS symptoms, they are not always successful, and some patients continue to live with significant pain and physical disability. 10 In addition, functional impairment may be further exacerbated by psychosocial factors. ...
Background
Greater trochanteric pain syndrome (GTPS) is a commonly diagnosed medical issue, yet there are little data assessing the relative morbidity of GTPS. We sought to characterize the morbidity on presentation of GTPS and compare it to that of patients with end-stage hip osteoarthritis awaiting total hip arthroplasty. We hypothesized that patients with GTPS would have morbidity similar to or worse than that of patients with osteoarthritis.
Materials and Methods
This retrospective case-control study examined patient-reported outcome measures of 156 patients with GTPS (193 hips) and 300 patients with hip osteoarthritis before total hip arthroplasty (326 hips). Patients with secondary hip conditions or previous hip surgeries were excluded from the study. Patient-reported outcome measures were analyzed using an equivalence test and two one-sided t tests.
Results
Equivalence in mean visual analog scale pain scores between GTPS and osteoarthritis was established with a tolerance margin of ±10. The difference in mean visual analog scale pain scores was 0.35 (95% CI, −0.86 to 0.16; P =.02). The Hip disability and Osteoarthritis Outcome Score Quality of Life was much worse for patients with GTPS, placed well outside of the ±10 tolerance margin, and the difference in mean scores was 1.72 (95% Cl, −2.17 to −1.26; P =.99). Equivalence in mean UCLA Activity scores between GTPS and osteoarthritis was established with a tolerance margin of ±5. The difference in mean UCLA Activity scores was 0.002 (95% CI, −0.45 to 0.43; P <.01).
Conclusion
The morbidity and functional limitations of patients with GTPS were similar to those of patients undergoing total hip arthroplasty. GTPS remains a functional problem for patients, and clinicians and researchers should consider GTPS as seriously as hip osteoarthritis. [ Orthopedics . 202x;4x(x):xx–xx.]
... The presence of a clinical picture of GTPS in patients referred for treatment for degenerative diseases of the lumbar spine can be attributed to both the untimely diagnosis of this disease at the prehospital level and significant difficulties in the differential diagnosis of GTPS and radiculopathy. The differential diagnosis for hip pain is broad and complex [27]. According to the literature, the symptoms of GTPS and radiculopathy accompany each other in a large number of cases [17]. ...
Greater trochanter pain syndrome (GTPS) is highly discussed during spine surgeons, accompanies lumbar pain and complicates differential diagnosis. The aim is to raise awareness among physicians and demonstrate the lumbar spine degenerative diseases (LSDD) association with GTPS.
A retro-prospective analysis enrolled 172 patients with LSDD with GTPS signs. Group I – retrospective (n = 112), group II – prospective (n = 60). Patients of group II with the confirmed diagnosis clinically and by the ultrasound recieved a GCS injection (Betamethasone 2 mg\ml + 5 mg\ml — 1.0). Also the VAS, X-ray and SPSS Statistics package were used.
112 patients in group I, 89 (79.5%) had increased pain in the hip early postOp to 7.8 points by VAS. All patients required trigger point injections of GCS and 68 (77%) received a repeat injection. 76 from 112 patients were tracked for long-term results, and recurrence of GTPS was detected in five people who treated conservatively for three months without dynamics. They were identified GTPS by ultrasound. During the injection, 39 from 43 (90%) patients noted pain reduction to 2.1 by VAS, but symptoms of radiculopathy or spinal stenosis persisted. Two patients (5%) did not note any changes. Two patients (5%) noted complete pain regression and refused the surgery.
Timely detection of GTPS among spinal surgeons influences tactics and, in some cases, allows one to avoid unnecessary surgical interventions. In turn, ignoring the symptoms of GTPS in the preoperative period can lead to pain intensification in the greater trochanter after surgery for degenerative diseases of the spine.
... Modifying activity, giving non-steroidal anti-inflammatory drugs, and injecting corticosteroids locally (With or without anesthesia) are all examples of conservative techniques that make up the treatment. If problems persist and pain continues, surgical procedures such as bursectomy to release the iliotibial band, hip cuff repair, and trochanteric reduction osteotomy may be necessary [6] . The successful use of radial shock wave therapy for planter fasciitis, Achilles tendinitis, and lateral epicondylitis led to the development of extracorporeal shock wave therapy as a therapeutic alternative for GTPs [1,7,8] . ...
... MRI is the favored modality for evaluation of the hip region disorders. Treatment options ranges from conservative as analgesic, physical therapy and local anaesthetic injection to surgical treatment in recurrent and persistent symptoms [6,7]. ...
Background
Greater trochanteric pain syndrome (GTPS) refers to pain and tenderness over the greater trochanter. It is a common entity of lateral hip pain that is usually related to the overuse or small injuries of the gluteus medius or minimus tendons and their surrounding bursae. MRI is the favored modality for evaluation of the hip region disorders. Treatment options ranges from conservative to surgical treatment.
Results
Trochanteric (sub-gluteal maximus) bursal fluid was the most common finding found in 55 hips (73%), followed by gluteal tendinosis (64%) and partial thickness gluteal tendon tear (29%). Full thickness tear of the gluteal tendons occurred in 10 hips (13%). The relation between gluteal tendinosis and greater trochanteric bursal fluid was statistically significant ( P < 0.05 ) with sensitivity and specificity of 85% and 78% respectively.
Conclusion
MRI should be utilized in a simple systemized approach by MSK radiologist in order not to miss a finding that may influence the surgical outcome of the patient presenting with GTPS.
... For patients with lateral hip pain, such as GTPS, surgery is generally reserved for recalcitrant cases of patients who have failed optimal conservative treatment options, and functional outcomes following surgery are generally good [31]. Surgical procedures are dependent on underlying pathology but may involve lengthening or release of the ITB band and fascia lata, repair of a gluteal tendon tear, minimally invasive endoscopic bursectomy, or open reduction trochanteric osteotomy [32][33][34][35]. The criteria for surgical intervention in refractory cases of GTPS remain ambiguous and not well-established [32,36]. ...
The purpose of this article is to provide a synopsis of the current medical understanding of hip pain highlighting its relation to anatomical location and underlying pathology. We describe the i) mechanism of the hip joint, ii) classification of hip pain, iii) prevalence of hip pain, iv) purported causes, v) associated risk factors, vi) clinical presentation, vii) diagnosis and classification, and viii) treatment options. A quiz serves to assist readers in their understanding of the presented material.
... The Greater Trochanteric Pain Syndrome (GTPS) is a chronic and debilitating condition with functional limitations similar to advanced coxarthrosis (Fearon et al., 2014). It is more common in women aged 40-60 years (Barratt et al., 2017;Chowdhury et al., 2014), being the cause of hip pain in 10-20% of patients who present to primary care, with an incidence of 1.8 per 1000 patients/year (Lievense et al., 2005). Historically, GTPS was commonly diagnosed as trochanteric bursitis (Long et al., 2013). ...
Background
Different outcome measures can be used to assess pain and disability in individuals with Greater Trochanteric Pain Syndrome (GTPS), including the Victorian Institute of Sports Assessment for Gluteal Tendinopathy (VISA-G), Oswestry Disability Index (ODI), Patient Specific Functional Scale (PSFS) and Global Perceived Effect (GPE).
Objective
To translate, cross-culturally adapt and validate VISA-G to Brazilian Portuguese and to evaluate the measurement properties of the VISA-G.BR, ODI, GPE, and PSFS in individuals with GTPS.
Design
This is a longitudinal clinimetric study.
Methods
Sixty-eight individuals with GTPS participated in this study. The questionnaires VISA-G.BR, ODI, PSFS, and GPE were administered to participants at the initial assessment, 24-48 hours and 30 days after the initial assessment. Internal consistency and construct validity for the VISA-G.BR were assessed. Reliability, agreement, ceiling and floor effect, and responsiveness were described for all instruments.
Results
The Cronbach Alpha for internal consistency value for VISA-G.BR was 0.65. The construct validity analysis showed a strong correlation value between ODI and VISA-G.BR (r = -0.77). The agreement analysis performed for all questionnaires showed SEM values ranging from 0.64 (PSFS) to 4.2 (VISA-G.BR). GPE scale had a floor effect. The responsiveness analysis performed for all questionnaires showed low values of effect size ranging from -0.07 to 0.3.
Conclusion
The VISA-G.BR is a valid and reliable instrument to assess the disability of individuals with GTPS. The ODI and PSFS instruments can also be used in the evaluation of this population.
