Greater Trochanteric Pain Syndrome (GTPS): Everything you Need To Know About Side Hip Pain.

Hip pain can be a frustrating and debilitating condition that can have a real impact on your quality of life. Hip pain can limit your ability to walk and exercise, and even disrupt your sleep.

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of pain on the side of your hip and it affects millions of people worldwide.

Relevant Anatomy

The greater trochanter is a bony prominence located on the upper part of the femur, just below the hip joint. It serves as an attachment point for several muscles, including the gluteus medius and minimus, which play a crucial role in hip stability and movement. A tendon is a strong, fibrous connective tissue that attaches muscle to bone. So, when we are referring to the gluteal tendons, we are referring to the fibrous tissue which connects the gluteus medius and gluteus minimus tendons to the greater trochanter.

Glute med and glute min are important contributors to hip stability and maintaining the alignment of the pelvis during single leg stance activities, such as walking or running.

The ilitibial band (ITB) is a thick band of connective tissue on the outside of your leg which runs over the top of the greater trochanter and gluteal tendons.

The trochanteric bursae are small fluid-filled sacs located around the greater trochanter. Their main function is to reduce friction between the greater trochanter and the surrounding soft tissues, such as tendons and muscles, during movement of the hip joint. The trochanteric bursae also help to cushion and distribute the forces that occur during weight-bearing activities, such as walking or running.

The bursae that we will mainly reference in this article is the trochanteric bursae. However, the subgluteus medius and subgluteus mininus bursae can also be involved in GTPS.[i]

Greater Trochanteric Pain Syndrome is a multifactorial condition that can be caused by a combination of factors. Here we take a look into this condition, and I hope to provide you with some answers to help your hip pain, or perhaps even someone you know.

What can cause pain in the side of your hip?

Greater trochanteric pain syndrome:
As mentioned, greater trochanteric pain syndrome is a multifactorial condition that can be caused by a combination of factors. Read down on this information page where we will take a look into this condition and provide you with some answers for greater trochanteric pain syndrome.

  • Gluteal tendinopathy:
    You can tear a tendon. However, often tendon pain is related to a change in the structure of a tendon, rather than a tearing of the actual fibrous tissue. “We use the term ‘tendinopathy’ to encompass a range of tendon disorders, and we will elaborate on this topic in the relevant section below.” It is more appropriate for us to use our clinical findings and manage your pain based on your presentation, that it is to routinely send for imaging to establish a diagnosis.
  • Trochanteric bursitis: An enlarged bursae is often referred to as bursitis. However, the trochanteric bursa is often thickened without showing typical signs of inflammation. Anomalies of the bursae are observed in similar proportions of symptomatic and asymptomatic hips (people without any hip pain at all have thickened bursae).[ii] It is also important to consider why the bursae is thickened. Bursae abnormalities such as increased fluid, or thickening occur as reactive or secondary findings to tendinopathy or involvement from another tissue.[iii] This is why it is now preferable to avoid diagnosing “bursitis” as the primary problem.
  • Coxa Saltans (snapping hip syndrome): Snapping hip syndrome, also known as coxa saltans (or dancer’s hip), is a clinical condition characterized by an audible or palpable snapping sensation that is heard during movement of the hip joint. It is usually painless but can sometimes be accompanied by discomfort or a sensation of tightness in the hip. The snapping sensation can arise from within the hip joint, or outside the hip, such as the ITB flicking over the greater trochanter.[iv]
  • Hip osteoarthritis: Hip osteoarthritis is a condition in which the cartilage that cushions the joint between the hip bone (femur) and the pelvis wears down over time, leading to pain, stiffness, and reduced mobility.
  • Hip labrum tear: The labrum is a cartilage ring that lines the hip socket. A tear in the labrum can cause pain in the side of the hip, as well as clicking or catching sensations in the joint.
  • Muscle strain: Straining or overuse of the muscles in the hip region can cause pain in the side of the hip. This can occur with activities such as running or jumping.
  • Lumbar spine referral: Pain that originates from the lower back can refer to other areas. Including the side of your hip.
  • Fibromyalgia: A thorough history and examination usually enables us to distinguish between these conditions. Imaging is rarely needed but can be used it we need clarity on what is causing your pain and we think that accurate dx will change our Treatment Plan.
[ii] Woodley, S. J., Nicholson, H. D., Livingstone, V., Doyle, T. C., Meikle, G. R., Macintosh, J. E., & Mercer, S. R. (2008). Lateral hip pain: findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy, 38(6), 313-328. https://doi.org/10.2519/jospt.2008.2685

