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Greater Trochanteric Pain Syndrome: An Update on Diagnosis and Management
Abstract
Greater trochanteric pain syndrome (GTPS) is a common cause of extra-articular lateral hip pain. The underlying etiology of GTPS ranges from gluteus medius and minimus tendinopathy or tears, to external coxa saltans or iliotibial band syndrome. Historically, this source of lateral hip pain was typically diagnosed as trochanteric bursitis as it was believed to be due to inflammation of the subgluteus maximus bursa. However, recent imaging and histopathological studies have shown that most cases are instead due to underlying gluteus medius or minimus tendon disorders. Identifying the specific pain generator in GTPS is important as the treatment differs depending on the cause. Strengthening should be prescribed in cases of gluteal tendinopathy; corticosteroid injections and NSAIDs may be helpful in cases of primary bursitis; and surgery may be indicated in functionally limiting gluteal tendon tears unresponsive to conservative treatment.
... Em atletas, os fatores incluem o desgaste assimétrico dos calçados, corrida em superfícies desniveladas e rígidas, treinamento inadequado e a fraqueza dos abdutores do quadril. Por outro lado, quando o quadril adota níveis mais altos de flexão que podem modificar a tensão sobre a banda iliotibial mediante a ligação presente entre as fáscias da banda iliotibial, glútea e lombo dorsal, pode causar compressão dos tendões glúteos e sintomas dolorosos recorrentes 15,16 . Os fisioterapeutas necessitam de respaldo científico para a prática clínica, pois as evidências na literatura científica ainda são incipientes sobre as ferramentas usuais para o diagnóstico clínico precoce e as estratégias necessárias para as ações de reabilitação no manejo adequado. ...
... As injeções de corticosteroides e anestésicos locais têm obtido destaque em virtude da promoção do alívio na condição dolorosa. Entretanto, elas têm apresentado eficácia nas estratégias combinadas quando administradas precocemente, apresentando indícios de recidivas quando utilizadas em estágios mais avançados 16,26 . ...
... 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.
... However hip adduction will also increase if the pelvis translates in the frontal plane over the grounded foot (Figure 1). An association between altered kinematics and GT is largely based on clinical supposition [13][14][15] as only one study reports pelvis position during SLS in GT [4]. On the basis of visual observation, Bird et al. categorized trunk and pelvic position during SLS as "normal" or "abnormal", reporting abnormal pelvic position associated with GT [4]. ...
Background:
Lateral hip pain during single leg loading, and hip abductor muscle weakness, are associated with gluteal tendinopathy, but it has not been shown how or whether kinematics in single leg stance differ in those with gluteal tendinopathy.
Purpose:
To compare kinematics in preparation for, and during, single leg stance between individuals with and without gluteal tendinopathy, and the effect of hip abductor muscle strength on kinematics.
Methods:
Twenty individuals with gluteal tendinopathy and 20 age-matched pain-free controls underwent three-dimensional kinematic analysis of single leg stance and maximum isometric hip abductor strength testing. Maximum values of hip adduction, pelvic obliquity (contralateral pelvis rise/drop), lateral pelvic translation (ipsilateral/contralateral shift) and ipsilateral trunk lean during preparation for leg lift and average values in steady single leg stance, were compared between groups using an analysis of covariance, with and without anthropometric characteristics and strength as covariates.
Results:
Individuals with gluteal tendinopathy demonstrated greater hip adduction (standardized mean difference (SMD)=0.70, P=0.04) and ipsilateral pelvic shift (SMD=1.1, P=0.002) in preparation for leg lift, and greater hip adduction (SMD=1.2, P=0.002) and less contralateral pelvic rise (SMD=0.86, P=0.02) in steady single leg stance than controls. When including strength as a covariate, only between-group differences in lateral pelvic shift persisted (SMD=1.7, P=0.01).
Conclusion:
Individuals with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg stance than pain-free controls. This finding is not influenced by pelvic dimension or the potentially modifiable factor of body mass index, but is by hip abductor muscle weakness.
Greater trochanteric pain syndrome (GTPS) is a common cause of lateral extra-articular hip pain. Most cases are due to underlying gluteus medius or minimus tendinopathy or tears and are noninflammatory in nature. It is important to identify the primary pain generator in GTPS to determine the optimal treatment for this condition. Treatments can range from focused physical therapy to pain or anti-inflammatory medications, cortisone or platelet-rich protein injections, shock-wave therapy, or surgical repair.
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.