... Imaging studies could be helpful to obtain a diagnosis, including conventional radiography and ultrasonography. MRI should be reserved for specific situations (Chowdhury et al., 2014). Differential diagnosis of lateral hip pain includes (Ho & Howard, 2012): GTPS, hip joint disease and lumbar spine disease (referred). ...
Tendon disorders represent some of the most frequent musculoskeletal complaints worldwide. In the athletic population, tendinopathy could affect different anatomical districts. Tendons surrounding hip and pelvis are frequently involved due to overuse and high functional demands in the athletes. These disorders negatively impact on sport performance, since they are a long-lasting clinical condition requiring a multimodal management. Great trochanter pain syndrome, proximal hamstring tendinopathy, insertional adductor tendinopathy and ileopsoas tendinopathy are the most common clinical conditions involving tendon structures of the hip and pelvis. Due to the anatomical complexity of the region, the relationship with pelvic organs, the demographic and anthropometric characteristics of the athletes, the differential diagnosis between these musculoskeletal disorders and other diseases is often difficult to conduct and some therapeutic options are challenging. Modification of risk factors, changes in training protocols, some specific therapeutic exercise programs and rehabilitation procedures have been proposed as an efficient conservative management strategy, guarantying a complete recovery of athletic function. Surgical approaches are required in a specific subset of patients. This narrative literature review aims to summarize current understanding and areas of ongoing research about the clinical features, diagnostic keys and therapeutic options of the main clinical tendinopathies surrounding hip and pelvis.
... First, magnetic resonance imaging could be useful in some individuals with an uncertain diagnosis for making a definitive diagnosis as to the cause of lateral hip pain. 36 Second, the possible causes of participants' activity limitations were not taken into account in our study. Also, primary and secondary educational levels were more prevalent among our participants than university level. ...
Objective
Greater trochanteric pain syndrome (GTPS) is a common condition that can cause lateral hip pain. The single-leg-squat test (SLST) may be used by physicians in primary care environments to evaluate patients’ dynamic stability. The aim of this study was to evaluate the dynamic stability and strength of lateral abduction hip movements in primary care patients with GTPS in relation to their perceived pain interference in life.
Methods
A descriptive observational study was carried out in a primary health care center. Fifty-four participants with GTPS were included in this study and divided into lower- and higher-interference groups (n = 30 and 19, respectively) according to the Graded Chronic Pain Scale. Participants were evaluated for their lateral abduction hip strength and the SLST.
Results
The SLST showed a statistically significant difference between groups with respect to hip-joint posture and movement level (P = .043) but not for other SLST domains or lateral abduction hip strength (P > .05).
Conclusion
Patients with GTPS with more pain interference in their lives had poorer dynamic stability with respect to hip-joint posture and movements based on the SLST but did not present impaired lateral hip abduction strength in comparison with those who perceived lower pain interference in life.
... No entanto, o estudo 11 enfatizou que o tratamento conservador concomitante com o uso da injeção local de corticosteroides (CSI) produziu efeitos em longo prazo, reduzindo assim as chances de recorrência. Enquanto que, os estudos 16,27,28 evidenciaram que as injeções laterais de glicocorticoides promovem alívio na sintomatologia em curto prazo, com melhora da dor e da função, mas a longo prazo os efeitos são mínimos. Em relação à importância do manejo da dor, de modo conservador combinado (reabilitação e fármacos), o tratamento mais frequente para a tendinopatia é o exercício, sendo preconizado como a principal forma de tratamento, tratamento fisioterapêutico (padrão-ouro), podendo ser potencializada a eficácia quando associado às intervenções com uso da injeção local 6,13 . ...
BACKGROUND AND OBJECTIVES:
The greater trochanteric pain syndrome is a painful condition that involves changes in the gluteus medius and gluteus minimus, which can interfere with the performance of functional tasks. The study aimed to analyze the conservative treatment strategies for pain management, the instruments, and provocative tests used in the evaluation of this syndrome.
CONTENTS:
A systematic search for articles published in indexed journals in the Medline, Scielo, PEDro, Cochrane Library, VHL Regional Portal, ScienceDirect database was conducted, using AND and OR Boolean operators for the primary “Gluteal tendinopathy” crossing with the secondary descriptors “AND conservative treatment; AND rehabilitation; AND physiotherapy; AND management; AND physiotherapy treatment; OR greater trochanteric pain; OR trochanteric syndrome”, in English and Portuguese, from 2014 to 2019. The primary outcome aimed to identify the conservative treatment and/or combined for pain management, and the secondary outcome aimed to outline the instruments and tests to assess the greater trochanteric pain syndrome.
CONCLUSION:
Given the lack of studies and the difficulty of consensus among authors, it was not possible to reach conclusions about the efficacy of the protocols.
... Hip: The greater trochanteric pain syndrome is very frequent, and its etiological diagnosis is sometimes difficult. Trochanteric bursitis is rare and the role of US for the diagnosis of gluteal tendinopathy is far from es-tablished, although it seems the most appropriate firstline imaging method [228][229][230] . Ultrasound can also be used to establish adductor tendon disease, tears of the rectus femoris, tendinosis of tensor fascia lata, ischial bursitis and labral lesions [231][232][233][234][235][236][237] . ...
Introduction:
Ultrasound (US) is a relatively cheap, easily available and reliable method to improve the care of rheumatic patients. However, its use in rheumatology practice is very heterogeneous and needs to be standardized.
Objectives:
To develop recommendations for the use of US in rheumatic diseases endorsed by the Portuguese Society of Rheumatology.
Methods:
A systematic literature review of the available recommendations on the use of ultrasound in rheumatic diseases was performed and presented in a Portuguese Society of Rheumatology meeting to a subgroup of rheumatologists and rheumatology trainees with special interest in the subject. The most important topics to be addressed were selected and assigned to subgroups for literature review and draft recommendations. Following an iterative process of consensus, the final recommendations were developed, and their level of agreement voted anonymously online. A recommendation was approved when the average level of agreement was ≥ 7.5 in a 10-point Likert scale.
Results:
Fourteen recommendations were produced regarding nine rheumatology topics: rheumatoid arthritis, spondyloarthritis, connective tissue diseases, polymyalgia rheumatica, vasculitis, crystal-deposition diseases, soft tissue rheumatism, osteoarthritis and ultrasound-guided procedures.
Conclusion:
We developed an up-to-date guidance in the form of recommendations for the use of US in nine different areas of rheumatology. As ultrasound is an important imaging modality with increasing use in the rheumatology setting, and there are frequent technological advances in the ultrasound machines and probes, in parallel with continuous associated research, these recommendations should be regularly updated.
... US can provide a dynamic examination, is inexpensive, and is able to detect calcification better than MRI. It can also be a valuable tool during aspiration and injection [17]. By convention, patients with GTPS are initially treated nonoperatively with various modalities and results including extracorporeal shock wave therapy (ESWT), cortisone injection, ITB stretching, and gluteal strengthening [18]. ...
Introduction:
Greater trochanteric pain syndrome (GTPS) includes patients with symptoms of peritrochanteric pain, gluteus medius/minimus tendinopathy, and external snapping hip. Non-operative treatment includes iliotibial band (ITB) stretching, gluteal exercises and cortisone injections. When surgery is indicated due to the failure of non-operative strategies, open Z-plasty at the level of the greater trochanter has been the traditional procedure. Endoscopic release of the ITB and bursectomy at the level of the greater trochanter has over the last decades evolved and is established as an alternative method of surgery.
Case reports:
We here present a case series with 11 consecutive patients who have undergone endoscopic release of the ITB and bursectomy at the level of the greater trochanter due to GTPS. The patients were all Caucasians, 43-years of age, and six were female. The patients retrospectively scored their pre-operative function and pain during follow-up at 28 months (range 15-42). Post-operative pain and function were scored at follow-up. In this paper, we discuss investigation, differential diagnoses, surgical options, and outcomes in the treatment of GTPS. All patients reported significant reduction of pain, and 10 of 11 patients reported an improvement in function. We observed no complications.
Conclusions:
Endoscopic release of the ITB and bursectomy at the level of the greater trochanter appears to be an effective and safe procedure when conservative treatment options for GTPS have failed.
... Greater trochanteric pain syndrome (GTPS) represents a clinical condition which includes pain and tenderness around the greater trochanter area, which can radiate to the lateral side of the hip or thigh and is generally associated with trochanteric bursitis, but literature also suggests a degeneration process or a tearing of the gluteal tendons 78,79 . Conservative treatment consists of medication, rest, physical therapy or corticosteroid injections. ...
... Subjects with primary or secondary symptomatic painful osteoarthritis were selected because of the presence of radiographic signs of hip OA by X-ray, with quantitative measurement of joint space width and determination of OA severity (grade 3-4 at the Kellgren-Lawrence (KL grading score) radiological grading scale [28]. Some of them performed also MRI more informative for the articolar cartilagine loss, bone marrow lesion and other connective and bone tissue abnormality [29]. ...