Why do we call it greater trochanteric pain syndrome? Why not bursitis or tendinitis?

Pain is this area is often associated with a combination of factors, including tendinopathy, bursitis, and gluteal muscle dysfunction. Sometimes, the pain experienced in greater trochanteric pain syndrome can involve neural sensitization, rather than a problem with the tissues themselves. Conditions like fibromyalgia can be associated with this.[v]

An isolated diagnosis like gluteal tendinitis, gluteal tendinosis, or trochanteric bursitis may omit important aspects of a persons problem.

Using the term “greater trochanteric pain syndrome” provides a broader and more accurate description of the condition, as it encompasses the various factors that can contribute to hip pain. In addition, GTPS implies a complex and multifactorial condition, rather than a single, isolated issue such as tendinitis or bursitis. This approach can help us to better diagnose and manage the condition, by considering all the possible contributing factors and tailoring treatment accordingly.

Radiological findings for patients with greater trochanteric pain syndrome (GTPS) report variable incidence, with bursitis incidence ranging from 4% to 46% and gluteal tendinopathy ranging from 18% to 50%.[i]

What does greater trochanteric pain syndrome feel like?

Greater trochanteric pain syndrome (GTPS) typically causes pain on the outer part of the hip, buttock, or thigh. The pain may be sharp, burning, or aching and can range from mild to severe. It can also be tender to the touch, especially over the greater trochanter. It is common for people to experience pain when walking, running or climbing stairs. Some people with GTPS may also experience pain when lying on their side, and often people report stiffness in the morning or after prolonged periods of sitting.

What causes greater trochanteric pain syndrome?

When assessing an individual presenting with hip pain, it is crucial to take into account the various tissues that may be involved in GTPS. This includes factors such as gluteal tendinopathy, gluteal muscle or tendon tears, trochanteric bursitis, coxa saltans, and fibromyalgia. Understanding the extent to which each of these factors is contributing to the patient’s symptoms can help tailor an effective treatment plan.

Causative factors generally include:

Compression forces against the gluteal tendons and greater trochanter:
Laying on the effected hip is an obvious way to compress the area. And many people with greater trochanteric pain syndrome will report that this causes pain.

However, compressive forces can also be applied through the ilitibial band (ITB) which is a thick band of connective tissue on the outside of your leg which runs over the top of the gluteal tendons.

This compressive force is increased if there is a greater angle at your hip.

One way to measure this angle is to use the Q-Angle, which is the angle formed between 2 imaginary lines:

  • One line drawn from a bony protuberance at the front of your pelvis (the ASIS), to the middle of your kneecap.
  • The second line, in basic terms, runs along your thigh bone.

We can us this angle to assess the alignment of the hip and knee joints.

The Q-angle is variable between people, usually greater in woman due to their naturally wider pelvis. A greater Q angle means there is more compressive stress on the tissues around the greater trochanter, making them more susceptible to sudden increases in load such as a lot more walking or stair climbing.[vi]

This angle is also increased when you bring one leg across the other. You may be doing this without realising it. Examples include:

  • Sitting with one leg crossed over the other (PIC)
  • Certain exercises such as clams
  • Stretching your gluteal muscles
  • Laying on the unaffected side- This is easily rectified by placing something b/w your knees- put this in management?

