Version May 2024
INTRODUCTION — Greater trochanteric pain syndrome (GTPS) is one of the most common causes of lateral hip pain in adults. In most instances, GTPS is due to a gluteus medius or gluteus minimus tendinopathy, with variable involvement of the regional bursae.
Historically, the term "trochanteric bursitis" was used to describe any pain around the lateral hip. However, advanced imaging and histopathologic studies have shown that involvement of the trochanteric bursae in patients with lateral hip pain is uncommon and, when present, exists as a secondary or associated finding. Thus, trochanteric bursitis is a misnomer when it used to describe all causes of lateral hip pain. In fact, primary trochanteric bursitis is very rare and is typically of microbial etiology.
The clinical presentation, diagnosis, differential diagnosis, and management of GTPS are reviewed here. An overview of the musculoskeletal examination of the hip and groin is presented separately. (See "Musculoskeletal examination of the hip and groin".)
BACKGROUND
Epidemiology — Greater trochanteric pain syndrome (GTPS) is common. The best estimates of prevalence are from a large, community-based study with over 3000 adults aged 50 to 70 years, in which unilateral GTPS was present in 15 percent of females and 6.6 percent of males [1]. Bilateral GTPS was reported in 8.5 and 1.9 percent of females and males, respectively. The usual age at presentation is over 50 years, and the female-to-male ratio is approximately 4:1.
Risk factors — Risk factors for GTPS include female sex, obesity, knee pain, and low back pain [2]. Other conditions associated with GTPS include scoliosis; other spinal disorders, especially lumbar spinal stenosis; a leg length discrepancy; arthritis (of any etiology) of the hip, knee, and foot; and painful foot disorders such as plantar fasciitis, Achilles tendinopathy, bunion, Morton neuroma, or callus.
Etiopathogenesis — GTPS is a repetitive overload tendinopathy of the gluteus medius and minimus muscles, which play a primary role in hip abduction and pelvic stabilization in walking, stair climbing, running, and standing on one leg [3]. The high rate of tendinopathy, partial tendon rupture, and entheseal damage, plus the risk factors described above (see 'Risk factors' above), all suggest that mechanically induced tissue failure is a key feature of GTPS.
The pathogenetic role of regional bursae in GTPS has been a matter of debate. One study attempted to clarify the role of bursa versus tendon pathology in patients with GTPS by comparing biopsies of tendon and bursa from 34 patients undergoing surgery for refractory GTPS with those of 29 controls undergoing total hip replacement [4]. A higher concentration of substance P was found in trochanteric bursa, but not in tendon, of patients with GTPS compared with tendon and bursa tissue in controls. However, it is not known whether these findings apply to the more common, milder forms of GTPS.
Relevant anatomy — The greater trochanter and peritrochanteric tissues have been viewed as analogous to the greater tubercle of the humerus and rotator cuff tendons of the shoulder. Similar to rotator cuff tendinopathy in the shoulder, GTPS is a derangement of the hip abductor and rotator muscle-tendon complex. The gluteus medius and minimus muscles are located deep to the gluteus maximus, part of which courses broadly from the posterior ilium and sacrum, over the trochanteric bursa, and inserts on the iliotibial band (with the other portion of the gluteus maximus traversing inferiorly to the gluteal tuberosity of the posterior femur) (figure 1). Another similarity to rotator cuff tendinopathy is that asymptomatic gluteal tendinopathy, with or without partial rupture, frequently occurs in older adults [5]. (See "Rotator cuff tendinopathy".)
Magnetic resonance imaging (MRI) shows that GTPS ranges broadly in severity and can include manifesting as edema at the enthesis, tendinopathy, partial and complete tendon rupture, muscle atrophy and fat replacement, or avulsion [3,5-7]. Tears of gluteus medius and minimus result in compensatory tensor fascia lata hypertrophy, as this muscle takes a greater share of the abductor load [8].
The iliotibial tract is a reinforcement of the deep fascia that extends from the iliac crest to the lateral tibial (Gerdy) tubercle (figure 2) [9]. Near its origin, the iliotibial tract is tightly apposed to the greater trochanter, and contracture of the iliotibial tract may contribute to GTPS by compressing the enthesis of the gluteus medius and gluteus minimus muscles. Several bursae present in the trochanteric region may react to tendon damage [10-12]. The trochanteric bursae (figure 3) and a more distal gluteofemoral bursa lie beneath the iliotibial tract and gluteus maximus, over the greater trochanter. The gluteus medius and gluteus minimus bursae lie between these tendons and the greater trochanter. More detailed information on the anatomy and biomechanics of the hip can be found elsewhere. (See "Musculoskeletal examination of the hip and groin", section on 'Anatomy and biomechanics'.)
DIAGNOSTIC EVALUATION — There are no established diagnostic criteria for greater trochanteric pain syndrome (GTPS). We diagnose GTPS in patients with the following symptoms and signs, regardless of the presence of another condition that could explain the trochanteric pain:
●Presence of lateral hip pain
●Local tenderness to palpation of the greater trochanter, most marked at its superoposterior facet (posterior corner)
Clinical presentation — The key complaint in patients with GTPS is lateral hip pain near the greater trochanter. Pain increases with ambulation, prolonged standing, rising from a chair, climbing stairs, ascending inclines, and with direct pressure when lying on the painful side. Patients often note that they awaken at night when rolling onto the affected side.
