Anatomy

The greater trochanter is a large bony prominence located on the outside of the top of the femur (long thigh bone). It is a muscular attachment point for two Real Bridesgluteal muscles; gluteus minimus and gluteus medius (see image below). These muscles help to stabilise and control movements at the hip. Over the top of both muscles is the large gluteus maximus muscle, this is the only gluteal muscle that does not attach onto the greater trochanter.

Both gluteus minimus and gluteus medius originate on the crest of the hip (iliac crest) where they form the musculature of the lateral (outer) hip. Both muscles attach onto the greater trochanter via their tendon. Tendons attach the muscle to the bone.

Located between both the gluteus minimus and gluteus medius tendon and the overlying gluteus maximus muscle sit the trochanteric. Bursa are naturally occurring sacs lined in a friction reducing substance called synovial fluid. They are located throughout the body (over a 100 in total) and are designed to provide a protective cushion between adjacent structures to allow smooth, frictionless gliding during movement.

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain and pain emanating over the greater trochanter. Recent studies have shown up to 25% of the general population experience this pain (Strauss et al., 2010). GTPS is also known as trochanteric bursitis and gluteus medius tendinopathy. This reflects the differing structures that can be involved in this issue and one of the reasons it is important to have a full assessment and an ultrasound scan to identify which specific structures are effected in your presentation. The management strategies can vary significantly depending on the anatomical structure involved.

Risk factors associated with greater trochanteric pain syndrome (GTPS) have been highlighted by Mellor et al. (2016) and include:

  • Sex – women between 40 and 60 years of age have the highest incidence rate of suffering from GTPS
  • Hip weakness – particularly weakness of the gluteus minimus and gluteus medius muscles (known as the abductors), the opposite muscles (known as the adductors) and the glutus maximus muscles. Poor strength of the abdominals can also contribute to this problem. Weakness results in poor pelvic and hip control and stability, altering biomechanics and causing increased pressure on the structures surrounding the greater trochanter. This is commonly observed in runners due to sub optimal training techniques.
  • Tight hip muscles – especially your hip flexors
  • Sedentary lifestyle i.e. lack of regular exercise
  • Poor prolonged posturing – for instance, crossing legs or standing with one hip hitched
  • High Body Mass Index (BMI)/obesity
  • Direct trauma to the lateral hip

Which anatomical structures can be effected?

Symptoms associated with GTPS can be caused by pain generated from either from one of the two gluteal tendons or from the surrounding bursa.

1. Pain originating from gluteus minimus/medius tendons

If subjected to prolonged periods of increased compressive forces the gluteal tendons can become inflamed and irritated. Tendon inflammation is referred to tendinitis. Repetitive episodes of tendinitis effects tendon healing parameters resulting in a compromised, thickened tendon. This process is known as tendinopathy.

Research has revealed that gluteal tendon pathology occurs due to increased compression forces sustained by these tendons due to one or more of the above risk factors (Mellor et al., 2016). Gluteal tendinopathy is believed to be the primary cause of GTPS and has been observed in 23% of women and 8.5% of men aged between 40 and 60 years of age (Lee et al. 2016).

2. Pain originating from the bursa

The presence of greater trochanteric bursitis has been positively correlated with concomitant pathology within the hip joint such as hip osteoarthritis or femoral acetabular impingement (FAI) (Schapira et al., 1986 cited by Strauss et al., 2010). It is therefore crucial that a comprehensive assessment of the whole hip is completed when assessing for GTPS.

Under normal circumstances the bursa is able to provide effortless, friction-free movement of muscles and tendons. However, when demand increases, due to one or more of the above risk-factors the gluteal bursae can become inflamed. Bursal inflammation is referred to bursitis and is a common cause of significant musculoskeletal pain. Bursitis is often associated with a gluteal tendinopathy and was for many years believed to be the primary cause of GTPS. However, due to advances in imaging techniques such as MRI and diagnostic musculoskeletal ultrasound imaging it is now known to be less common than previously thought (Mellor et al., 2016).

How do you know if you have GTPS?

Greater trochanteric pain syndrome is typically gradual and insidious in its onset, in other words there was no obvious cause or specific incident. On occasion, the pain can start due to a fall onto the outside of the hip. Symptoms often begin as intermittent episodes of pain which typically resolve with a short period of rest. As GTPS progresses these intermittent episodes often become more frequent.

Common symptoms of GTPS include:

  • Pain over the lateral aspect of the hip located at the level of the greater trochanter.
  • Pain with prolonged periods of standing, walking or running
  • Pain with crossing legs or standing one hip hitched (for example when carrying a child on your hip)
  • Pain at night/difficulty sleeping on that side
  • Poor balance and standing on one leg often associated with pain

How do we diagnose GTPS?

A correct and accurate diagnosis is essential in informing your clinician of the most effective treatment plan for you.  A diagnosis is made using a combination of clinical tests and diagnostic imaging.