Poor hip and pelvic control:
This is usually the result of muscle weakness. One key role of your gluteal muscles is to stabilize the stance leg when you walk. They perform this role in synchrony with your adductor muscles and trunk muscles.

Lacking stability in your hip due to muscle weakness can lead to excessive hip sway weight-bearing activities such as walking or running, increasing the Q- angle and causing tension and compression on the gluteal muscles and tendons that attach to the greater trochanteric region.

A rapid increase in training load:
Particularly high-impact activities such as running or jumping. However, we do find that because this condition is more prevalent over 40 years of age[iii], a too rapid increase in walking is more a more frequent presentation.

When you increase your activity level too quickly, your muscles and tendons stabilising the hip may not have enough time to adapt to the new demands being placed on them. The body tries to repair it by laying down new collagen fibers. However, this repair process can lead to an accumulation of collagen, resulting in thickening and stiffening of the tendon. The body also reacts by growing extra blood vessels and new nerves in the local area which can contribute to the hypersensitivity. This thickened, stiff hyper vascularised, hypersensitised tendon is what we then call tendinopathy.

The issue here is that rest does not repair this process. Indeed, for proper recovery to occur, mechanical loading is critical. We need to apply an adequate loading program that is gradual, for the tendon fibres to organise themselves appropriately.

Being Female:
Woman are diagnosed with greater trochanteric pain syndrome 3-5 times more frequently than men.[viii][ix]

Women are more most likely prone to GTPS due to differences in pelvic biomechanics. Females have a larger pelvic width relative to whole body width, with consequent greater prominence of the trochanters and associated increased tension of the ITB over the trochanter. A lower femoral neck shaft angle may also be a predisposing factor, as this increases compression of the gluteus medius tendon on the greater trochanter.[ix]

Greater trochanteric pain syndrome is most prevalent between the ages of 40 to 60 years of age.[iii] We consider this to be relative to changing oestrogen levels. Oestrogen may have a protective effect on tendons by increasing blood flow to the tendon.

We do see younger woman with GTPS. However, they tend to present a little differently. From my experience, these people present with more irritability, but shorter duration of pain.

Having problems in nearby body parts:
Research shows that people who have knee osteoarthritis on the same side as their greater trochanteric pain syndrome (GTPS) have a higher risk of developing GTPS. Additionally, people who have knee osteoarthritis on the opposite side also have a higher risk of developing GTPS.[viii]

People who experience persistent lower back pain are 3.44 times more likely to have GTPS compared to someone without lower back pain.[ii] It needs to be considered however, that it is possible that the same causative factors are responsible for both conditions. Rather than trying to establish a chicken or egg scenario. Poor pelvic stability can certainly be a causative factor for lower back pain as well.

Being overweight (?):
Researchers found that people with a higher BMI were more likely to have GTPS. However, when the researchers considered other factors such as tenderness in the iliotibial band (ITB), knee osteoarthritis (OA), low back pain (LBP), age, and sex, the association between BMI and GTPS was no longer significant. This means that while BMI may have an initial effect on GTPS, it is not the only factor, and other conditions or factors may also be contributing to the development of GTPS.[viii]

Direct trauma to the side of your hip:
Direct trauma to the side of the hip can cause damage or irritation to the gluteal tendons, trochanteric bursa, or other soft tissue structures in the area. This can lead to inflammation, pain, and restricted movement of the hip. This is not the typical story for persisting GTPS. In the exclusion of tissue injury (fractures, tendon tearing or hip joint injuries), pain as a result of direct trauma usually settles down without becoming persistent like GTPS can.

Snapping hip syndrome (Coxa Saltans):

Snapping hip syndrome can also contribute to GTPS. There are several tissues can cause snapping hip syndrome. When the snapping is related to the anterior part of the gluteus maximus or posterior ITB snapping over the greater trochanter, the increased friction and pressure on the underlying tendon may be associated with developing greater trochanteric pain syndrome.[iv]

What causes trochanteric bursitis?

