Greater Trochanteric Pain Syndrome

Welcome to OCS Field Guide, the podcast that helps you study smarter for the OCS exam. Hello, we're back and we appreciate everyone's patience with us over this last hiatus. Today we're going to take a look at greater trochanteric pain syndrome, which is sometimes referred to even more generally as extra-articular lateral hip pain. The orthopedic section currently does not have a clinical practice guideline for this condition, and research is relatively sparse. But this is actually a more common condition than Achilles tendinopathy, so you're certain to see it in the clinic and in some form on the exam. Fortunately, there is a brief, readable international consensus statement on greater trochanteric pain syndrome that was published earlier this year, so I'm going to pull together some information from that paper and a few others to help you out. Like most syndromes, greater trochanteric pain syndrome is not a single diagnosis. We've moved towards this label because the diagnoses that it encompasses were often misdiagnoses, and so it's better to be general until we can be fairly certain of the root cause. Additionally, the label recognizes that individuals with lateral hip pain can have several of these conditions at the same time, so it gives us a more comprehensive clinical picture. The conditions that fit under the greater trochanteric pain syndrome umbrella include external snapping hip, proximal iliotibial band syndrome, trochanteric bursitis, gluteus medius or gluteus minimus tendinopathy, and gluteus medius or gluteus minimus tearing. Most likely, the vast majority of patients you see with greater trochanteric pain syndrome arrive at your clinic with a clinical label of trochanteric bursitis. However, trochanteric bursitis is actually relatively uncommon. Studies that compare individuals with greater trochanteric pain syndrome to healthy controls find no histological differences in the trochanteric bursa. One small MRI study on individuals with greater trochanteric pain syndrome found that only 8.3% had findings consistent with trochanteric bursa distention, while about 46% had findings consistent with a gluteus medius tear, and about 63% had findings consistent with gluteus medius tendinitis. In other words, trochanteric bursitis is usually not the correct diagnosis in individuals who have lateral hip pain. Let's start by talking population and pathoanatomy. Greater trochanteric pain syndrome is most common in women in their fourth to sixth decade of life. Mechanically, we think the root cause involves some kind of overloading of the hip abductor muscles and/or compression from the iliotibial band on the greater trochanter, bursa, and gluteal tendons. These factors can then lead to the diagnoses we just mentioned, and possibly more than one at the same time. Patients with greater trochanteric pain syndrome often demonstrate hip abductor weakness, impaired frontal plane pelvic control, think like hip drop like a trindelenburg gait, hypertrophy of the tensor fascialata, and thickening of the iliotibial or IT band. Let's focus for a second on the hip abductor weakness and tensor fascialata hypertrophy. The abductor weakness could be the result of a tear or tendinopathy, and the TFL might have hypertrophy to compensate, or just general abductor weakness without a tear could have led to the same compensation. We call that the TFL attaches to the IT band, which covers the greater trochanter. If patients are using their TFL for lateral hip stability, then the IT band is being tensioned and creating additional compressive force on the greater trochanter. This compression can cause general tissue inflammation due to friction, which we call proximal IT band syndrome, or it can snap back and forth over the greater trochanter, which we call an external snapping hip, or it can irritate and inflame the trochanteric bursa, which we call trochanteric bursitis, or it can contribute to the gluteal tendinopathy, or just cause an exacerbation of tendinopathy pain due to increased pressure on the tendon. So to recap, greater trochanteric pain syndrome can be caused by gluteal tendinopathies or trochanters, or it can be caused by compression or friction from the IT band on the greater trochanter. Sometimes these are related, with the TFL trying to compensate for hip abductor weakness and thus creating more compression on the greater trochanter. Next let's talk about examination. First we will talk about diagnosing greater trochanteric pain syndrome generally, and then we will focus on the individual diagnoses that fit within that syndrome. The key symptom in greater trochanteric pain syndrome is pain at the lateral hip that is worse during single leg weight bearing and when any pressure is applied to the lateral hip. So patients will report pain with activities like walking or climbing stairs or sleeping on their side at night. Patients that apply pressure to the greater trochanter by adding tension to the IT band can cause pain as well. That includes anything that involves hip adduction past neutral, things like sleeping on the unaffected side or sitting with crossed legs. Occasionally the pain can