Clinical assessment of GTPS includes:

  • Direct questioning designed to reveal how, when and why your pain started
  • Muscle strength testing
  • Muscle flexibility testing
  • Hip joint range of motion
  • Functional testing including assessing your walking, running, squatting and balance

Diagnostic musculoskeletal ultrasound imaging has been proven to be an effective diagnostic tool for the evaluation of the evaluation of the gluteal tendons (Connell et al., 2003). Diagnostic musculoskeletal ultrasound produces real time, dynamic images that are capable of not only evaluating tendon structure but also inflammation and swelling associated with both tendinopathy and bursitis.

Complete has a team of highly skilled clinicians with dual qualifications in both physiotherapy and musculoskeletal sonography. During your initial assessment your clinician will be able to accurately diagnose GTPS using both clinical examination and diagnostic musculoskeletal ultrasound. If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

How do we treat GTPS?

The vast majority of patients with GTPS respond well to conservative management. Conservative management typically consists of physiotherapy treatment involving:

  • Activity modification techniques to reduce compressive load through the lateral hip
  • Progressive strengthening exercises for the gluteal muscle groups, adductor muscles and abdominals
  • Hip stretching exercises
  • Biomechanical re-education of poorly controlled movement patterns such as during a squatting motion
  • In some cases, a physiotherapist may also provide soft tissue manipulation and/or acupuncture to relieve pain and symptoms

Here are a few top tips that you may like to try yourself:

  • Be careful how you sit and stand. Crossing your legs or standing with one hip hitched can increase compression on your lateral hip structures
  • Try some Pilates exercises such as glutes bridging (see below)
  • Try not lying on your affected side at night. Place a pillow between your knees to help keep your legs aligned while sleeping
  • Avoid activities that make the pain significantly worse, but try and stay as active as possible
  • Try applying a topical anti-inflammatory gel such as Voltarol. Seek advice from a pharmacist first

What if conservative management does not work?

If you have completed a course of physiotherapy, including rehabilitative exercise, and you remain symptomatic then injection therapy may be suitable for you.

Injection therapy is clinically indicated in the following circumstances:

  • Pain is affecting your ability to complete activities of daily living including work and recreational activity
  • Pain is affecting your ability to sleep at night
  • Pain is affecting ability to complete your physiotherapy rehabilitation
  • Pain has been persistent for over 3 months

There were two clinically effective, evidence-based injection options available for the treatment of GTPS.

These techniques are corticosteroid injection and platelet rich plasma (PRP) injections. Both of these will be discussed below.

Current research promotes the use of ultrasound guidance for all musculoskeletal injections. Evidence has shown ultrasound guided injections to be significantly more accurate than landmark guided injection techniques. Increased accuracy has been shown to reduce post-injection complications and significantly reduce patient’s pain levels.  A diagnostic ultrasound machine is used to provide real-time imaging allowing accurate needle placement within the target tissue.

At Complete all injections are completed under ultrasound guidance. You do not need to be referred by a GP or bring a prescription. Our same day service includes a full clinical assessment, diagnostic ultrasound scan, medication prescription and ultrasound-guided injection. If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

Ultrasound-guided corticosteroid injection

A corticosteroid is a potent anti-inflammatory medication which is routinely used within musculoskeletal medicine and is an effective means of reducing pain associated with inflammation. Research has shown corticosteroid a clinically effective medication for significantly reducing pain associated with GTPS (Mellor et al., 2016). Corticosteroid medication is regularly combined with a short-acting local anaesthetic increasing comfort during the procedure.

Ultrasound-guided platelet rich plasma injection (PRP)

PRP injections require a small amount of blood to be taken from the vein, usually from your arm. The extracted blood is then spun at high speeds using a centrifuge machine which separates the blood molecules. Plasma molecules separated during this procedure are then reinjected, under ultrasound guidance, in and around the affected gluteal tendons. Blood plasma has been shown to have potent healing properties and is able to facilitate optimal healing within tendons (Lee et al., 2016). Once again, a short-acting local anaesthetic is used to increase comfort during this procedure.

At Complete we recommend that to gain the best results after an injection that you start a course of physiotherapy within two weeks of the injection. For more information or to book an appointment please call 020 7482 3875 or email injections@complete-physio.co.uk

References:

CONNELL, D.A., BASS, C., SYKES, C.J., YOUNG, D. and EDWARDS, E., 2003. Sonographic evaluation of gluteus medius and minimus tendinopathy. European radiology13(6), pp. 1339-1347.

LEE, J.J., HARRISON, J.R., BOACHIE-ADJEI, K., VARGAS, E. and MOLEY, P.J., 2016. Platelet-Rich Plasma Injections With Needle Tenotomy for Gluteus Medius Tendinopathy: A Registry Study With Prospective Follow-up. Orthopaedic Journal of Sports Medicine4(11), pp. 2325967116671692.

MELLOR, R., GRIMALDI, A., WAJSWELNER, H., HODGES, P., ABBOTT, J.H., BENNELL, K. and VICENZINO, B., 2016. Exercise and load modification versus corticosteroid injection versus ‘wait and see’ for persistent gluteus medius/minimus tendinopathy (the LEAP trial): A protocol for a randomised clinical trial. BMC Musculoskeletal Disorders17(1), pp. 196.

STRAUSS, E.J., NHO, S.J. and KELLY, B.T., 2010. Greater trochanteric pain syndrome. Sports Medicine and Arthroscopy Review18(2), pp. 113-119.