Greater Trochanteric Pain Syndrome
1. Introduction
Greater trochanteric pain syndrome is a common condition causing pain that is most often felt around the bony prominence on the outer part of the upper thigh (1). This bony prominence, which can be palpated through the skin, is known as the greater trochanter. It serves as a useful attachment point for the gluteal muscles. These are muscles that originate around the pelvis and insert into the greater trochanter. The role of these muscles is to primarily stabilise your leg when you place weight on it, particularly during walking (3). The muscles connect to the greater trochanter via tendons. Tendons are tough, fibrous bands of tissue that are designed to withstand stress and strain. In some cases, tendons become painful with use. When this happens, we call it “tendinopathy”. Greater trochanteric pain syndrome is a tendinopathy of the gluteal muscles that are commonly seen in primary care (3, 6).
Tendinopathy occurs because of an alteration in the rate that the tendon regenerates in response to daily load (7). Our tendons undergo changes in response to stress and strain that help to keep them healthy. In some cases, the amount of stress and strain we place our tendons under can exceed their capacity to cope. After a time, the tendon can become painful and weakened when placed under stress. This results in pain with day-to-day activities such as walking, climbing stairs and sitting. It used to be felt that tendinopathy developed due to inflammation of the tendons. However, we now understand tendinopathy to be more of a failed healing response within the tendon, where it cannot manage the day-to-day stress and strain it is subjected to (8). Pleasingly, tendinopathy usually recovers well with the right treatment and advice and is not a sign of a more serious medical condition.
Frequently Asked Questions
- Greater trochanteric pain syndrome (GTPS) – also referred to as gluteal tendinopathy – is a condition affecting the tendons that insert into the upper thigh bone. It is a common cause of pain felt around the hip and pelvis.
- Common.
- Greater trochanteric pain syndrome is the cause of pain in up to 20% of adults with pain in the hip or pelvis area (1, 2).
- No.
- With the right rehabilitation approach, greater trochanteric pain syndrome generally recovers well.
- Greater trochanteric pain syndrome is not linked to any other serious medical conditions.
- Greater trochanteric pain syndrome is seen in females more than males.
- It tends to affect those over the age of 50 (3).
- Patients who have diabetes or high cholesterol may be at greater risk.
- Those who are overweight (4).
- Localised pain to the bony prominence on the outside of the upper thigh (known as the greater trochanter).
- Pain with lying on the affected side, walking or going up and downstairs.
- In the early stages, pain may be present at the beginning of exercise and then improve during activity, only to reappear when stopping.
- Patients may develop a painful limp – known as a Trendelenburg gait – due to pain originating from the tendon during the walking cycle (4,5).
- Modify or reduce your activity to manage your pain.
- Progressive and appropriate exercises to strengthen the tendon have been shown to be one of the most effective treatments.
- Advice by a qualified physiotherapist will be helpful in most cases (5, 6).
- This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
- Initial recovery is usually within 2 to 3 months and full recovery is usually within 3 to 6 months.
- In persistent or long-standing cases, some patients may require prolonged rehabilitation (6).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Pain that is felt around the outside of the upper thigh (close to the greater trochanter).
- Pain that is typically produced with activities that require repeated use of the tendon. Walking, climbing stairs and sleeping on the affected side are all commonly reported aggravating activities.
- Patients may develop a painful limp, known as a Trendelenburg gait, due to pain and weakness of the muscles when walking (3, 4).
3. Causes
Greater trochanteric pain syndrome can develop because of sudden, unexpected changes in the amount of activity the gluteal tendon(s) is/are subjected to (5,8). This may be, for example, after a walking holiday or after starting a new type of sport or activity. However, in some patients, these changes can be subtle and are not obvious. We also know now that there are certain risk factors that increase the chances of those patients who are relatively inactive developing the condition. Being overweight, diabetic or having higher cholesterol can result in tendons that are more susceptible to smaller changes in load. It is also thought hormonal influences play a role in the development of greater trochanteric pain syndrome. Therefore, it is more often seen in female patients (2,3).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing greater trochanteric pain syndrome. It does not mean everyone with these risk factors will develop symptoms.
- Gender – females are more likely to develop the condition than males.
- Being overweight – increased load on the tendons as well as known systemic effects.
- Reduced flexibility or strength – tight or weaker gluteal muscles can influence their ability to withstand stress and strain.
- Sudden changes in activity or in training intensity can result in failure of the tendon to adapt (4).
5. Prevalence
Greater trochanteric pain syndrome is responsible for up to 20% of people presenting to their doctor with pain in the hip or pelvic region. It is seen in females more than males. It is most seen in female patients who are over the age of 50 (1,2).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRIs or ultrasound scans are usually not required to achieve a working diagnosis of greater trochanteric pain syndrome, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help recover from greater trochanteric pain syndrome. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Research is very clear that modifying the load that goes through the gluteal tendons is the key element that stimulates recovery. Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body. Avoiding activities that cause compression of the gluteal tendons such as walking and squatting can help modify pain, and specific exercise can help stimulate strength and recovery of the tendon itself. Try to avoid lying directly on the affected side, as well as activities that involve crossing your affected leg over the other.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing muscular imbalances associated with greater trochanteric pain syndrome. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Greater Trochanteric Pain Syndrome
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on early, appropriate loading of the affected tendon and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows, this should not exceed any more than 3/10 on your perceived pain scale.
- 0
- 1
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- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading of the gluteal tendons and lower limb strengthening. This should not exceed any more than 3/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected tendon complex. This is often in more challenging positions that replicate day to day activities. This should not exceed any more than 3/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting, and sprinting exercises (5, 7).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Podiatry referral to address gross bio-mechanical alignment issues may be helpful in the short term. However, there is a lack of quality evidence in regard to long-term value when it comes to tendon related injuries.
Corticosteroid injections should only be considered as a last resort if appropriate and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement, careful consideration is heavily encouraged as in some cases repeated injections can exacerbate and delay the recovery in greater trochanteric pain syndrome compared to exercise and education alone (9).
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References
- Barratt PA, Brookes N, Newson A. (2017) Conservative treatments for greater trochanteric pain syndrome: a systematic review. British Journal of Sports Medicine. 51, 97–104.
- Lievense A, Bierma-Zeinstra S, Schouten B (2005) Prognosis of trochanteric pain in primary care. Br J Gen Pract 55, 199–204.
- Chowdhury, R., Naaseri, S., Lee, J. and Rajeswaran, G. (2014) Imaging and management of greater trochanteric pain syndrome. Postgraduate Medical Journal. 90, 576-581.
- Mallow, M. and Nazarian, L.N. (2014) Greater trochanteric pain syndrome diagnosis and treatment. Physical medicine and rehabilitation clinics of North America. 25, 279-289.
- Diane Reid. (2015) The management of greater trochanteric pain syndrome: a systematic review. Journal of Orthopaedics 13, 15-28.
- Speers, C. J., & Bhogal, G. S. (2017). Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. The British journal of general practice : the journal of the Royal College of General Practitioners, https://doi.org/10.3399/bjgp17X693041. 67, 479–480.
- Cook JL, Purdam C. (2012) Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 46, 163-8. 10.1136/bjsports-2011-090414.
- Cook JL, Rio E, Purdam CR (2016) Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine. 50, 1187-1191
- Mellor R, Grimaldi A, Wajswelner H, Hodges P, Abbott JH, Bennell K, 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 Musculoskelet Disord. 30;17:196. doi: 10.1186/s12891-016-1043-6. PMID: 27139495; PMCID: PMC4852446.
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