The most useful part of the clinical assessment when evaluating patients with hip pain is to ask patients to "point to where the pain is." Patients with GTPS and its rare mimickers point to the lateral hip, whereas patients with subgluteal or retrotrochanteric pathology point to the posterior hip, and those with articular hip disease point to the groin and the anteromedial thigh.
In the author's experience, GTPS can also result in fatigue and general malaise when it interferes with sleep, which further exacerbates the pain. GTPS has been shown to negatively impact quality of life in a small study of 42 patients with GTPS, with a detrimental effect similar to that of 20 patients with end-stage hip osteoarthritis [13].
There may be a contributory role of psychological factors in the severity of GTPS. In a cross-sectional cohort of 204 patients with GTPS, more severe tendinopathy was associated with higher pain catastrophizing, poorer quality of life, and a higher body mass index (BMI) and waist girth [14]. A possible contribution of psychological factors should be considered in patients with severe disease.
Physical examination — The physical examination of patients with lateral hip pain should include attention to the following:
●Observation of how the patient walks into the room, sits, rises from the chair, and removes shoes and socks. As examples:
•An antalgic limp and an inability to handle shoes and socks suggest hip joint disease rather than GTPS, although both conditions may coexist.
•A waddling gait, known as Trendelenburg gait, in which the body shifts to the affected side during the stance phase of gait, may be observed in both hip joint disease and GTPS. A positive Trendelenburg test may also be positive in both conditions (figure 4).
●Tenderness to palpation of the greater trochanter is the key physical examination finding of GTPS. With the patient lying on his or her unaffected side, the examiner palpates the greater trochanter and the peritrochanteric region. In patients with GTPS, there is typically direct tenderness to palpation over the greater trochanter. Tenderness is maximal in the superoposterior facet, or posterior corner, of the greater trochanter. This site corresponds to one of the insertions of the gluteus medius, with the other being on the lateral facet (figure 5). A tissue bulge is not a feature of GTPS and is a red flag that should be evaluated with an ultrasound (US) or MRI.
●Identification of comorbidities that may have contributed to, or caused, GTPS. These include obesity; scoliosis; lumbar spinal stenosis; reduced and painful lumbar spine motion; a leg length discrepancy; arthritis of the hip, knee, and foot; and other painful foot disorders such as plantar fasciitis, Achilles tendinopathy, a bunion, Morton neuroma, or a callus. (See 'Risk factors' above and 'Specific maneuvers' below.)
Specific maneuvers — In many instances, patients with GTPS also present with additional symptoms such as pain in the groin or radiating down the thigh, which can make the diagnosis more difficult. Thus, additional maneuvers are sometimes needed to confirm the presence of GTPS and to distinguish it from concomitant conditions or its mimickers. (See 'Differential diagnosis' below.)
When performing specific maneuvers to evaluate the hip, there are two key principles that help distinguish muscle-tendon pain from joint pain:
•Pain associated with muscle-tendon unit pathology is elicited by active and, in particular, resisted motion or by stretching.
•Pain associated with joint pathology is usually elicited by passive motion, which is often restricted.
Several maneuvers that help confirm the presence of a gluteus medius or minimus tendinopathy from GTPS are presented below, each of which has varying sensitivities and specificities [2,3,6,15-17]:
●Tenderness to palpation of the greater trochanter – The patient is asked to lie on the unaffected side, and the area around the greater trochanter is palpated.
●Assessing the range of motion of the hip – Isolated GTPS, in the absence of joint pathology, should cause little if any restriction in the passive range of motion of the hip when examined by the clinician. Although patients with isolated GTPS will frequently report focal pain at the trochanteric region during passive range of motion testing, reassurance from the examiner frequently permits full passive range of motion. Restriction in passive hip range of motion in an otherwise well patient (as most patients with GTPS are) indicates the presence of one or more additional hip processes besides just GTPS, including but not limited to osteoarthritis; early inflammatory arthritis (rheumatoid arthritis, spondyloarthritis, and others); dysplasia; impingement; fracture; labral tear; or avascular necrosis. (See 'Differential diagnosis' below.)
●Standing on one leg for 30 seconds – The patient is asked to stand on the painful leg for 30 seconds. Trochanteric pain during this period indicates gluteus medius tendinopathy.
●The resisted external derotation test – With the patient supine, the hip and knee on the affected side are both flexed 90 degrees, and then the hip is externally rotated. From this position, the patient is asked to rotate the thigh back to a neutral position while the examiner opposes this motion (picture 1). Trochanteric pain during resisted "derotation" of the externally rotated thigh (or resisted internal rotation of the hip) indicates a gluteus medius/minimus tendinopathy in patients with GTPS.
●Passive adduction with resisted abduction – The patient lies diagonally on the examining table on the unaffected side. The extended upper leg is adducted (descended) and then the patient is asked to push the leg up while the examiner opposes the motion (figure 6).