radiate up to the buttock or down the lateral thigh. The most useful tests for greater trochanteric pain syndrome appear to be palpation at the lateral hip, resisted hip ABduction and the resisted external derotation test. Clinicians should be able to reproduce the chief complaint with palpation of the lateral or posterior aspect of the greater trochanter. Resisted hip AB abduction is likely to be painful or very weak. The external derotation test involves placing the patient's supine, flexing the hip and knee to 90 degrees, externally rotating the hip, and then having the patient attempt to internally rotate the hip against resistance. The idea is that this position causes a greater proportion of the gluteus medius to function as an internal rotator, so pain and/or weakness implicates the gluteus medius. Now let's break down the individual diagnoses and talk about some other findings you might see. As we just discussed, bursitis is probably not what's going on with your patient, but if it is, you may be able to palpate an inflamed, boggy bursa at the greater trochanter. With glute minimus or medius tendinopathy, you can expect pain or significant weakness with resisted muscle testing, and the external derotation test is very useful here. The patient may also have a positive Trindelenberg sign. It is difficult to distinguish between tendinopathy and a tendon tear through clinical examination, but generally, tears are going to present with much more dramatic weakness than tendinopathy. With IT band syndrome and snapping hip, we suspect that excess tension on the IT band is the main problem. A positive OBERS test can implicate tightness in the TFL IT band complex, and palpation might reveal the TFL hypertrophy that we mentioned earlier. The biggest difference between IT band syndrome and snapping hip is that a patient with a snapping hip will report a history of snapping of the IT band over the greater trochanter while performing some specific movement, often internal rotation or external rotation. Before we move on, I do want to briefly note that you can also have an IT band syndrome that causes lateral knee pain due to friction over the femoral epicondyle. Just recognize that that is a different IT band syndrome, although the cause might be the same. Let's move on and discuss differential diagnosis. The two main other diagnoses that can present as lateral hip pain are lumbar radiculopathy and intraarticular hip pathology, especially osteoarthritis. Rural hip pain that changes with lumbar spine motion would suggest radiculopathy, as well as myotomal weakness, dermatomal sensation changes, and diminished or absent reflexes. An intraarticular condition would be suspected with a positive scour test, a positive Faber test with a B-is-in-Bravo, which is also called Patrick's test, or a positive Phaedyr test with a D-is-in-Delta. For hip OA specifically, you're looking for age over 50 with morning stiffness and loss of hip passive range of motion, particularly hip internal rotation. If the actual problem is greater trochanteric pain syndrome, you should not see a significant loss of passive range of motion. Finally, let's talk treatment. There is an impairment-based classification system that was published in IJSPT by DeSantis and Martin in 2022 that you might want to take a look at for more detail, but I'm going to summarize the big picture from this article and a few others. In general, we're going to treat based on the patient's irritability level and based on whether the problem is contractile, i.e. gluteal tendons, or non-contractile, i.e. bursa, and inflammation. No matter what the cause is, when patients are highly irritable, we need to work on activity modification to reduce the frequency and intensity of aggravating behaviors. This means reducing the amount of time spent in single leg stance, like encouraging the patient to put on pants while sitting instead of while standing. It may also mean sleep modification to eliminate pressure on the hip or prolonged hip AD duct reduction on the affected side, so no sleeping on the affected hip and no sleeping on the unaffected hip without a pillow between the knees to prevent AD ductsion past neutral. Patients should also refrain from sitting with their legs crossed. Continuing to think about the highly irritable patient, DeSantis and Martin suggest soft tissue mobilization should be performed on the gluteal and TFL muscle bellies, but not the tendon or the greater trochanter, in order to avoid contributing to tissue irritation. This appears to be based on expert opinion, so you can judge for yourself. If the problems contractile, either gluteal tendinopathy or tears, or an over-enthusiastic TFL trying to compensate for apiduct or weakness, then the long-term goal is to strengthen the gluteus medius and minimus. During the high irritability stage, this might involve submaximal isometrics progressing towards isotonics while ensuring that the TFL is not compensating for the other abductors. As irritability decreases, these exercises can be progressed towards slow, heavy load concentric and eccentric to facilitate tendon repair. DeSantis and Martin notes that closed-chain hip abductor