Background: Hip Osteoarthritis (OA) causes pain and disability. Here we evaluate abobotulinumtoxinA (Dysport®) (AboBoNT-A) injections versus placebo as a novel treatment option to improve hip range of motion, pain and quality of life. Methods: This prospective randomized double-blind multicenter study (EudraCT # 2012-004890-25) recruited 46 outpatients with hip OA who were randomized 2:1 to the Treatment Group (TG; 31 subjects), or the Placebo Group (PG; 15 subjects). The TG received 400 U of AboBoNT-A injected into the adductor muscles, and the PG received placebo solution. The primary endpoints were the difference in Harris Hip Score (HHS) and Visual Analogic Scale for pain (VAS) at Week 4 between groups (TG vs. PG). Secondary endpoints were the change from baseline in HHS, VAS pain, Medical Research Council scale for muscle strength (MRC) and Short Form scale (SF-36) scores. Results: In TG at Week 4, the HHS and VAS score were significantly improved compared to PG, and pairwise assessments showed significant improvements in HSS and VAS pain at each time point compared to baseline for TG. No significant changes were observed in MRC and SF-36 over time, though SF-36 showed a positive trend. There were no significant differences from baseline in the PG. No adverse events were detected in either treatment group. Conclusions: AboBoNT-A injections in hip OA improve range of motion and pain without any significant side effects.
Greater trochanteric pain syndrome (GTPS) is a frequent disorder characterized by lateral hip pain related to different structural causes including gluteus medius and minimus tendinopathy, bursitis, enthesitis, and others and is predominantly seen in middle-aged women. It was referred to in the past as “trochanteric bursitis,” but multiple studies have demonstrated that an isolated bursitis without tendon abnormality is rare. In this chapter, we will describe the anatomy of the greater trochanter and the clinical manifestations and imaging features of the different structural abnormalities associated with GTPS and give an overview of therapeutic options.
Objective
This study aimed to address the gap in knowledge assessing the impact of visceral and subcutaneous body fat on 3-dimensional computed tomography imaging in patients with greater trochanteric pain syndrome (GTPS) in comparison with those primarily diagnosed with osteoarthritis (OA).
Materials and Methods
We evaluated adult patients with a confirmed diagnosis of GTPS from our institutional hip-preservation clinic spanning 2011 to 2022. Selection criteria included their initial clinic visit for hip pain and a concurrent pelvis computed tomography scan. These patients were age- and sex-matched to mild-moderate OA patients selected randomly from the database. Visceral and subcutaneous fat areas were measured volumetrically from the sacroiliac joint to the lesser trochanter using an independent software. Interreader reliability was also calculated.
Results
A total of 93 patients met the study criteria, of which 37 belonged to the GTPS group and 56 belonged to the OA group. Both groups were sex and race matched. Average age in GTPS and OA groups was 59.3 years and 56 years, respectively. For GTPS group, average body mass index was 28.9 kg/m ² , and for the OA group, average body mass index was 29.9 kg/m ² , with no significant difference ( P > 0.05). Two-sample t test showed no significant differences in the visceral fat, subcutaneous fat, or the visceral fat to total fat volume ratio between the GTPS and OA groups. There was excellent interreader reliability.
Conclusions
Our results indicate that there is no significant difference in fat distribution and volumes among GTPS and OA patients. This suggests that being overweight or obese may not be directly linked or contribute to the onset of GTPS. Other factors, such as gluteal tendinopathy, bursitis, or iliotibial band syndrome, might be responsible and need further investigation.
OBJECTIVE: We aimed to evaluate the accuracy of clinical tests that are used to diagnose greater trochanteric pain syndrome (GTPS) in clinical practice.
DESIGN: Diagnostic test accuracy systematic review with meta-analysis.
LITERATURE SEARCH: MEDLINE, Embase, CINAHL, AMED, and SPORTDiscus were searched using key words mapped to diagnostic test accuracy for GTPS.
STUDY SELECTION CRITERIA: Studies with published or derivable diagnostic accuracy data were included.
DATA SYNTHESIS: Risk of bias was assessed using the QUADAS-2 tool, and certainty of evidence, via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MetaDTA “R” random-effects models were used to summarize individual and pooled data including sensitivity, specificity, likelihood ratios, and pretest/posttest probabilities.
RESULTS: From a database yield of 858 studies, 23 full texts were assessed. We included 6 studies for review, involving 15 tests and 272 participants (314 hips). Overall certainty of evidence ranged from very low to moderate. Meta-analysis of 6 tests revealed sequenced test clusters able to significantly shift pretest-posttest probability for or against a GTPS diagnosis. In people reporting lateral hip pain, a negative gluteal tendon (GT) palpation test followed by a negative resisted hip abduction test significantly reduced the posttest probability of GTPS from 59% to 14%. In those with a positive GT palpation test followed by a positive resisted hip abduction test, the posttest probability of GTPS significantly shifted from 59% to 96%.
CONCLUSION: The value of magnetic resonance imaging for diagnosing GTPS is debated. We have identified a straightforward, clinically useful diagnostic test cluster to help confirm or refute the presence of GTPS in people reporting lateral hip pain. J Orthop Sports Phys Ther 2024;54(1):26-49. Epub 10 August 2023. doi:10.2519/jospt.2023.11890
A comprehensive understanding of the anatomy and biomechanics of muscle fibers and tendons is crucial to comprehend their functions. The orientation of tendon fibers plays a significant role in the pathologies that affect them and the resulting functional impairments. In this review, we provide detailed information on the origin, insertion, and fiber orientation of selected muscles and tendons, as well as their functional significance. To aid in comprehension, we have included illustrations depicting the anatomy and fiber orientation, as well as cross-sectional MR images that highlight important imaging features of normal anatomy and tears of select lower extremity tendons.
Overuse injuries of the hip are common, and clinical diagnosis may be difficult because of overlapping and nonspecific clinical symptoms. Imaging can play an essential role in guiding diagnosis and management. Femoroacetabular joint structural abnormalities result in various conditions that can predispose patients to early development of osteoarthritis. Repetitive stress on the skeletally immature hip can result in apophyseal injuries. Notable nonosseous overuse hip pathologies include athletic pubalgia, trochanteric bursitis, and injuries involving the iliopsoas myotendinous unit. Timely diagnosis of overuse injuries of the hip can facilitate improved response to conservative measures and prevent irreversible damage.
The purpose of this article is to provide a synopsis of the current medical understanding of lateral hip pain, highlighting greater trochanteric pain syndrome (GTPS) and its relation to lateral hip pain. Common causes of lateral hip pain, GTPS as a cause of lateral hip pain, prevalence of GTPS, clinical presentation of GTPS, associated risk factors, history and physical examination, laboratory testing, diagnostic imaging, and treatment options are described. A quiz serves to assist readers in their understanding of the presented material.
Lateral hip pain is a common complaint in primary care and sports medicine settings. However, a precise diagnosis for lateral hip pain is often a challenge due to complex anatomy and broad differential diagnosis. As a result, vague terminology such as greater trochanteric pain syndrome is frequently utilized to describe pain in this region, which limits the clinician’s ability to provide optimal management strategies. This chapter will review specific lateral hip disorders including gluteal tendinopathy, greater trochanteric bursopathy, external snapping hip, and iliotibial tendinopathy with the aim of enhancing clinical evaluation, diagnosis, and focused treatment for these disorders. Nerve impingement syndromes affecting the lateral hip are covered elsewhere.KeywordsLateral hipGluteal tendinopathyGreater trochanteric pain syndromeGreater trochanteric bursopathyExternal snapping hipExternal coxa saltansIliotibial tendinopathyProximal iliotibial band syndromeRehabilitationMusculoskeletal ultrasound
Lateral hip pain and peritrochanteric disorders are a common cause of hip pain in athletes. The term greater trochanteric pain syndrome (GTPS) has been used over the years to describe a spectrum of conditions that cause lateral-sided hip pain, including tendinopathies and strains of the hip abductor complex, trochanteric bursitis, external snapping hip syndrome, and proximal iliotibial band syndrome. Diagnosis of these conditions may be challenging due to variability and sometimes overlap in their clinical presentations. Recent advancements in our understanding of pathomechanics, biomechanics, and anatomic relationships between bony structures and soft tissues in the hemipelvis have resulted in better treatments and more accurate diagnostic tools. In this chapter, we will review common peritrochanteric disorders and the current treatments and diagnostic modalities.
