Greater Trochanteric Pain Syndrome (GTPS)
Greater trochanteric pain syndrome (GTPS) is the umbrella term that encompasses the pathophysiology of abductor/gluteus medius and minimus tendinopathy +/- trochanteric/subgluteal bursitis. It affects 1.8 individuals per 1000 patients globally, making this a very common musculoskeletal complaint. It affects women disproportionately, with a 2- to 5-fold increase compared to men. It typically manifests in the 4th through 6th decades of life but can affect older age ranges as well. Greater Trochanteric Pain Syndrome (Greater Trochanteric Bursitis) – StatPearls – NCBI Bookshelf. Risk factors include a high BMI due to the higher demand placed on the tendons and hip joint to perform day-to-day tasks. As with other tendons, underlying metabolic disease and autoimmune disease can affect tendon health and be associated with poorer outcomes due to the chronic systemic inflammation. Tendinopathy – PubMed.
It was initially suggested that GTPS was due to an isolated bursal inflammatory process, but evidence now suggests that more commonly the pain driver is related to the gluteal tendons in the way of tendinopathic changes. It is hypothesised that the tendons can become compressed underneath the iliotibial band, causing localised friction and microtrauma to the gluteus medius and minimus attachments. This microtrauma incites tissue degradation with disorganisation of the collagen fibres and an increase in the microvasculature and sensory nerve innervation, with the tendons themselves giving rise to symptoms. Tendinopathy – PubMed.
What are the signs and symptoms?
Patients often describe an insidious onset of lateral hip pain, with them typically able to pinpoint symptoms quite easily to the greater trochanteric attachment site. They are focally tender with local compression; hip movements are typically preserved and unprovocative but end-of-range external rotation can provoke symptoms (FABER’s test) due to the lengthened/stretched position of the gluteal tendons Greater Trochanteric Pain Syndrome – PubMed. Resisted testing of the abductors can also provoke symptoms.
The condition is aggravated with periods of ambulation and climbing stairs, sleeping becomes difficult and disturbed, especially when lying on the affected side due to localised compression. Symptoms can on occasions radiate down the anterolateral thigh to the level of the knee.
How is it diagnosed?
GTPS is typically a clinical diagnosis Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology – PubMed, an x-ray may be arranged to exclude any arthrosis in the hip joint, as sometimes the clinical picture can be unclear. Ultrasound and MRI can confirm the changes to the gluteal tendons and trochanteric bursae but are not routinely needed to make the diagnosis if your clinical symptoms are clear.
Ultrasound does, however, allow for targeted intervention and aspiration of distended bursae, which can provide an additional therapeutic benefit, and assessment of any concurrent pathology, such as tendon tears and hydroxyapatite deposition (calcification), that can on occasion be amenable to specific treatment.
How are they treated?
For the mainstay, this condition is treated conservatively.
- Advice/education, activity modification +/- analgesia/short course of NSAIDs. In some cases, all that is needed is a change in sleeping habits (avoiding compression positions and prolonged stretched positions of the gluteal tendons, e.g., cross-legged sitting) and a period of unloading to allow things to settle.
- If symptoms persist, the first-line management is physiotherapy. It follows the basic principles of any tendinopathic tendon. This is a structured and progressive rehab programme to improve the tolerance and capacity of the gluteal tendons. Shockwave therapy is an non-invasive adjunct that some patient find helpful in settling their lateral hip pain Extracorporeal Shockwave Therapy for Greater Trochanteric Pain Syndrome: A Systematic Review with Meta-Analysis of Randomized Clinical Trials – PubMed.
- In persisting cases an ultrasound-guided steroid and local anaesthetic injection into the trochanteric bursa can be helpful. Further compliance with physiotherapy is important afterwards to allow the best prognosis. Comparison of the effects of ultrasound-guided steroid injection and anatomic landmark-guided injection on pain and disability in greater trochanteric pain syndrome – PubMed
- An ultrasound-guided PRP injection is a potential alternative to repeated steroid injections in refractory cases that can be helpful in carefully selected patients with Greater Trochanteric Pain Syndrome and the Efficacy of Platelet-Rich Plasma Injections: A Systematic Review – PMC. However, the long-term efficacy remains a debate: Efficacy of Platelet-Rich Plasma Versus Placebo for the Treatment of Greater Trochanteric Pain Syndrome: A Double-Blinded Randomized Controlled Trial – PubMed.
Surgical intervention.
- Surgery is rarely indicated and usually the last resort for patients with isolated GTPS, as the general consensus is that outcomes are usually poor, with many patients still experiencing symptoms postoperatively. However, for refractory and severe cases surgical intervention may be considered, which can include gluteal tendon repair and ITB release +/- bursectomy through both open and endoscopic techniques with positive outcomes reported for carefully selected patients. Good functional outcomes after endoscopic treatment for greater trochanteric pain syndrome – PubMed
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