Purpose. In the last few years, evidence has emerged to support the possible association between increased BMI and susceptibility to some musculoskeletal diseases. We systematically review the literature to clarify whether obesity is a risk factor for the onset of tendinopathy. Methods. We searched PubMed, Cochrane Central, and Embase Biomedical databases using the keywords "obesity," "overweight," and "body mass index" linked in different combinations with the terms "tendinopathy," "tendinitis," "tendinosis," "rotator cuff," "epicondylitis," "wrist," "patellar," "quadriceps," "Achilles," "Plantar Fascia," and "tendon." Results. Fifteen studies were included. No level I study on this subject was available, and the results provided are ambiguous. However, all the 5 level II studies report the association between obesity measured in terms of BMI and tendon conditions, with OR ranging between 1.9 (95% CI: 1.1-2.2) and 5.6 (1.9-16.6). Conclusions. The best evidence available to date indicates that obesity is a risk factor for tendinopathy. Nevertheless, further studies should be performed to establish the real strength of the association for each type of tendinopathy, especially because the design of the published studies does not allow identifying a precise cause-effect relationship and the specific role of obesity independently of other metabolic conditions.
This study introduces and validates the Hip Lag Sign, a new clinical parameter to determine hip abductor damage, which appears to be one major cause for greater trochanteric pain syndrome. 26 patients who underwent standardized MRI-examination were prospectively enrolledbetween October 2009 and March 2012. A standard physical examination of the hip was performed, including the Hip Lag Sign as it is defined for the first time in this work. Hip Lag Sign results were statistically compared toMR images, to pain levels measured with the visual analogue scale and to results of the modified Harris Hip Score as a universal and well established diagnostic tool for the hip. Chi2- and Mann-Whitney-U-analysis were applied. Diagnostic accuracy was tested with 2×2-table-calculations.Kappa statistics were used to analyze inter-observer variability. A positive Hip Lag Sign is significantly associated with MRI-proven hip abductor damage (p<0.001). The Hip Lag Sign has a sensitivity of 89.47% and a specificity of 96.55%. The positive and negative predictive values are 94.44%, resp. 93.33%. Its diagnostic Odds Ratio is 239.000 (p<0.001; 95%-CI: 20.031-2827.819). The number needed to diagnose was 1.16.Inter-observer consistency was 98.1% and kappa statistics for inter-observer variability were 0.911. The Hip Lag Sign is specific and sensitive, easy and fast to perform and allows a reliable assessment on the hip abductors' status, especially when there is no access to further diagnostic devices such as MRI for example due to restricted resources like in developing countries. Thus, we recommend the inclusion of the Hip Lag Sign into everyday hip examinations, especially dealing with patients suffering from greater trochanteric pain syndrome.
Background:
Previous studies have shown improvement in patellar tendinopathy symptoms after platelet-rich plasma (PRP) injections, but no randomized controlled trial has compared PRP with dry needling (DN) for this condition.
Purpose:
To compare clinical outcomes in patellar tendinopathy after a single ultrasound-guided, leukocyte-rich PRP injection versus DN.
Study design:
Randomized controlled trial; Level of evidence, 1.
Methods:
A total of 23 patients with patellar tendinopathy on examination and MRI who had failed nonoperative treatment were enrolled and randomized to receive ultrasound-guided DN alone (DN group; n = 13) or with injection of leukocyte-rich PRP (PRP group; n = 10), along with standardized eccentric exercises. Patients and the physician providing follow-up care were blinded. Participants completed patient-reported outcome surveys before and at 3, 6, 9, 12, and ≥26 weeks after treatment during follow-up visits. The primary outcome measure was the Victorian Institute of Sports Assessment (VISA) score for patellar tendinopathy at 12 weeks, and secondary measures included the visual analog scale (VAS) for pain, Tegner activity scale, Lysholm knee scale, and Short Form (SF-12) questionnaire at 12 and ≥26 weeks. Results were analyzed using 2-tailed paired and unpaired t tests. Patients who were dissatisfied at 12 weeks were allowed to cross over into a separate unblinded arm.
Results:
At 12 weeks after treatment, VISA scores improved by a mean ± standard deviation of 5.2 ± 12.5 points (P = .20) in the DN group (n = 12) and by 25.4 ± 23.2 points (P = .01) in the PRP group (n = 9); at ≥26 weeks, the scores improved by 33.2 ± 14.0 points (P = .001) in the DN group (n = 9) and by 28.9 ± 25.2 points (P = .01) in the PRP group (n = 7). The PRP group had improved significantly more than the DN group at 12 weeks (P = .02), but the difference between groups was not significant at ≥26 weeks (P = .66). Lysholm scores were not significantly different between groups at 12 weeks (P = .81), but the DN group had improved significantly more than the PRP group at ≥26 weeks (P = .006). At 12 weeks, 3 patients in the DN group failed treatment and subsequently crossed over into the PRP group. These patients were excluded from the primary ≥26-week analysis. There were no treatment failures in the PRP group. No adverse events were reported. Recruitment was stopped because interim analysis demonstrated statistically significant and clinically important results.
