Hip Bursitis (Greater Trochanteric Pain Syndrome)
The term “greater trochanteric pain syndrome” (GTPS) describes a collection of overlapping conditions that cause lateral-sided hip pain, including hip bursitis, iliotibial band syndrome, and strain or tendinopathy of the hip abductor muscles. Although clinicians often focus on bursal pain generators for GTPS, studies show that hip abductor (gluteus medius) tendinopathy is a significantly more common culprit. GTPS and its associated disorders result from common biomechanical deficits and produce common complaints.
The typical hip has six bursa strategically positioned beneath tendons to reduce friction over bony prominences. Any of these bursae may become painfully inflamed. The most common and notorious site involves the greater trochanteric bursa, a superficial bursa that lies between the iliotibial band and greater trochanter. This, or any other bursal inflammation may occur in response to acute trauma, but more commonly develops from repetitive mechanical overloading.
Tensor fascia lata hypertonicity and iliotibial band tightness generate excessive lateral hip compression and are predisposing factors for greater trochanteric pain syndrome. TFL/ ITB tighteness may be secondary to hip abductor weakness, foot hyperpronation, pes planus, or leg length inequality. Approximately 1/3 of patients with GTPS demonstrate leg length discrepancies.
The hip abductors (i.e. gluteus medius and minimus) are central to GTPS as an etiologic factor and a source of ongoing symptoms. The gluteus medius serves as a primary hip abductor with innervation from the superior gluteal nerve (L4-S1). The muscle originates from the posterior surface of the iliac crest and inserts at two sites on the greater trochanter – the lateral facet and the superior posterior facet. Hip abductor weakness manifests functionally by allowing the contralateral pelvis to drop during single leg stance activities, including ambulation. This causes excessive thigh adduction and medial rotation, creating significant biomechanical disadvantages at the knee and hip, particularly increased tension of the iliotibial band and compression of the greater trochanteric bursa.
Primary symptomatic contributions to GTPS from the hip abductors include muscle trigger points, musculotendinous strains, tendinosis, tendinopathy, and tendon degeneration. Tendinosis or tendinopathy is characterized by injury, failed healing, and subsequent tendon degeneration. The process begins with collagen fiber disruption and a disorganized healing process that fails to regenerate a “normal” tendon. Failed healing is blamed on a hyperplastic but ineffective microvascular system.
More significant “strains” of the gluteus medius tendon are sometimes referred to as the “rotator cuff tears of the hip” and may be present in nearly one-fourth of the elderly population. Tears of the gluteus medius or gluteus minimus tendons progress much like rotator cuff tears- beginning as interstitial partial anterior tears and progressing to full thickness tears.
Who gets it?
Greater trochanteric pain syndrome affects a wide spectrum of patients but is most common in middle-aged to elderly adults. The condition affects both active and sedentary populations. GTPS is two to four times more common in females, affecting up to 15% of women. The condition is present bilaterally in up to one-third of GTPS patients. Twenty to thirty-five percent of patients affected with GTPS suffer with concurrent lower back pain. The chronicity of GTPS is impressive. Thirty-six percent of patients will be symptomatic at one year, and 29% have ongoing complaints after five years. Those with concurrent lower extremity osteoarthritis have nearly a five times greater risk of persistent symptoms.
Greater trochanteric pain syndrome presents as chronic, persistent pain in the lateral hip, buttock, and proximal thigh. The presence of leg numbness or pain radiating significantly beyond the knee could suggest an alternate diagnosis. Groin crease pain could indicate acetabular pathology, particularly osteoarthritis. GTPS symptoms are often provoked by sitting with the affected leg crossed, transitioning to a standing position, prolonged standing, climbing stairs, and high-impact activities, such as running. Patients may limit activity as a result of pain, and an antalgic gait is possible. Sleep disturbances are common, since lying on the affected side often provokes symptoms.
The most classic physical finding of GTPS is tenderness to palpation over the greater trochanter. Tenderness along the posterior aspect of the greater trochanter may indicate gluteus medius involvement, while discomfort at the anterior aspect may suggest a contribution from the gluteus minimus. Hypertoncity and tenderness are common in the hip adductors, psoas, tensor fascia lata, gluteal, and lumbar musculature. Clinicians should not ignore the gluteus maximus, as this muscle inserts on the ITB.
Do I need X-rays?
In many cases, radiographs are unnecessary for the initial assessment of GTPS. Surface irregularities of the greater trochanter are not reliable radiographic indicators for the diagnosis of greater trochanteric pain syndrome. Radiographs may be warranted in cases of trauma or when needed to rule out avascular necrosis, fracture, osteoarthritis, osseous FAI (Cam deformity), or other pathology. Radiographs should be performed on all patients presenting with significant loss of motion or the inability to bear weight. Children and pre-pubescents with hip pain will likely require radiographs to exclude Legg-Calve-Perthes disease and slipped capital femoral epiphysis (SCFE), respectively. Cases that are unresponsive to a trial of conservative care require further diagnostic work-up. Plain film radiographs would include AP and frog leg views. In cases where the diagnosis cannot be confirmed clinically, MRI is the current standard of imaging for GTPS and hip abductor tendon tears.
Can Chiropractic or Physical Therapy Help?
The differentiation of specific contributors to GTPS is challenging. Fortunately, most of these problems arise from common biomechanical deficits. The goal of treatment should be correct faulty mechanics and to prevent future overload. Conservative treatment of GTPS can exceed a 90% success rate. Rest, activity modification and pain relief are the first lines of defense. Patients with acute pain may need to temporarily limit or discontinue aggravating activities. Anti-inflammatory modalities could include ice, ultrasound, or electrical stimulation. Patients may apply ice or use ice massage at home. The use of counter-irritant creams may provide symptomatic relief.
How is it treated?
Stretching and myofascial release techniques may be needed for the TFL/ ITB, external hip rotators, hip flexors, gluteus maximus, quadriceps, and hip abductors. Performing deep soft tissue massage and myofascial release prior to stretching may improve treatment outcomes. The addition of IASTM may stimulate remodeling of the gluteus medius and gluteus minimus tendons. A specific emphasis should be placed on strengthening the hip abductors and external rotators. Patients should be taught proper squatting and hip hinge techniques to limit hip internal rotation. While isolated hip stretching and strengthening exercises may be necessary to improve mobility and strength, those exercises and their associated gains do not necessarily translate to improved functional movement patterns. For lasting improvement, patients must be subsequently taught to ‘groove” new movement patterns, via activity-specific exercises.
A successful treatment program must address the entire mechanical chain. Arch supports or custom foot orthotics may be necessary to correct excessive foot pronation. Clinicians should assess for and correct joint restrictions in the lumbar spine, hip, and pelvis. After correction of functional leg length inequalities, a heel lift may be required to correct for any residual structural deficits.
The medical co-management of GTPS includes NSAIDs and the injection of local anesthetics or corticosteroids. Some research, including at least one randomized control clinical trial has shown benefit for combined corticosteroid and lidocaine injections.