Introduction
Greater trochanteric pain syndrome (GTPS) is an umbrella term used to describe several pathologies contributing to lateral hip pain. The most prevalent pathology is gluteal tendinopathy. Conservative management of GTPS is predominantly now focused on the use of corticosteroid injections (CSIs) and gluteal exercises.
Aim
To compare CSIs and gluteal exercises on pain in adults with GTPS.
Method
A systematic search of AMED, CINAHL, MEDLINE, EMBASE, TRIP and the Cochrane Library was conducted from inception to January 2021. Critical appraisal was completed using the Critical Appraisal Skills Programme tool. Data were extracted to obtain population characteristics and procedural details.
Results
Seven articles met the eligibility criteria out of a total of 336; five articles were randomised control trials (RCT) and two were cohort studies, equivalent to 758 and 70 participants, respectively. Studies generally reported significant benefits of CSIs <12 weeks and gluteal exercises >8 weeks for the reduction in lateral hip pain (p < .05). Critical appraisal demonstrated varied study quality and significant heterogeneity.
Conclusion
CSIs appear to be a successful treatment intervention in the short-term to decrease lateral hip pain but not in the long-term. Gluteal exercises plus education on avoiding tendon compression appears to be as successful as CSIs in the short and superior in the long-term.
Tendons and ligaments may be subject to acute or chronic sports-related injury. This chapter reviews the structural properties of tendons and ligaments that give rise to their unique imaging features and account for patterns of injury seen. The superb soft tissue contrast offered by ultrasound and MRI make them the most widely used imaging modalities for assessing tendons and ligaments, with the dynamic capabilities of ultrasound being particularly advantageous. We describe the important imaging features of normal tendons and ligaments and show examples of acute and chronic injuries. The chapter will also review the role radiographs and CT play in assessment of tendon and ligament injuries, particularly with reference to avulsion fractures and malalignment following ligament rupture. In some cases arthrography may better demonstrate the integrity of ligaments around a joint and this along with novel techniques such as elastography and dual energy CT are also discussed.
Musculoskeletal regional pain syndromes (RPS) often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can, in most cases, reveal the cause for pain and direct the subsequent management of the conditions.
Yet, when in doubt, imaging methods, such as ultrasound (US) may support the clinical assessment. This paper reviews the underlying pathologies of some of the most frequently encountered RPS and the role of musculoskeletal US imaging for their diagnosis and treatment. If available, data on diagnostic accuracy and comparisons with gold standards are reported. The article stresses the importance of anatomical and sonoanatomical knowledge for the proper interpretation of the US images, points out the advantages and disadvantages of this imaging tool, and suggests the future research agenda.
Greater trochanteric pain syndrome (GTPS) is a common problem that is both debilitating and challenging to manage. In the past, the terms GTPS and greater trochanteric bursitis were used interchangeably, however, inflammation is not always a feature, and in fact, overuse or injury of the gluteal muscles may be the predominant feature. GTPS is now understood to involve multiple pathologies that affect the intra-articular or peri-articular spaces of the hip. Early detection and management of GTPS by GPs can improve patients’ quality of life. Currently, the use of corticosteroid injection therapy and imaging in the management of GTPS may be suboptimal. The aim of this article is to review the current management of GTPS, evidence for the efficacy and duration of action of corticosteroid injection therapy and the role of imaging techniques in the diagnosis and management of GTPS, including the ability to identify pathology and predict treatment response.
Ultrasound (US) assists in the determination of the pathology underlying greater trochanteric pain syndrome (GTPS); however, there exists no consensus regarding the US criteria used to define these pathologies. We aim to explore these US definitions and their associated prevalence. “Trochanteric bursitis” was defined in 10 studies (13 included studies) and was heterogeneously described. “Tendinopathy” was defined in 4 studies, while 7 studies defined “tendinosis.” “Tendon tears” were defined in 8 studies, 6 of which distinguished between “partial- and full-thickness tears.” Tendon pathology was most frequent in 5 studies (prevalence: 7%–93%), and bursitis in 2 studies (prevalence: 10%–75%); 3 studies had equal distribution. Methodological quality was limited in the descriptions of GTPS and US approaches. Together, we document the lack of standardized US definitions of the pathologies underlying GTPS. This may explain the heterogenous prevalence of US findings. Standardized definitions are needed to improve the reliability of future GTPS studies.
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily affects the joints, with the main clinical manifestations being chronic, symmetrical, and peripheral multi-joint inflammatory lesions. Drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCs), disease-modifying anti-rheumatic drugs (DMARDs), and biologics play a very important role in the treatment of RA. Of these, the most commonly used are chemical drugs, such as NSAIDs, GCs, and DMARDs. In recent years, a number of new compounds have emerged for the treatment of RA, such as SYK inhibitors, JAK inhibitors, NSAID-CAI drugs, and Syk/PDGFR-α/c-Kit inhibitors. In this review, we summarize the most recently developed anti-RA chemical drugs and discuss the synthesis and biological activities of these various new compounds.
Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.
Aims
Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures.
Patients and Methods
Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis.
Results
A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R ² = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R ² = 0.4985). Age, HADSA, patient’s percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R ² = 0.5802).
Conclusion
Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800–807.
Purpose:
Surface irregularities of the greater trochanter have been described as a potential radiographic sign of greater trochanteric pain syndrome (GTPS). We report a diagnostic accuracy study to evaluate the clinical usefulness of trochanteric surface irregularities on plain radiographs in the diagnosis of GTPS.
Methods:
We retrospectively identified the anteroposterior pelvic radiographs of a consecutive group of 38 patients (representing a 27.5% series prevalence) diagnosed with GTPS (mean age 69.5 years ± 16.1 [standard deviation], 27 females, 11 males) based on clinical symptoms and a positive response to a local anaesthetic and steroid injection. A control group consisted of 100 patients (mean age 73 years ± 17.1 [standard deviation], 67 females, 33 males) with either hip osteoarthritis listed for hip arthroplasty (n = 50), or with an intracapsular neck of femur fracture (n = 50) both presenting between January and July 2017. Radiographs were cropped to blind observers to the presence of hip osteoarthritis or intracapsular fracture but included the trochanteric region. The radiograph sequence was randomised and separately presented to 3 orthopaedic surgeons to evaluate the presence of trochanteric surface irregularities.
Results:
The inter-observer correlation coefficient agreement was acceptable at 0.75 (95% CI, 0.60-0.84). Trochanteric surface irregularities including frank spurs protruding ⩾2 mm were associated with a 24.7% positive predictive value, 64.0% sensitivity, 25.7% specificity, 74.3% false-positive rate, 36.0% false-negative rate, and a 65.3% negative predictive value for clinical GTPS.
Conclusion:
Surface irregularities of the greater trochanter are not reliable radiographic indicators for the diagnosis of greater trochanteric pain syndrome.
We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description.
We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.
Pain around the greater trochanter is still a common clinical problem that may be secondary to a variety of either intra-articular or periarticular pathologies. Gluteal tendon pathologies are one of the primary causes of greater trochanteric pain, with attrition of the fasciae latae against the gluteus medius and minimus tendons, and the trochanteric bursa being possible causes. Key sonographic findings of gluteal tendinopathy, bursitis, and differential diagnosis are described in this overview. Clinical diagnosis and treatment of greater trochanteric pain syndrome is still challenging; therefore ultrasound is helpful to localize the origin of pain, determine underlying pathology, and, based on these findings, to guide local aspiration and/or injection in cases of tendinopathy and/or bursitis.
Background Effective treatment of hip pain improves population health and quality of life. Accurate differential diagnosis is fundamental to effective treatment. The diagnostic criteria for one common hip problem, greater trochanteric pain syndrome (GTPS) have not been well defined.
Purpose To define the clinical presentation of GTPS.
Methods Forty-one people with GTPS, 20 with hip osteoarthritis (OA), and 23 age-matched and sex-matched asymptomatic participants (ASC) were recruited. Inclusion and exclusion criteria ensured mutually exclusive groups. Assessment: the Harris hip score (HHS), a battery of clinical tests, and single leg stance (SLS). Participants identified the site of reproduced pain. Analysis: Fisher's exact test, analysis of variance (ANOVA) informed recursive partitioning to develop two classification trees.
Results Maximum walking distance and the ability to manipulate shoes and socks were the only HHS domains to differentiate GTPS from OA (ANOVA: p=0.010 and <0.001); OR (95% CI) of 3.47 (1.09 to 10.93) and 0.06 (0.00 to 0.26), respectively. The lateral hip pain (LHP) classification tree: (dichotomous LHP associated with a flexion abduction external rotation (FABER) test) had a mean (SE) sensitivity and specificity of 0.81 (0.019) and 0.82 (0.044), respectively. A non-specific hip pain classification tree had a mean (SE) sensitivity and specificity of 0.78 (0.058) and 0.28 (0.080).