●The FABER test – The FABER (flexion-abduction-external rotation) test, or Patrick test, may elicit lateral hip pain in patients with GTPS by stretching the portion of the gluteus medius/minimus that rotates the hip medially. With the patient supine, the examiner lifts the knee on the affected side (hip flexion), places the heel next to the opposite knee, and lets the knee fall to the side (picture 2).
The FABER test is used in various conditions and is only useful when the patient is first asked to "point to where the pain is" and the FABER test reproduces the pain. Pain in the lateral hip supports GTPS, pain in the groin suggests hip joint disease, and pain in the buttock suggests sacroiliac joint disease. (See "Musculoskeletal examination of the hip and groin", section on 'Tests for lateral hip pain'.)
In a systematic review examining the accuracy of physical examination maneuvers in diagnosing GTPS, the combination of palpation over the greater trochanter at the gluteal tendon insertions, along with resisted hip abduction, substantially shifted the pre- and post-test probability of GTPS for patients reporting lateral hip pain [18]. Specifically, absence of pain with both maneuvers decreased the post-test probability of GTPS from 59 to 14 percent, while presence of pain with both maneuvers increased the post-test probability from 59 to 96 percent.
An additional maneuver that can help identify leg length inequality, which may be contributing to GTPS and can be addressed in patients with persistent symptoms, is described below:
●Leg length measurement – There is general agreement that gross leg length inequality may contribute to GTPS. However, there is little evidence on the magnitude or proportion of the leg inequality that should be corrected [19]. The author uses a step-wise correction of 50 percent of a 2 cm difference or greater. Leg length discrepancy can be evaluated by standing behind the patient, placing the hands over the iliac crests, and estimating if they are level. This is the author's preferred method of leg length measurement. Another approach is to use measuring tape held with one hand on the anterior superior iliac spine (ASIS) and the other hand on the tip of the medial malleolus. The tape measurement method is relatively accurate in measuring leg length discrepancy and shows excellent agreement when compared with computed tomography (CT) scans of the lower limbs [20]. Radiography is the gold standard for measurement but is usually unnecessary. Full-limb radiographs are accurate and cause little radiation exposure.
Imaging — In a patient with nontraumatic lateral hip pain, imaging studies are rarely informative and often not necessary as part of the initial evaluation, especially if the history and physical examination suggest the presence of an isolated GTPS (see 'Clinical presentation' above and 'Physical examination' above). An exception is acute calcific tendinitis, which should be suspected when the lateral hip pain is extreme and relentless. The presence of an amorphous calcium deposit on plain radiographs is diagnostic of the condition and has specific therapeutic implications. Also, if the clinical assessment raises concern of a second pathologic process, such as restricted passive range of motion of the hip from articular pathology, or if a patient is refractory to initial management strategies (see 'Treatment' below), then additional imaging is often indicated. Preferred initial imaging modalities include plain film radiography of the hip and (if available) office-based US. MRI should be reserved for specific situations, such as when the probability of partial or complete muscle rupture is high based on the results of clinical testing or when a tumor is suspected.
Conventional radiography — An anteroposterior view of the pelvis may be informative for patients with GTPS if the clinical assessment suggests articular hip pathology. Radiographs can assess for concurrent hip osteoarthritis, lesions that lead to femoroacetabular impingement (FAI), osteonecrosis, or a femoral neck fracture. Radiography may also identify the presence of an amorphous deposit of calcium salts in the vicinity of the greater trochanter, which can be seen in patients with symptoms of acute calcific tendinitis (see 'Differential diagnosis' below). In GTPS, contour irregularities larger than 2 mm in the superolateral greater trochanter are associated with abductor tendon abnormalities by MRI, including peritendinous edema of gluteus medius [21].
Ultrasonography — If available, an office-based US can be performed in patients with GTPS. US can identify the culprit tendon lesion as well as distended bursae. As an example, a retrospective review of US examinations in 877 GTPS patients revealed gluteus medius tendinosis in 236 patients, gluteus minimus tendinosis in 143 patients, and tendinosis of both muscles in 59 patients [22]. Thickening of the iliotibial band was noted in 250 patients with GTPS. Trochanteric bursitis and gluteus minimus bursitis was observed in 177 and 3 patients, respectively. Presently, however, data are insufficient to advise that all patients with GTPS undergo routine US assessment, since it is not clear that identification of a specific culprit tendon lesions changes management decisions or outcomes. The role of US in detecting mimicking lesions and guiding procedures is addressed later. (See 'Differential diagnosis' below and 'Oral NSAIDs or glucocorticoid injection' below.)
Instructional videos demonstrating proper performance of the US examination of the hip and related pathology can be found at the website of the American Medical Society for Sports Medicine: sports US hip pathology. Registration must be completed to access these videos, but no fee is required.
Magnetic resonance imaging — MRI provides the greatest detail of underlying pathology in GTPS, including tendinosis, partial and complete tendon rupture, muscle atrophy, fat replacement, enthesopathies, and bursal effusions. Increased signal intensity in T2-weighted images indicates gluteal tendinosis and reveals partial or complete tendon tears (image 1) [7].
MRI is essential in refractory GTPS cases prior to surgery, to further define solid or cystic lesions around the greater trochanter found by US, and in the diagnosis of osteomyelitis, metastatic or primary tumors, fractures, and osteoid osteomas. (See "Imaging techniques for evaluation of the painful joint".)