Conclusion:
A therapeutic regimen of standardized eccentric exercise and ultrasound-guided leukocyte-rich PRP injection with DN accelerates the recovery from patellar tendinopathy relative to exercise and ultrasound-guided DN alone, but the apparent benefit of PRP dissipates over time.
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.
In order to investigate the functional anatomy of gluteus minimus we dissected 16 hips in fresh cadavers. The muscle originates from the external aspect of the ilium, between the anterior and inferior gluteal lines, and also at the sciatic notch from the inside of the pelvis where it protects the superior gluteal nerve and artery. It inserts anterosuperiorly into the capsule of the hip and continues to its main insertion on the greater trochanter.
Based on these anatomical findings, a model was developed using plastic bones. A study of its mechanics showed that gluteus minimus acts as a flexor, an abductor and an internal or external rotator, depending on the position of the femur and which part of the muscle is active. It follows that one of its functions is to stabilise the head of the femur in the acetabulum by tightening the capsule and applying pressure on the head. Careful preservation or reattachment of the tendon of gluteus minimus during surgery on the hip is strongly recommended.
To assess the outcomes for patients seen in a rheumatology service presenting with features of the greater trochanteric pain syndrome (GTPS) and the impact of imaging results on the outcomes of treatment.
Retrospective audit, using a phone interview was performed to establish links between results of imaging undertaken in the diagnostic work-up of patients with lateral hip pain and clinical outcomes for these patients. Patient perceptions of the effectiveness of interventions were also assessed.
Forty-five patients were included (82% female, mean age 69.6 years). Sixty-nine percent underwent radiological work-up, including plain X-rays (55%), computed tomography scans (64%), magnetic resonance imaging (48%) and ultrasound (90%). Coexistent trochanteric bursitis (TB) and gluteal tendinopathy were the most commonly elucidated pathologies accounting for the symptomatic presentation of 40% of patients. Forty-one patients underwent some form of intervention, most commonly injection of local anesthetic and corticosteroid (LACS) into the region of the TB (87%), two-thirds of which were undertaken under radiological guidance. Pain reduction was maximal following the third injection, with a significantly better response to unguided interventions and levels of symptomatic relief following the first injection being a good indicator of the probability of complete remission. Radiological demonstration of isolated TB correlated with a greater reduction in lateral hip symptoms following LACS TB injections both in the immediate post-injection phase and in the long-term.
The results of this audit suggest that the management of GTPS has reasonable patient outcomes; however, a prospective study with greater patient numbers is needed to confirm these results.
Musculoskeletal injury causes pain and when chronic can affect mental health, employment and quality of life. This study examined work participation, function and quality of life in people with greater trochanteric pain syndrome (GTPS, n=42), severe hip osteoarthritis (OA, n=20) and an asymptomatic group (ASC, n=23). No differences were found between the symptomatic groups on key measures, both were more affected than the ASC group, they had lower quality of life score (p<0.001), Harris Hip Score (p<0.001) and higher Oswestry Disability Index (p<0.001). Participants with GTPS were the least likely to be in fulltime work (prob. GTPS=0.29; OA=0.52; and ASC=0.68). GTPS appears to confer levels of disability and quality of life similar to levels associated with end stage hip OA.
The purpose of this study was to assess the surgical outcomes of endoscopically repaired full-thickness abductor tendon tears using validated outcome measures.
After institutional review board approval was obtained, clinical outcome data were retrospectively collected from patients who underwent endoscopic gluteus medius and/or minimus repair by a single surgeon between August 2009 and September 2011. With a minimum follow-up of 1 year, patients were evaluated using the modified Harris Hip Score and the validated Hip Outcome Score (HOS). The HOS questionnaire included 2 subsections: HOS-Activities of Daily Living and HOS-Sports. Physical examination data were gathered during routine clinic visits, 1 year postoperatively. Statistical analysis was descriptive. The change in strength testing postoperatively was assessed with the Wilcoxon signed rank test, with significance set at P ≤ .05.
Twelve patients were identified, 1 of whom was excluded; 10 of 11 patients (91%) completed the study requirements. The mean patient age was 65.9 years (range, 60 to 74 years), 70% were women, and the mean follow-up period was 23 months (range, 13 to 38 months). The mean postoperative scores were 84.7 (SD, 14.5) for the modified Harris Hip Score and 89.1 (SD, 11.3) for the HOS-Activities of Daily Living, with 90% patient satisfaction. All patients had clinically and statistically improved abductor tendon strength (P = .004). Patients with good to excellent outcomes were younger (P < .001). There were no complications identified.
In our small series, endoscopic abductor tendon repair was an effective surgical intervention after failed conservative management at short-term follow-up. Patients had reliably good to excellent outcomes with improved strength during hip abduction, were at low risk of complications, and were satisfied with the outcome. In addition, younger patients achieved better outcomes.
Level IV, therapeutic case series.