Conclusions Patients with LHP in the absence of difficulty with manipulating shoes and socks, together with pain on palpation of the greater trochanter and LHP with a FABER test are likely to have GTPS.
Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional “number of criteria present” format and “classification tree” techniques.
Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation ≥15º, pain present on internal rotation of the hip, morning stiffness of the hip for ≤60 minutes, and age >50 years, or 2) hip internal rotation <15º and an erythrocyte sedimentation rate (ESR) ≤45 mm/hour; if no ESR was obtained, hip flexion ≤115º was substituted (sensitivity 86%; specificity 75%).
Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR <20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%).
The “number of criteria present” format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an ostophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.
We undertook a study to evaluate the effectiveness of corticosteroid injections in primary care patients with greater trochanteric pain syndrome (GTPS).
We evaluated the effect of corticosteroid injections compared with expectant treatment (usual care) in a pragmatic, multicenter, open-label, randomized clinical trial in the Netherlands. Patients (aged 18 to 80 years) with GTPS visiting 81 participating primary care physicians were randomly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). Primary outcomes of pain severity (numerical rating scale 0 to 10) and recovery (yes or no total or major recovery) were evaluated at 3-month and 12-month follow-up visits. Adverse events were collected at 6 weeks.
At the 3-month follow-up visit, 34% of the patients in the usual care group had recovered compared with 55% in the injection group (adjusted OR = 2.38; 95% CI, 1.14-5.00, number needed to treat = 5). Pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 (95% CI, 0.31-2.05) and in pain with activity of 1.30 (95% CI, 0.32-2.29). At the 12-month follow-up, 60% of the patients in the usual care group had recovered compared with 61% in the injection group (OR = 1.05; 95% CI, 0.50-2.27). Pain severity at rest and on activity decreased in both groups and the 12-month follow-up showed no significant differences, with adjusted differences of 0.14 (95% CI, -0.75 to 1.04) for pain at rest and 0.45 (95% CI, -0.55 to 1.46) for pain with activity. Aside from a short period with superficial pain at the site of the injection, no differences in adverse events were found.
In this first randomized controlled trial assessing the effectiveness of corticosteroid injections vs usual care in GTPS, a clinically relevant effect was shown at a 3-month follow-up visit for recovery and for pain at rest and with activity. At a 12-month follow-up visit, the differences in outcome were no longer present.
Greater trochanteric pain syndrome can be severely debilitating. Ideal imaging modalities are not established, treatments are not reliably evaluated, and the underlying pathology is not well understood.
Using surgical and histopathology findings as a gold standard, we therefore determined the positive predictive value of preoperative ultrasound assessment for greater trochanteric pain syndrome recalcitrant to nonoperative management. In addition, we report the outcomes of gluteal tendon reconstructive surgery using validated clinical and functional outcome tools and evaluate the contribution of the tendon and bursa to greater trochanteric pain syndrome.
We reviewed 24 patients who had combined gluteal tendon reconstruction and bursectomy. Preoperative ultrasound imaging was compared with surgical findings. In the absence of a greater trochanteric pain syndrome specific outcome tool, surgical outcomes for pain and function were assessed via a 100-mm visual analog scale, the modified Harris hip score, and the Oswestry Disability Index. Strength also was measured. The tendon and bursa tissue collected at surgery was histopathologically reviewed.
In our small study, ultrasound had a high positive predictive value for gluteal tendon tears (positive predictive value = 1.0). Patients reported high levels of pain relief and function after surgery; tendon and bursa showed pathologic changes.
Ultrasound appears to be clinically useful in greater trochanteric pain syndrome; reconstructive surgery seems to relieve pain and the histopathologic findings show tendinopathy and bursa pathology coexist in greater trochanteric pain syndrome.
Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
To determine whether fluoroscopic guidance improves outcomes of injections for greater trochanteric pain syndrome.
Multicentre double blind randomised controlled study.
Three academic and military treatment facilities in the United States and Germany.
65 patients with a clinical diagnosis of greater trochanteric pain syndrome.
Injections of corticosteroid and local anaesthetic into the trochanteric bursa, using fluoroscopy (n=32) or landmarks (that is, "blind" injections; n=33) for guidance.
Primary outcome measures: 0-10 numerical rating scale pain scores at rest and with activity at one month (positive categorical outcome predefined as >or=50% pain reduction either at rest or with activity, coupled with positive global perceived effect). Secondary outcome measures included Oswestry disability scores, SF-36 scores, reduction in drug use, and patients' satisfaction.
No differences in outcomes occurred favouring either the fluoroscopy or blind treatment groups. One month after injection the average pain scores were 2.7 at rest and 5.0 with activity in the fluoroscopy group compared with 2.2 and 4.0 in the blind injection group. Three months after the injection, 15 (47%) patients in the blind group and 13 (41%) in the fluoroscopy group continued to have a positive outcome.
Although using fluoroscopic guidance dramatically increases treatment costs for greater trochanteric pain syndrome, it does not necessarily improve outcomes.
Clinical trials NCT00480675.
We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description. We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.
Objective:
The purpose of this study is to describe the imaging findings of tears and avulsive injuries of the gluteus medius tendon in elderly women and to evaluate the importance of diagnosis and the implications of treatment in the realm of lateral hip pain.
Conclusion:
Elderly women are susceptible to a spectrum of gluteal tendon abnormalities of the hip, notably tears and avulsive injuries of the gluteus medius tendon, that can be a cause of lateral hip pain and may be underdiagnosed or misdiagnosed. The MR imaging findings of this entity are instrumental in establishing the correct diagnosis in the setting of lateral hip pain and initiating appropriate treatment.
This study was conducted to determine the prevalence of tendinosis and tears of gluteus medius and minimus muscles in patients presenting with buttock, lateral hip, or groin pain; describe the MR imaging findings; and discuss their probable relationship to the greater trochanteric pain syndrome.
Two hundred fifty MR imaging examinations of the hip were performed for the evaluation of buttock, lateral hip, or groin pain. The findings were reviewed for changes in the morphology or signal intensity of gluteus medius and minimus muscles and tendons and for any peritendinous abnormality including distention of regional bursae.
Thirty-five studies met our criterion of showing either tendinosis or tears of gluteus medius and minimus muscles as the primary positive finding. Eight patients had complete retracted tears of the gluteus medius, and 14 patients had partial tears; in 13 patients, MR findings were consistent with tendinosis. The gluteus minimus muscle was also involved in 10 patients. MR imaging findings were the same as those described for tears and tendinosis of other regions of the body. Surgical proof of a tendon tear was obtained in six patients.
Tendinopathy of the hip abductors and gluteus medius and minimus muscles was a common finding on MR imaging in our patients with buttock, lateral hip, or groin pain. Tendinopathy is probably a frequent cause of the greater trochanteric pain syndrome, a common regional pain syndrome that can mimic other important conditions causing hip pain including avascular necrosis and stress fracture. Moreover, it is likely that trochanteric bursitis is associated with tendinopathy.
Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, they can result in extensive rehabilitation time. Thus, an accurate diagnosis and well-organized treatment plan are critical. Because loads of up to eight times body weight have been demonstrated in the hip joint during jogging, presumably even greater loads can occur during vigorous athletic competition. The available imaging modalities are effective diagnostic tools when selected on the basis of a thorough history and physical examination. Considerable controversy exists as to the cause and optimal treatment of groin pain in athletes, or the so-called "sports hernia." There has also been significant recent attention focused on intraarticular lesions that may be amenable to hip arthroscopy. This article briefly reviews several common hip and groin conditions affecting athletic patients and highlights some newer topics.
We describe a new operative procedure for patients with chronic trochanteric bursitis. Between March 1994 and May 2000, a trochanteric reduction osteotomy was performed on ten patients (12 hips). All had received conservative treatment for at least one year. Previous surgical treatment with a longitudinal release of the iliotibial band combined with excision of the trochanteric bursa had been performed on five hips. None had responded to these treatments.
The mean follow-up was 23.5 months (6 to 77). The mean Merle d’Aubigné and Postel score improved from 15.8 (8 to 20) before to 27.5 (18 to 30) after operation, six patients showing very great improvement, five great improvement and one fair improvement. We conclude that trochanteric reduction osteotomy is a safe and effective procedure for patients with refractory trochanteric bursitis who do not respond to conservative treatment.
Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17-61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12-48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.