DIFFERENTIAL DIAGNOSIS — A variety of other conditions that can result in lateral hip pain are described below [23].
●Hip joint disease – Hip joint disease, such as hip osteoarthritis, typically results in anteromedial thigh and groin pain, but may radiate laterally and simulate greater trochanteric pain syndrome (GTPS). Hip joint disease and GTPS may also coexist. One way to distinguish GTPS from hip joint disease is to bring the hip passively through flexion, internal rotation, and external rotation with the hip flexed 90 degrees. Restriction of motion and endpoint pain would suggest hip joint disease. The FABER (flexion-abduction-external rotation) test (picture 2) would be positive in both conditions; however, in GTPS, the pain would be lateral and, in hip disease, inguinal or inguinofemoral. In such a patient, a diagnosis of GTPS is reinforced by palpation and the response to a trochanteric anesthetic blockade. Identifying GTPS in a patient with hip osteoarthritis is not inconsequential and may help with pain management. (See "Clinical manifestations and diagnosis of osteoarthritis", section on 'Hip'.)
●Fibromyalgia – Patients with fibromyalgia may have an unrelated GTPS. This may be suspected when the lateral hip tenderness is disproportionately intense on one side. GTPS may be detected by the "standing on one leg for 30 seconds" maneuver and the resisted external derotation test, which lead the patient's attention away from the greater trochanter (see 'Specific maneuvers' above). These should be performed bilaterally without asking leading questions. A small study showed that pain sensitization is frequent in GTPS, as it was present in 8 of 18 patients, and none of 18 matched healthy controls [24]. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)
●Calcific tendinitis of the gluteus medius and/or gluteus minimus tendons – Amorphous hydroxyapatite deposits may cause acute inflammation near tendon insertions. This condition, which tends to resolve spontaneously, occurs most often in the supraspinatus and infraspinatus tendons but may occur at other sites such as the gluteus medius or minimus tendons [25,26]. The intensity of inflammation may be extreme, similar to urate gout. Plain radiographs are usually diagnostic, showing small, fluffy calcium deposits adjacent to otherwise normal tendons. Large, obstructive calcium masses may be effectively treated with US-guided lavage and local glucocorticoid [26,27]. (See "Basic calcium phosphate (BCP) crystal-associated calcific periarthritis (tendinopathy)".)
●Femoroacetabular impingement – Femoroacetabular impingement (FAI) is a condition of young to middle-aged individuals, in which an abnormally shaped femoral head and neck junction and/or acetabulum create impingement during anterior hip flexion [28,29]. Pain is felt in the groin or proximal to the greater trochanter. Distinguishing features of FAI include limited flexion or internal rotation of the hip and groin pain when the hip is flexed 90 degrees, adducted, and internally rotated (FADDIR test) (picture 3). Other hip maneuvers are often normal in patients with FAI. (See "Imaging evaluation of the painful hip in adults", section on 'Femoroacetabular impingement' and "Musculoskeletal examination of the hip and groin", section on 'Tests for acetabular pathology'.)
●Septic and tuberculous trochanteric bursitis – Swelling and tenderness at the greater trochanter, particularly when there has been a puncture wound or the patient is immunocompromised, should raise suspicion of a microbial trochanteric bursitis. These cases are entirely different from routine cases of GTPS, where no swelling, portal of entry of infection, or predisposing conditions are present. If there is a clinical suspicion of septic trochanteric bursitis and a fluid collection is observed on ultrasound (US) or MRI, the lesion should be incised and drained, and antibiotics promptly started (see "Septic bursitis"). Cases of tuberculous trochanteric bursitis have also been reported and should at least be considered in the appropriate clinical context of patients at risk for extrapulmonary tuberculosis [30-32]. In a review of cases of tuberculous trochanteric bursitis, 27 of 28 patients had an erosion of the greater trochanter [31]. Thus, concurrent trochanteric osteomyelitis is consistent with a tuberculous etiology of trochanteric bursitis. (See "Clinical manifestations, diagnosis, and treatment of miliary tuberculosis".)
●Snapping hip syndrome – Another cause of lateral hip pain is the coxa saltans or "snapping hip." Snapping hip is caused by the iliotibial tract sliding forward over the greater trochanter during hip flexion (external snapping hip syndrome) or from the sliding of the iliopsoas tendon over the iliopectineal eminence or the femoral head (internal snapping hip syndrome). Intraarticular snapping can also occur from pathology within the hip joint. Patients may seek medical attention due to the snapping or the trochanteric pain, and if the snapping is not mentioned by the patient, the condition may be diagnosed as GTPS (see "Imaging evaluation of the painful hip in adults", section on 'Snapping hip syndrome'). Office-based US is a useful imaging modality for this condition, since the snapping hip can be visualized with dynamic imaging techniques [33].
●A mass lesion in the peritrochanteric region – Any firm bulge in the peritrochanteric region should raise the suspicion of a soft tissue sarcoma, as the root of a limb is a prime site for these lesions. Further evaluation of these patients should be guided by a surgical oncologist. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma".)