exercises produce more gluteus medius EMG activity than any open-chain activity except sideline abduction, so we should be progressing towards closed-chain exercises as soon as the patient is able to tolerate it. During the low irritability stage, DeSantis and Martin suggest pain-free hip abductor strengthening. At this point, I'm going to briefly pull from some other sources to give you a more complete picture. We're primarily interested in lateral hip stretching if we think the IT band is creating too much compression on the greater trochanter. This has led some to focus on IT band stretching or IT band foam rolling. Keep in mind that the IT band is non-contractile. Comps to stretch the IT band in cadaver studies have demonstrated that the proximal third, you know, the part with the tensor fascialata, which is contractile, lengthens about twice as much as the middle or distal sections of the IT band. Additionally, some have focused on foam rolling the IT band either to lengthen it or to break up adhesions between the IT band and the lateral quadriceps underneath. But a nice little study by Hall and Smith in 2018 compared foam rolling over the IT band to foam rolling over the hip abductor muscles. They found that foam rolling over the IT band only produced a 2% improvement in hip adduction passive range of motion, but foam rolling the abductors, you know, the contractile structures, produced a 15% improvement in hip adduction passive range of motion. This is a long way of saying if someone has a lateral snapping hip or lateral hip pain from IT band compression, they should be focused on targeting and foam rolling the tensor fascialata and abductors, not the middle and distal IT band. Please tell your runners. But enough about that, let's return to the matter at hand. The final component of treatment we should focus on in the low irritability stage is frontal plane control. If patients are continuing to walk with a Trindelenberg type gait, then they are continuing to repeatedly compress that lateral hip tissue. It's a good idea to try to minimize that to help them make a full recovery. This might include core strengthening and neuromuscular training in addition to ongoing hip abductor strengthening. Now if the problem is non-contractile, like trochanteric bursitis, DeSantis and Martin suggests a very similar progression. The biggest difference is that there's more of a focus on reducing tissue irritation and inflammation in the high irritability phase, so anti-inflammatory modalities like ice might be considered here. We still want to strengthen the abductors, but our goal here is to focus on strengthening them to improve frontal plane motor control, not because we think there's a tendonopathy and we're trying to stimulate tendon repair. Let's finish with a practice question. A 48-year-old female patient presents with left lateral hip pain that started bothering her on her daily hikes about a month ago. It gradually progressed until it was bothering her at night when she tried to sleep on her affected side. The pain is a 2 out of 10 in the morning, but it progresses to a 7 out of 10 during the day with any walking activities that last longer than 10 minutes. Physical examination reveals the following. Left hip passive internal rotation 28 degrees, right hip internal rotation 33 degrees, left hip passive adduction 20 degrees and painful, right hip adduction 25 degrees, local tenderness on the posterior greater trochanter, and hip abductor MMT 3 out of 5 with pain on the left and 4 out of 5 on the right. Which of the following treatments would be most appropriate for this patient at this time? 1. You should recognize that this is a greater trochanteric pain syndrome case, because even though she has some passive range of motion limitations, she is younger than is typical for OA, her range of motion is not limited enough to be OA, and her pain pattern better fits greater trochanteric pain. 2. You'll want to see if there are clues about what type of greater trochanteric pain she has. She has significant left abductor weakness with pain on MMT, so we suspect gluteus medius or minimus pathology is involved here. 3. You'll want to look for irritability. 7 out of 10 pain after 10 minutes of activity is definitely on the high irritability side of things, so we'll want to pick our treatment accordingly. The correct answer is B, submaximal hip abductor isometric exercises. Unlike many other tendinopathies where submaximal isometrics probably don't generate enough force to stimulate changes, the current recommendations for greater trochanteric pain syndrome is to start with submaximal isometrics when there is high tissue irritability. Ice is not contraindicated, but it is more appropriate if bursitis or inflammatory processes are going on. Inferior hip mobilizations are similarly not going to hurt, but they aren't going to address the main issue, and foam rolling over the IT band, as I emphasized, is not going to do much of anything for the hip. That is it for this episode. I'll post references for a couple of the studies I mentioned in the show notes if you want to read more. 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