Our objective was to describe the sonographic appearance of the gluteus medius and minimus tendons in normal subjects, and to illustrate the spectrum of sonographic findings in gluteus tendinopathies. Sonography was performed in 20 asymptomatic volunteers. Seventy-five consecutive patients (59 women, 16 men; mean age 57.1 years) presented with pain and point tenderness over the greater trochanter. There were 43 right hips and 32 left hips. Ten patients provided a history of a traumatic incident with subsequent symptoms (mean duration 3.2 months). All patients underwent sonography to assess the site and severity of injury, and to discriminate tendinosis from partial and complete tear. Calcific foci, bony change, and fluid in the trochanteric bursae were noted. Twenty-two patients subsequently underwent surgery. Fifty-three (53 of 75) patients showed sonographic evidence of gluteus medius tendinopathy. Twenty-eight patients were thought to have tendinopathy without discrete tear. Sixteen patients had partial tears and 9 full-thickness tears. Gluteus minimus tendinopathy was detected in 10 of 75 patients. Foci of tendinopathy and partial tears were more common in the deep and anterior portions of the gluteus medius tendon attachment. Eight patients had fluid pooling in the trochanteric bursae. Findings were confirmed in 22 patients at surgery. Sonography can identify gluteus medius and minimus tendinopathy and provides information about the severity of the disease.
Fifteen patients with identical symptoms of pain and tenderness at the tip of the greater trochanter are reviewed. Diagnosis by the referring doctor was usually osteoarthritis of the hip or sciatica, but localised tenderness and pain on resisted abduction were the only clinical signs. Radiographs were usually normal. Most cases were relieved by one or more local steroid injections. This disorder has much in common with tennis elbow, golfer's elbow, coccydynia and policeman's heel. We suggest that all these conditions may be traction syndromes.
Purpose
A snapping hip (coxa saltans) secondary to a tight iliotibial band rarely needs surgical intervention. The purpose of this study is to present the surgical results of refractory external-type snapping hip by Z-plasty of the iliotibial band.
Materials and Methods
Nine symptomatic snapping hips in 8 consecutive patients (1 bilateral) from August 1997 through March 2002 who underwent an iliotibial band Z-plasty were reviewed.
Results
Eight of the 9 hips were in active-duty military and 1 was a civilian, with an average age of 25.6 years (range, 21 to 38 years). Mean duration of symptoms prior to surgical intervention was 25.2 months (range, 16 to 39 months) with an average follow-up of 22.9 months (range, 7 to 38 months). All patients had complete resolution of the snapping hip, and all but 1 returned to full unrestricted activities. The 1 failure had persistent groin pain but no residual snapping.
Conclusions
Patients with snapping hip of the iliotibial band refractory to conservative treatment are rare. The surgical results of Z-plasty are excellent and predictable. Careful screening is necessary to preclude other confounding diagnoses. Z-plasty is recommended as an effective surgical treatment of the refractory snapping hip secondary to iliotibial band tightness.
Lateral hip pain is a common problem in middle-aged women. This pain is usually attributed to trochanteric bursitis and treated as such. This study reports the results of investigation, the findings at surgery, the operative technique, the histopathologic findings, and the results of gluteal tendon repair in 72 patients with long-standing trochanteric pain and reports a classification of the operative findings. Six patients (7%) in the original study cohort of 89 patients were lost to follow-up, but of the remaining patients, 65 of 72, or 90%, were pain-free or had minimal pain (P < .00001). Surgical reconstruction of detached gluteal tendons causing chronic lateral hip pain addresses the problem directly and reliably relieves the symptoms of so-called “trochanteric bursitis.”
The trochanteric syndrome frequently masquerades as sciatica. Tenderness and pain in the region of the trochanter major, often with irradiation of this pain down the posterolateral aspect of the thigh, constitute a well-defined syndrome. This symptom pattern is analogous to the so-called bursitis of the shoulder. The locus of pathology is in the abductor mechanism of the hip. The cause of the primary form is wear and tear, that of the secondary form the presence of foreign material, such as the end of a hip nail. Roentgenograms often reveal calcification in the tendons inserting into the trochanter. The condition is not rare. Local injection of hydrocortisone relieves the symptoms of the primary type.Tendonitis, tenosynovitis, and bursitis about the glenohumeral joint are well known to the profession. These conditions are recognized and lumped together by the laity as bursitis of the shoulder. The analogous conditions in the region of the
Disorders causing lateral hip pain are encountered frequently by physicians. Evaluating these problems can be challenging because of the myriad of potential causes, the complex anatomy of the peritrochanteric structures, and the inconsistently described etiologic factors. Misconceptions about the causes of lateral hip pain and tenderness are common, frequently leading to approaches that only provide temporary solutions rather than address the underlying pathology. Trochanteric bursitis is implicated frequently but is seldom the primary cause of pain in chronic cases. It is important to address hip rotator cuff tendinopathy and pelvic core instability. Treatment options include therapeutic exercise, physical modalities, corticosteroid injections, extracorporeal shock wave therapy, and regenerative injection therapies. For recalcitrant cases, surgery may be appropriate. By understanding the anatomy of the peritrochanteric structures, and the pathologic processes most likely responsible for symptomatology and dysfunction, the physician will be prepared to provide effective long-term solutions for this common problem.
Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter.
We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected.
Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months.
Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS.
Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported.
Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS.
The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.
Trochanteric bursitis (TB) is a self-limiting disorder in the majority of patients and typically responds to conservative measures. However, multiple courses of nonoperative treatment or surgical intervention may be necessary in refractory cases. The purpose of this systematic review was to evaluate the efficacy of the treatment of TB.
A literature search in the PubMed, MEDLINE, CINAHL, and ISI Web of Knowledge databases was performed for all English language studies up to April 2010. Terms combined in a Boolean search were greater trochanteric pain syndrome, trochanteric bursitis, trochanteric, bursitis, surgery, therapy, drug therapy, physical therapy, rehabilitation, injection, Z-plasty, Z-lengthening, aspiration, bursectomy, bursoscopy, osteotomy, and tendon repair.
All studies directly involving the treatment of TB were reviewed by 2 authors and selected for further analysis. Expert opinion and review articles were excluded, as well as case series with fewer than 5 patients. Twenty-four articles were identified. According to the system described by Wright et al, 2 studies, each with multiple arms, qualified as level I evidence, 1 as level II, 1 as level III, and the rest as level IV. More than 950 cases were included.
The authors extracted data regarding the type of intervention, level of evidence, mean age of patients, patient gender, number of hips in the study, symptom duration before the study, mean number of injections before the study, prior hip surgeries, patient satisfaction, length of follow-up, baseline scores, and follow-up scores for the visual analog scale (VAS) and Harris Hip Scores (HHS).
Symptom resolution and the ability to return to activity ranged from 49% to 100% with corticosteroid injection as the primary treatment modality with and without multimodal conservative therapy. Two comparative studies (levels II and III) found low-energy shock-wave therapy (SWT) to be superior to other nonoperative modalities. Multiple surgical options for persistent TB have been reported, including bursectomy (n = 2), longitudinal release of the iliotibial band (n = 2), proximal or distal Z-plasty (n = 4), osteotomy (n = 1), and repair of gluteus medius tears (n = 4).
Efficacy among surgical techniques varied depending on the clinical outcome measure, but all were superior to corticosteroid therapy and physical therapy according to the VAS and HHS in both comparison studies and between studies. This systematic review found that traditional nonoperative treatment helped most patients, SWT was a good alternative, and surgery was effective in refractory cases.
The gluteus medius and minimus muscle-tendon complex is crucial for gait and stability in the hip joint. There are three clinical presentations of abductor tendon tears. Degenerative or traumatic tears of the hip abductor tendons, so-called rotator cuff tears of the hip, are seen in older patients with intractable lateral hip pain and weakness but without arthritis of the hip joint. The second type of tear may be relatively asymptomatic. It is often seen in patients undergoing arthroplasty for femoral neck fracture or elective total hip arthroplasty (THA) for osteoarthritis. The third type of abductor tendon dysfunction occurs with avulsion or failure of repair following THA performed through the anterolateral approach. Abductor tendon tear should be confirmed on MRI. When nonsurgical management is unsuccessful, open repair of the tendons with transosseous sutures is recommended. Good pain relief has been reported following endoscopic repair. Abductor tendon repair has had inconsistent results in persons with avulsion following THA. Reconstruction with a gluteus maximus muscle flap or Achilles tendon allograft has provided promising short-term results in small series.