●Piriformis syndrome and other subgluteal or retrotrochanteric conditions – In piriformis syndrome, the sciatic nerve is compressed beneath, or across, the piriformis muscle. Other causes of nerve compression in the subgluteal space include the superior gemellus, obturator internus, and inferior gemellus muscles, as well as a narrow ischiofemoral space (figure 7) [34,35]. These conditions feature buttock pain, an inability to sit on the painful buttock, tingling, and numbness, plus pain shooting down the posterior thigh and into the leg. In the ischiofemoral syndrome, pain on walking is relieved by short steps and keeping the legs wide apart. Pain is reproduced by hip extension, adduction, and external rotation. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Compression/trauma in the sciatic notch/gluteal region'.)
●Iliolumbar ligament strain – Iliolumbar ligament strain is a pain syndrome that may involve the trochanteric region and occurs with stretching a damaged iliolumbar ligament. Pain is reproduced when the trunk is bent to the contralateral side.
●Lumbar deep somatic pain radiation – Lumbar pain, regardless of etiology, may radiate to the buttock, posterior thigh, and sometimes leg without reaching the foot. Clinical tests to determine the origin of the lumbar pain, whether of the intervertebral discs, the facet joints, or the lumbar musculature, are not reliable [36]. Trochanteric pain and tenderness is a frequent association in these patients. Nonspecific lumbar pain (ie, without a specific demonstrable etiology) is also frequently associated with pain and tenderness in the trochanteric region. In a study including 150 patients with chronic nonspecific low back pain, the gluteus medius was weaker and more tender in patients with low-back pain compared with controls [37]. A trochanteric infiltration with a mixture of a local anesthetic and a depo-glucocorticoid may be useful to determine the contribution of GTPS to the overall symptomatology in these patients. (See "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis".)
Conversely, pain from GTPS may be erroneously attributed to the lumbar spine. This was demonstrated by a study in which 20 percent of 247 patients referred for evaluation to a spine center had GTPS [38]. Several of these patients, who were predominantly females, had undergone failed spinal surgery. Because lumbar spine disorders and GTPS frequently coexist, the clinical question is less often "which of these is the source of pain?" and more often "which of these pain sources accounts for the majority of the patient's symptoms and disability?"
●Sacroiliac disease – In sacroiliitis, the pain radiates to the buttock, posterior thigh, and trochanteric region. However, it may be distinguished from GTPS in that sacroiliac pain is typically nocturnal and improves slowly (in 30 or more minutes) upon arising. Sacroiliitis may also occasionally cause sciatica, which may alternate sides [39]. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'History'.)
●Pseudosciatica – The use of this term varies among clinicians. For some, pseudosciatica implies a dull, deeply felt, poorly localized pain that radiates down the lower extremity in a nondermatomal distribution. This deep somatic pain occurs in iliolumbar ligament strain, facet joint osteoarthritis, spondylolisthesis, sacroiliitis, and GTPS. In GTPS, pain extends straight down in the lateral thigh and leg (following the iliotibial tract), whereas in other conditions it is felt posteriorly in the lower lumbar region, buttock, trochanteric region, and back of thigh. For other clinicians, pseudosciatica follows the characteristic sciatic nerve distribution, although paresthesiae and areflexia are thought to be rare [40]. An overstuffed wallet may also cause this syndrome [41]. (See "Imaging evaluation of the painful hip in adults", section on 'Nerve entrapment syndromes'.)
●Herpes zoster – Herpes zoster in the L3-5 dermatomes may superficially resemble GTPS. Thus, the pre-rash stage of herpes zoster should be considered in the patient describing a segmental burning pain in the region of the greater trochanter. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Clinical manifestations'.)
●Neuropathies that cause trochanteric or inguinal pain – The subcostal nerve (T12) runs beneath the 12th rib and in severe scoliosis, may be entrapped between rib and pelvic rim. Because a lateral branch of this nerve innervates the skin in the lateral hip, confusion with GTPS may arise. The iliohypogastric nerve (L1), which may be damaged by lower abdomen incisions and laparoscopy, also has a cutaneous branch that reaches the lateral hip and may therefore lead to the same confusion [42]. Damage to the ilioinguinal (L1) and genitofemoral (L1-2) nerves causes inguinal pain that may superficially resemble hip disease. Finally, the lateral femorocutaneous nerve (L2-3) exits the pelvis medial to the anterior superior iliac spine (ASIS) on its way to the skin in the anterolateral thigh. This nerve is frequently compressed by a heavy, tense, and prominent abdomen, such as in ascites and pregnancy [43], as well as by external pressure such as that caused by tight-fitting waistbands or belts. This common neuropathy, known as meralgia paresthetica, has led to confusion with GTPS. These various neuropathies manifest burning pain, paresthesias, and hypesthesia. (See "Overview of lower extremity peripheral nerve syndromes".)
●Stress fracture of the femoral neck – A stress fracture of the femoral neck may manifest as lateral hip pain. This condition should be suspected in runners whose pain consistently occurs before the end of a run. (See "Overview of stress fractures" and "Running injuries of the lower extremities: Patient evaluation and common conditions", section on 'Femoral neck stress fracture'.)
●Osteonecrosis of the femoral head – The greater trochanter may be a site of referred pain in patients with osteonecrosis of the femoral head. (See "Treatment of nontraumatic hip osteonecrosis (avascular necrosis of the femoral head) in adults".)