Pain over the lateral aspect of the hip commonly is attributed to trochanteric bursitis. Typical findings include local tenderness and weakness of hip abduction. When conservative measures fail to relieve symptoms, surgical release of the iliotibial band over the greater trochanter has been recommended. In the management of seven such patients, an unusual finding was encountered: partial tear of the gluteus medius tendon at its attachment to the greater trochanter. Each patient presented with increasing hip pain of duration of months to years. There were no diagnostic findings on physical examination. Magnetic resonance imaging showed an abnormal signal within the tendon of gluteus medius and fluid within the trochanteric bursa. The disrupted tendons were reattached to bone with heavy nonabsorbable suture. At a median followup of 45 months (range, 21-60 months), all patients were free of pain.
To assess the association between trochanteric surface irregularities seen on conventional radiographs and magnetic resonance (MR) evidence of abductor tendon abnormalities.
A total of 150 consecutive patients were evaluated in this retrospective study (age range, 21-88 years; mean age, 58.7 years ± 16.1 [standard deviation]; 57 men, 93 women). Because patients' rights are protected by a procedure in which they are asked to provide general approval for their records and images to be reviewed for scientific purposes, specific approval by the institutional review board was not required. Two readers independently analyzed conventional radiographs and MR images of the hip. Trochanteric surface was graded on conventional radiographs as normal, osseous irregularities extending 1-2 mm, or osseous irregularities extending more than 2 mm. On MR images, the gluteus minimus and gluteus medius tendons were classified as normal or as having tendinopathy or a partial- or full-thickness tear. Logistic regression analysis and the Fisher exact test were used for statistical analysis. Sensitivity, specificity, accuracy, positive and negative predictive values, and positive likelihood ratio were calculated. To assess interobserver agreement, a κ statistic was used.
The positive predictive value of surface irregularities larger than 2 mm for MR tendinopathy or a partial- or full-thickness tear was 90% (37 of 41 patients). The sensitivity of radiographic changes was 40%; the specificity, 94%; the accuracy, 61%; the negative predictive value, 49%; and the positive likelihood ratio, 5.8. Interobserver agreement for detection of trochanteric surface irregularities on conventional radiographs ranged from 0.28 to 0.76.
Pronounced (>2 mm) surface irregularities of the greater trochanter on conventional radiographs were associated with abductor tendon MR abnormalities.
Originally defined as "tenderness to palpation over the greater trochanter with the patient in the side-lying position," greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans.
Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.
Tears of the gluteus medius tendon at the greater trochanter have been termed "rotator cuff tears of the hip." Previous reports have described the open repair of these lesions.
Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term.
Case series; Level of evidence, 4.
Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys.
At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal.
With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.
Eighteen patients who were initially diagnosed as having trochanteric bursitis refractory to conventional therapy are reported. The most common causes of pseudotrochanteric bursitis were lumbar radiculopathy (L2, L3), lumbar facet syndrome with pain referred to the lateral thigh, and entrapment neuropathies involving the subcostal, and the lateral cutaneous branches of the iliohypogastric nerves. Less common causes were undisplaced femoral neck fracture, adiposa dolorosa, and hip abductor muscle strain. Diagnosis was facilitated by selective neuroblockade.
In 72 patients followed for two years, the diagnosis of trochanteric bursitis was based on precise clinical signs without significant contribution from laboratory tests or radiologic signs. In six of the patients (8.3%) the bursitis was an isolated condition of unknown origin. Six other patients had rheumatoid arthritis without involvement of the ipsilateral hip joint. The remaining 60 patients (83.4%) had pathologic conditions of the adjacent areas, such as symptomatic lumbar spine arthrosis or ipsilateral hip damage, conditions that often mask the actual source of pain and disability. A rapid and prolonged improvement of the pain and disability caused by the bursitis was achieved in all 65 patients (90.3%) treated by local corticosteroid and anesthetic infiltrations: in 48 patients after one, in 13 after two and in 4 after three local treatments. Local corticosteroid infiltration proved to be the treatment of choice as well as a diagnostic test.
Thirty-six cases of simple trochanteric bursitis were evaluated, particular in regard to corticosteroid injections. The syndrome was mostly chronic, prevalent in older females, interspersed with other diseases. Diagnostic criteria are purely clinical. One or two local corticosteroid injections gave excellent response in two-thirds, improvement in the remaining cases. One-fourth relapsed in 2 years. Trochanteric bursitis should always be considered in hip pain syndromes, as it is so easily relieved.
Fifteen patients with identical symptoms of pain and tenderness at the tip of the greater trochanter are reviewed. Diagnosis by the referring doctor was usually osteoarthritis of the hip or sciatica, but localised tenderness and pain on resisted abduction were the only clinical signs. Radiographs were usually normal. Most cases were relieved by one or more local steroid injections. This disorder has much in common with tennis elbow, golfer's elbow, coccydynia and policeman's heel. We suggest that all these conditions may be traction syndromes.
Bursitis is a common cause of lower extremity pain in patients presenting to primary care physicians. Several bursae in the lower extremity account for most of these injuries, including the ischiogluteal, greater trochanteric, pes anserine, medial collateral, prepatellar, popliteal and retrocalcaneal. Often the symptoms are mild, with the patient successfully self-treating through activity modification and other conservative measures. A systematic approach to the evaluation and treatment of patients with bursitis, including prevention, relative rest, ice, compression, elevation, anti-inflammatory medication and treatment modalities such as ultrasound and electrical stimulation, combined with a structured rehabilitation program, will greatly facilitate the healing process.
We conducted an open observational study to assess the short and longterm effect of single local glucocorticosteroid injection for trochanteric bursitis.
75 patient diagnosed with trochanteric bursitis based on clinical criteria were injected; 20, 32, and 22 patients each received 6, 12, and 24 mg betamethasone, respectively, mixed with 4 cm3 of 1% lidocaine. A standardized baseline questionnaire was administered to assess the severity and functional limitation due to trochanteric pain, including the visual analog scale for pain. Patients were followed at Weeks 1, 6, and 26 to determine their response to treatment.
77.1, 68.8, 61.3% of responding patients reported improvement in pain at Week 1, 6, and 26, respectively. Patients receiving higher doses of betamethasone were more likely to experience pain relief (p < 0.0123).
Corticosteroid and lidocaine injection for trochanteric bursitis is an effective therapy with prolonged benefit.
Coxa saltans, or "snapping hip," has several causes. These can be divided into three types: external, internal, and intra-articular. Snapping of the external type occurs when a thickened area of the posterior iliotibial band or the leading anterior edge of the gluteus maximus snaps forward over the greater trochanter with flexion of the hip. The internal type has a similar mechanism except that it is the musculotendinous iliopsoas that snaps over structures deep to it (usually the femoral head and the anterior capsule of the hip). Intra-articular snapping is due to lesions in the joint itself. Diagnosis of the external and internal types is usually made clinically. Radiography can be useful in confirming the diagnosis, particularly when bursography shows the iliopsoas tendon snapping with hip motion. Other radiologic modalities, such as computed tomography, magnetic resonance imaging, and arthrography, may also be helpful, especially when there is an intra-articular cause. Most cases of snapping hip are asymptomatic and can be treated conservatively. However, if the snapping becomes symptomatic, surgery may be necessary. There may also be a role for arthroscopy in the treatment of intra-articular lesions.
This study examined patients with greater trochanteric pain syndrome (GTPS) to determine the prevalence of gluteus medius pathology by utilizing magnetic resonance imaging (MRI), and to evaluate the presence of Trendelenburg's sign, pain on resisted hip abduction, and pain on resisted hip internal rotation as predictors of a gluteus medius tear in this group of patients.
Twenty-four subjects with clinical features consistent with GTPS were recruited. A standard physical assessment was performed at study entry, including assessment of the 3 specific physical signs. Following this initial assessment, MRI of the affected hip was performed. A 1.5T whole body MRI system was utilized, with T1 and T2 fast spin-echo sequences performed in the coronal and axial planes. All MR images were reviewed in random order by a single radiologist. In 12 patients, the 3 physical signs were assessed at study entry and at 2 months by the same observer and the intraobserver reliability for each of the signs was calculated.
All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg's sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg's sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).
The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg's sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg's sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.
The hip is surrounded by some of the body's most powerful muscles and strongest ligaments. Typical activities of daily living can subject this joint and its surrounding soft tissues to substantial forces, and such forces are greatly increased by athletic endeavors. The wide variety of acute, subacute, and chronic injuries to these structures can prove to be a diagnostic dilemma in spite of the numerous modalities available. A thorough understanding of the evaluation of the athlete with hip pain can enable the physician to make an earlier diagnosis, initiate earlier treatment, and allow for a safer return to sport.
To evaluate trochanteric anatomy with magnetic resonance (MR) imaging, bursography, MR bursography, and anatomic analysis.