●Morel-Lavallée lesion – A localized swelling caused by a shear force detaching the superficial tissues (skin plus subcutaneous fat) from the underlying fibrous fascia is known as the Morel-Lavallée lesion [44]. The hip and proximal thigh are the most common sites for this type of trauma. (See "Severe lower extremity injury in the adult patient", section on 'Soft tissue and bone assessment'.)
TREATMENT — Greater trochanteric pain syndrome (GTPS) is a self-limited condition in the majority of patients. Therefore, the goal of treatment is to relieve symptoms and prevent disability (algorithm 1) [45]. In the author's experience, most patients improve within a few months, though in some patients the symptoms can last one or two years.
Initial management — Initial therapy for patients with GTPS includes a combination of exercise and activity modification, pain relief with either oral nonsteroidal antiinflammatory drugs (NSAIDs) or a glucocorticoid injection, and treatment of associated comorbidities (algorithm 1).
Exercise and activity modification — For all patients with GTPS, we suggest referral to physical therapy for patients to be taught exercise and activity modification. Exercises usually involve isometric loading of gluteus medius, gluteus minimus, and quadriceps muscles as well as calf strengthening exercises [46-48]. Patients should also be instructed to avoid activities that may cause further tendon damage and take precautions to decrease the load on the affected tendons.
Activity modifications that can be incorporated into activities of daily living, recreation, and sports to relieve stress on the gluteus medius and gluteus minimus tendons include the following [47]:
●Minimize stair climbing, walking up hills
●Avoid hip adduction across the midline
●Sit with hips positioned higher than knees; avoid crossing legs while sitting
●Stand with equal weightbearing through lower limbs
●Avoid side-lying to reduce compressive tendon load
These activities can be reintroduced gradually once the symptoms of GTPS abate. Although various combinations of supportive therapies related to exercise and activity modification described above are frequently used to treat GTPS, the efficacy for any of these interventions is based on limited data [45]. The only trial to evaluate the use of exercise included 204 patients with gluteal tendinopathy who were randomized to receive either an eight-week education plus exercise program, a single glucocorticoid injection, or no treatment at all [48]. At eight weeks, the success rate on a global improvement scale was highest for the education plus exercise group (77.3 percent) compared with that of the glucocorticoid injection (58.5 percent) and the no treatment (29.4 percent) groups. Pain reduction followed the same pattern as global improvement across the three groups. At 52 weeks, the education plus exercise program was still better than the glucocorticoid injection group in terms of global improvement, but there was no longer a difference in pain reduction between these two groups. The exercises used in this study represent a paradigm change from the traditionally prescribed stretching of the iliotibial tract. By strengthening the abductor muscles and controlling adduction, the greater trochanter no longer acts as a fulcrum for the iliotibial tract and compression on the gluteal muscles entheses is avoided. An example of these exercises is shown in the figures (figure 8 and picture 4).
Oral NSAIDs or glucocorticoid injection — For patients with GTPS who are in acute discomfort and their rest is disturbed by night pain, we suggest initial treatment with nonsteroidal antiinflammatory drugs (NSAIDs). A local glucocorticoid injection is a reasonable alternative for the patient who wants a rapid response. There is no high-quality evidence that one of these interventions is better than the other, and in our experience, they both appear to be helpful in the short term.
Patients who opt to take NSAIDs should be informed of the potential cardiovascular, gastrointestinal, and other major risks of both nonselective NSAIDs and selective cyclooxygenase-2 (COX-2) inhibitors. In order to minimize toxicity, intermittent short- to mid-term use as required, in the minimal dose necessary to control symptoms, should be preferred over long-term fixed doses. The choice of NSAID is based upon a variety of factors including adverse effect profile, patient comorbidities, cost to the patient, and patient preference regarding frequency of administration. Examples of reasonable options include naproxen, meloxicam, diclofenac, or ibuprofen. (See "Management of moderate to severe knee osteoarthritis", section on 'Choice and use of oral NSAID' and "Management of moderate to severe knee osteoarthritis", section on 'Adverse effects of oral NSAIDs'.)
The efficacy of NSAIDs for GTPS has not been evaluated in clinical trials, and their efficacy for GTPS is largely based on their beneficial analgesic effects when used for other musculoskeletal indications. There are no trials that directly compare the use of NSAIDs with a local glucocorticoid injection. Possible indirect evidence comparing the two interventions comes from a trial in which 120 patients with GTPS were randomized to a local glucocorticoid injection or usual care with analgesics (which were not defined in the study) [49]. At three months follow-up, 55 percent of the patients in the injection group had recovered compared with 34 percent in the usual care group (who were given analgesics only). However, at the 12-month follow-up, the differences between the two groups were no longer present, and approximately 60 percent of GTPS patients in each group had recovered. Another trial that demonstrated the short-term beneficial effects of glucocorticoid injections included 204 patients with gluteal tendinopathy and randomized patients to one of three groups that consisted of education plus exercise, a single glucocorticoid injection, or no treatment [48]. Patients in the education plus exercise as well as the glucocorticoid injection groups had better global improvement and pain scores at eight weeks when compared with no treatment [48]. However, at 52 weeks, the effects of the glucocorticoid injection were not sustained, and measures of global improvement and pain were similar to those who did not receive treatment.