T1-weighted and fat-saturated T2-weighted (transverse, sagittal, coronal, and coronal oblique planes) MR imaging of the greater trochanter was performed in 10 cadaveric hips and 12 hips of asymptomatic volunteers. Three bursae comprising the trochanteric bursa complex were injected, and conventional radiography and MR imaging were performed. The specimens were sectioned for anatomic analysis, corresponding to the MR imaging planes. Tendon attachments and bursal localization were related to the facets of the greater trochanter.
The bony surface of the greater trochanter consists of four facets: anterior, lateral, posterior, and superoposterior. The gluteus medius muscle attaches to the superoposterior and lateral facets. The gluteus minimus muscle attaches to the anterior facet. The trochanteric bursa covered the posterior facet and the lateral insertion of the gluteus medius muscle. The subgluteus medius bursa was located in the superior part of the lateral facet, underneath the gluteus medius tendon. The subgluteus minimus bursa lies in the area of the anterior facet, underneath the gluteus minimus tendon, medial and cranial to its insertion, and extends medially covering the distal anterior part of the hip joint capsule. The trochanteric bursa is delineated with fat on both sides and can be seen on transverse nonenhanced T1-weighted images as a fine line curving around the posterior part of the trochanter.
MR imaging and bursography provide detailed information about the anatomy of tendinous attachments of the abductor muscles and the bursal complex of the greater trochanter.
To resolve ambiguity in the literature about the anatomy of the "trochanteric bursa" or trochanteric subgluteus maximus bursa, this study examines the constancy, structure, and relationships of this bursa in a series of anatomical dissections of the hip. Sixteen embalmed hip specimens, from subjects aged 63-91 years, were examined. Subgluteus maximus bursae were demonstrated in 13 hips. In each of these a bursa, the deep bursa, was seen immediately superficial to the common attachment of the gluteus medius, minimus, and vastus lateralis muscles onto the greater trochanter. In five hips a smaller second bursa, the superficial bursa, was reflected with the gluteus maximus muscle. In two hips, four bursae were identified. The additional bursae were associated with either the deep or the superficial bursa. Examination of histological samples from the bursal walls confirmed the presence of a synovial lining in varying stages of development in seven of the eight bursae examined. Branches of the inferior gluteal nerve were seen to supply deep and superficial bursae in two dissections. The study data indicate that subgluteus maximus bursae at the level of the greater trochanter are an expected finding in the older age group and that they vary in number, position, and histological appearance. These features give rise to the hypothesis that these bursae are acquired as a consequence of excessive friction between the greater trochanter and the gluteus maximus as it inserts into the fascia lata.
The hip joint is becoming increasingly recognized as a source of groin pain and, in the authors' experience, buttock and low back pain.
To determine the range of pathologic diagnoses, clinical presentation, and the correlation between magnetic resonance arthrographic, ultrasonographic, and arthroscopic findings in the hip joint.
We prospectively studied 25 consecutive hip arthroscopies to determine the range of pathologic diagnoses, clinical presentation, and the correlation between magnetic resonance arthrographic, ultrasonographic, and arthroscopic findings.
All of the hips arthroscoped had pathology. Back pain and hip pain were the 2 most common presentations. The only consistently positive clinical test result was a restricted and painful hip quadrant compared with the contralateral hip. Of the 17 patients whose flexion, abduction, external rotation (FABER) test results were reported at the time of examination, 15 (88%) were positive, and 2 (12%) negative. Plain radiographs were normal in all patients. All but 1 patient underwent magnetic resonance arthrography. Although specificity of 100% was achieved in our study, the sensitivity was significantly lower, with a relatively high number of false negatives. Hip arthroscopy proved the definitive diagnostic procedure for intraarticular pathology.
Hip pathology, particularly labral pathology, may be more common than has been previously recognized. In those patients with chronic groin and low back pain, a high index of suspicion should be maintained. Clinical signs of a painful, restricted hip quadrant and a positive FABER test result should suggest magnetic resonance arthrography in the first instance, but a negative magnetic resonance image should not preclude hip arthroscopy if there is high clinical suspicion of hip joint pathology.
Greater trochanteric pain syndrome (GTPS) is a regional syndrome characterized by pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh that may mimic the symptoms of lumbar nerve root compression. Despite these known features, the diagnosis of GTPS is often missed, and documentation of its prevalence in an orthopedic spine specialty practice is lacking.
To determine the prevalence of the GTPS in patients referred to a tertiary care orthopedic spine referral center for the evaluation of low back pain, and to describe the demographic and clinical characteristics of patients with this syndrome.
Retrospective analysis. Patient sample: A total of 247 consecutive patients referred for low back pain from August 1998 through December 2000.
Clinical response to injection, demographic characteristics, physical examination findings, prevalence of GTPS and preexisting diagnostic evaluations.
The diagnosis of GTPS was made based on history and physical examination and was confirmed by response to anesthetic corticosteroid injection. Demographic and clinical characteristics of the study group were evaluated. Follow-up data were available at a mean of 8 weeks postinjection (range, 2 to 48 weeks).
The prevalence of GTPS was 20.2% (51 of 252). Mean age (54 years) was the same for patients with (range, 25 to 85 years) and without (range, 17 to 85 years) GTPS. Significantly more women than men had GTPS (p<.03). Of the 51 patients diagnosed with GTPS at initial presentation, 54.9% (28 of 51) had already obtained a magnetic resonance imaging examination (although only 15.7%, ie, 8 of 51, demonstrated objective neurologic findings) and 62.7% (32 of 51) had previously been evaluated by an orthopedist or neurosurgeon; one patient had undergone two lumbar decompressions without clinical improvement before our evaluation.
GTPS accounts for a substantial proportion of patients referred to our center for evaluation of low back pain. Both primary care physicians and specialty surgeons may miss this diagnosis, most common in middle-aged women. Accurate recognition of this problem earlier in the evaluation of patients with low back, buttock or lateral thigh symptoms may dramatically reduce costly patient referrals and diagnostic tests and may prevent unwarranted surgery.
The purpose of our study was to determine the accuracy of MRI for diagnosing tears of the hip abductor tendons (gluteus medius and gluteus minimus) and to evaluate various signs of tendon disruption.
We retrospectively evaluated MRIs of 74 hips (in 45 patients) that were obtained using 35- to 42-cm fields of view and interpreted using primary and secondary signs of tendon disruption. Fifteen hips had surgically proven abductor tendon tears, and 59 hips were either asymptomatic or had surgically confirmed intact tendons. MRI findings were scored by two radiologists through consensus and then again independently by a third radiologist to determine interobserver agreement.
The accuracy of MRI for the diagnosis of tears of the abductor tendons was 91%. Statistically significant associations were found between tears of the abductor tendons and areas of high signal intensity superior to the greater trochanter on T2-weighted images (p < 0.0001), tendon elongation in the gluteus medius (p = 0.0028), tendon discontinuity (p = 0.016), and areas of high signal intensity lateral to the greater trochanter on T2-weighted images (p = 0.0213). Interobserver agreement was good to fair.
MRI showed good accuracy for the diagnosis of tears of the gluteus medius and gluteus minimus tendons. The identification of an area of T2 hyperintensity superior to the greater trochanter had the highest sensitivity and specificity for tears at 73% and 95%, respectively.
Trochanteric pain is the second most important diagnosis of hip problems presenting in primary care, but its incidence and prognosis in this context is largely unknown.
To determine the 1- and 5-year prognoses of trochanteric pain and the predictive variables for consistent complaints.
Retrospective cohort study.
One hundred and sixty-four patients (mean age = 55 years, 80% female) with incidental trochanteric pain in the years 1996 or 2000 were asked in 2001 for past and present symptoms of trochanteric pain. Therapeutic interventions, demographic factors and comorbidity were also investigated.
The databases of 39 GPs were screened in order to identify all incident cases with a suspicion of trochanteric pain in the years 1996 or 2000. These cases were sent a questionnaire.
The incidence of trochanteric pain in primary care is 1.8 patients per 1000 per year. After 1 year at least 36% still suffered from trochanteric pain, and after 5 years this was 29%. Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold risk of persistent symptoms after 1 year, as compared to patients without OA. Patients who had received a corticosteroid injection had a 2.7-fold chance of recovery after 5 years, as compared with patients who had not received an injection.
Trochanteric pain is shown to be a chronic disease in a substantial number of patients. The disorder is associated with much impairment when conducting daily activities.
Running has steadily gained in worldwide popularity and is the primary exercise modality for many individuals of all ages. Its low cost, versatility, convenience and related health benefits appeal to men and women of broad cultural, ethnic and economic backgrounds. With more children and adults participating in recreational and competitive running, the incidence of injuries has steadily increased. Most running-related injuries affecting the lower extremities are due to preventable training errors, and some may necessitate medical evaluation or a significant reduction in training.