Our approach to the injection without ultrasound (US) guidance is as follows: The dose of glucocorticoid is usually made up of a standard large-joint dose of 40 mg of methylprednisolone acetate or equivalent mixed with 5 mL of 1 percent lidocaine. With the patient lying on the unaffected side, the greater trochanter is identified by proximal palpation along the femur. The point of maximal tenderness is usually on the posterior corner, which corresponds to the superoposterior facet of the greater trochanter. A 22- or 25-gauge, 1.5-inch needle is inserted vertically to periosteal contact (picture 5). This site must be clearly identified before going ahead with the injection. The mixture of glucocorticoid with lidocaine is infiltrated radially to cover the base of a cone 2.5 cm in diameter, half on bone and half in the proximal soft tissues. When performing this radial deposition of the mixture, care should be taken not to sweep the needle through the tissues but rather to probe and re-probe with the needle in a radial distribution, taking care not to withdraw the needle completely out of the skin. Although bleeding or infection are extremely rare complications of this procedure (likely less than 1 in 10,000), patients should be instructed to report any swelling and tenderness developing at the site of infiltration. Although US guidance can be used when performing a local glucocorticoid injection for GTPS, in many circumstances it is not available. In addition, although there might be some marginal improvement in efficacy of US guidance compared with anatomy guidance for injections, the measured benefit for most patients is minimal or short lived and does not necessarily justify the increased time and cost of a US-guided procedure. As such, traditional anatomy-guided injections are still considered to be effective for most patients, and this approach is cost effective when compared with US-guided injections, at least in the initial injection management of most patients with GTPS [50,51]. There are little to no data about the comparison of anatomy- versus US-guided injections in patients who have GTPS that is refractory to the initial glucocorticoid injection. For these patients, US guidance may play a more important role.
Management of associated comorbidities — When possible, patients with comorbidities known to be associated with GTPS should receive additional management to address the specific condition. As examples, a patient with low back pain should engage in back strengthening exercises; a patient with a 1 cm or greater leg length discrepancy may benefit from a 50 percent correction with the use of an insole or heel lift; patients who are overweight or obese should participate in a weight reduction program. Aerobic conditioning is also generally beneficial for patients. This comprehensive approach may not only improve the GTPS but, in our experience, also helps with general wellness in the patient once pain is relieved.
Few studies have evaluated the effects of a specific intervention for any of the associated comorbidities. There is only one small observational study with significant methodologic limitations that found that the use of customized orthotics resulted in a higher rate of improvement compared with glucocorticoid injection alone [52].
Persistent symptoms
Reevaluate disease severity — In patients whose symptoms do not improve within two to three months, we confirm adherence to the initial management measures described above (eg, exercise and activity modification, management of associated comorbidities). The patient should also be reexamined with attention to physical findings suggestive of injury to the gluteus medius tendon. Specifically, maneuvers such as 30-second single leg standing or the resisted external derotation test may reveal findings suggestive of tendon injury. A Trendelenburg gait (leaning to the painful side in the support phase of gait) may have developed, which suggests serious damage to the gluteus medius tendon. Psychological factors should also be considered, particularly in patients with severe symptoms.
MRI should be obtained in patients with physical examination findings suggestive of gluteus tendon injury or in those whose symptoms have not improved in spite of adherence to the initial management approach. If the MRI shows a partial or complete tendon tear, the patient should be evaluated by a surgeon (see 'Surgery' below). In the absence of a tear, the patient may be treated again with NSAIDs or offered another glucocorticoid injection in the area of tendinosis [53,54], while continuing to reinforce adherence to an exercise program and addressing associated conditions. These measures should provide relief while the condition runs its natural course of spontaneous improvement. In the author's experience, the patient should not require more than three injections during the treatment period.
Unclear role of platelet-rich plasma injections and other therapies — The effectiveness of platelet-rich plasma (PRP) injections in GTPS is uncertain [55]. The author does not use PRP injections due to the limited data demonstrating efficacy and the high cost. Although a systematic review suggested that PRP injections may provide improvement in pain up to 12 months after injection [55], there are conflicting results among randomized trials comparing PRP injections with glucocorticoid injections. Furthermore, the use of different PRP formulations and different outcome measures used among studies make it difficult to compare outcomes [54,56,57]. In one of the larger randomized trials of 80 patients with symptomatic and radiologically confirmed GTPS, patients were randomized to receive either a glucocorticoid injection or a PRP injection under US guidance [54]. At two and six weeks' follow-up, a composite measure of pain and function was similar between the two groups. However, at 12 weeks, patients who received the PRP injection achieved greater clinical improvement on the composite pain and function outcome measure. Limitations to the study include the short duration of follow-up, the use of US guidance for only PRP, and the lack of a placebo arm.
Various other therapies have been used to treat GTPS, including topical heat, topical salicylates, topical menthol products, lidocaine patches, and topical NSAIDs. While some of these interventions may provide transient pain relief, there is no clear long-term role for any of them. Topical cannabidiol products are also of unproven value in GTPS [58]. US iontophoresis, which is sometimes used in combination with physical therapy, lacks supporting data as well.
The use of the expensive extracorporeal shockwave therapy (ESWT) deserves special mention, as some data suggest it may be beneficial for various tendon pathologies, including for GTPS. As an example, a systematic review including studies using ESWT for GTPS found that ESWT resulted in a greater reduction in pain compared with glucocorticoids at mid-term (approximately six months) and long-term (approximately 12 months) follow-up, but was comparable to physical therapy, stretching, and strengthening [59]. However, the studies included in the review were small, of low quality, and most did not include a sham control group. The uncertainty about the use of ESWT is likely to continue, as a published protocol to explore the role of ESWT for chronic musculoskeletal conditions does not include a sham control group [60].
Refractory symptoms
Surgery — Patients who have not improved after at least 12 months of medical therapy or have a tear of the gluteus medius on MRI should be referred for surgical evaluation. Open and arthroscopic repair of the torn tendons are successful in recalcitrant cases of GTPS [61]. Fat degeneration of muscle carries a high risk of delayed failure in patients treated arthroscopically [62-64].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues in muscle and tendon injury diagnosis and management" and "Society guideline links: Muscle and tendon injuries of the lower extremity (excluding Achilles)" and "Society guideline links: Hip and groin pain".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Bursitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology and anatomy – Greater trochanteric pain syndrome (GTPS) is the most common cause of lateral hip pain in adults. GTPS is usually due to a gluteus medius or minimus tendinopathy, with variable involvement of the regional bursae. (See 'Introduction' above and 'Epidemiology' above and 'Etiopathogenesis' above and 'Relevant anatomy' above.)
●Risk factors – Risk factors for GTPS include female sex, obesity, low back pain, scoliosis, a leg length discrepancy, hip and knee arthritis, and painful foot disorders such as plantar fasciitis. (See 'Risk factors' above.)
●Physical examination – The physical examination should reveal tenderness to palpation over the greater trochanter, with maximal tenderness over the superoposterior facet (or posterior corner) of the greater trochanter. (See 'Clinical presentation' above and 'Physical examination' above.)
●Imaging – Routine imaging with conventional radiographs or ultrasound (US) is often not necessary in patients with findings suggestive of isolated GTPS. However, for patients where there is concern for articular hip pathology, anteroposterior radiograph of the pelvis and, if available, an office-based US examination may be obtained. (See 'Imaging' above.)
MRI is suggested when the diagnosis of GTPS is unclear, there is concern for another underlying pathology, or to evaluate cases unresponsive to initial therapy. (See 'Imaging' above.)
●Diagnosis – The diagnosis of GTPS can be made in patients with the following symptoms and signs, regardless of the presence of another condition that could explain the trochanteric pain (see 'Diagnostic evaluation' above and 'Differential diagnosis' above):
•Presence of lateral hip pain
•Local tenderness to palpation of the greater trochanter
●General treatment principles – GTPS is a self-limited condition in the majority of patients. Therefore, the goal of treatment is to relieve symptoms and prevent disability. (See 'Treatment' above.)
●Initial management – Initial therapy for patients with GTPS includes exercise and activity modification, with consideration of either oral nonsteroidal antiinflammatory drugs (NSAIDs) or a glucocorticoid injection. Associated comorbidities (if present) often require management as well (algorithm 1). (See 'Initial management' above.)
•Oral NSAIDs or glucocorticoid injection - For patients with GTPS, we suggest initial treatment with oral NSAIDs, preferably on an as-needed basis (Grade 2C). A local glucocorticoid injection is a reasonable alternative for patients who prefer more immediate pain relief. There is no high-quality evidence that one of these interventions is better than the other, and in our experience, they both appear to be helpful in the short term. (See 'Oral NSAIDs or glucocorticoid injection' above.)
•Exercise and activity modification – For all patients with GTPS, we suggest referral to physical therapy for patients to be taught exercise and activity modification (Grade 2C). Exercises usually involve isometric loading of gluteus medius, gluteus minimus, and quadriceps muscles as well as calf strengthening exercises. Patients should also be instructed to avoid activities that may cause further tendon injury. (See 'Exercise and activity modification' above.)
•Management of associated comorbidities – When possible, patients with comorbidities known to be associated with GTPS should receive additional management to address the specific condition. (See 'Management of associated comorbidities' above.)
●Approach to patients with persistent symptoms – In patients with GTPS whose symptoms do not improve after a two- to three-month trial, we confirm adherence to the initial management measures. Psychological factors should also be considered, particularly in patients with severe symptoms. The patient should also be reexamined with attention to physical findings suggestive of a tear of the gluteus medius tendon. An MRI should be obtained in patients with physical findings suggestive of gluteus medius tendon injury or in those whose symptoms have not improved in spite of adherence to the initial management approach. If a partial or complete tear is shown, the patient should be referred for a surgical evaluation. If a tear is absent, the patient may continue with the initial management approach since there is a high probability that the condition will spontaneously remit. (See 'Reevaluate disease severity' above.)
●Refractory symptoms – Patients who have not improved after at least 12 months of medical therapy or who have a tear of the gluteus medius on MRI should be referred for surgical evaluation. (See 'Surgery' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Bruce Anderson, MD, and Juan J Canoso, MD, MACR, who contributed to earlier versions of this topic review.
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