The term “trochanteric bursitis” is not entirely accurate for lateral hip pain as bursitis refers to inflammation, whereas the trochanteric bursae can often be thickened without showing typical signs of inflammation. Trochanteric bursitis is usually not the sole cause of lateral hip pain, as gluteal tendinopathy is more likely to be the primary contributor. Bursitis may be present alongside tendinopathy.[i]

True bursitis can occur but it is rare. An example of this is septic bursitis which occurs when bacteria is introduced into the bursae. This might occur due to an infection such as a bacterial infection secondary to direct puncture to the skin, trauma, or cellulitis of the skin near the bursae.

What causes gluteal tendinopathy?

Tendinopathy is a general term that refers to any condition that affects the tendons, the fibrous connective tissue that attaches muscles to bones.

Gluteal tendinopathy can be caused by a variety of factors, including overuse or mechanical overload, incomplete healing with repetitive strain, or compression of the tendon at the attachment site. Gluteal tendinopathy may also be associated with a sudden traumatic event, or aging.

Weakness or changes in muscle bulk can also affect the balance of the abductor mechanism and increase compression of the gluteal tendons against the greater trochanter.

How long does gluteal tendinopathy take to heal?
Tendon healing is a complex process with the most accepted timeframe being 3-6 months.[x]

Gluteal tendon healing involves remodeling of the tendon cellular matrix to restore the normal structure and function of the tendon. During the healing process, the cells in your body will lay down new fibers in the tendon to help it repair. Through this process, the tendon becomes stronger and more resilient over time. Mechanical loading is one of the most important factors in tendon remodeling so recovery from tendon injury requires a careful management program.[x]

Many people’s experiences with side hip pain is that their pain experience doesn’t correlate with gluteal tendon healing timeframes. Some people experience pain relief far quicker than this. Some people experience ongoing pain long after the tissue healing timeframe. The reason for this is exactly as we mentioned before; there are often many factors involved when there is pain in the side of your hip.

When you present to YouMove Osteopathy with pain in the side of your hip, we will consider the individual characteristics responsible for your pain.

How is greater trochanteric pain syndrome diagnosed?

Hearing your story, along with a clinical examination is usually enough for an osteopath to diagnose greater trochanteric pain syndrome.

Medical History:
We will ask you questions about your symptoms, including the location, duration, and severity of your pain, as well as any factors that worsen or improve the pain.

Physical Exam:
During the physical exam, your osteopath will perform a series of tests to check for pain and tenderness in the greater trochanteric region of your hip. They may also evaluate your gait and range of motion in your hip joint. It is often important to consider other potential diagnoses such as hip joint related pain.

Imaging Studies:
The best way to visualize the area is with an ultrasound. Sometimes, this may be combined with a hip X-Ray if we want to also assess the hip joint.

We usually do not need to send you for imaging to make the diagnosis of GTPS. And sometimes imaging is ill-advised. The reason for this is that it is very common for people to show changes to the gluteal tendons and trochanteric bursae who have never had hip pain. Imaging may cause undue focus on the findings, rather than to focus on what’s important, such as your pain and functional capacity. Finally, we often see significant improvements in people’s pain, even though the ultrasound continues to look similar. This is like your skin having healed after a wound, even though there remains scar tissue there.

Do you need to rest if you have GTPS?

Complete rest is usually not necessary or beneficial in the long term. It is important to maintain physical activity at a level that does not exacerbate the pain, as inactivity can lead to muscle weakness and further impair function. Gradually increasing activity levels and incorporating appropriate exercises, as guided by your osteopath, can help improve symptoms and function in the long term.

How do you treat greater trochanter pain syndrome?

The management GTPS is best split into two phases. The first being to settle the pain down and the second being to promote resilience in the tissues to help graduate you towards your goals.

Settle down the pain.

We can usually achieve some quick wins by combining manual treatment with activity modification and position awareness.

a) Manual treatment:
Osteopaths have a variety of effective hands-on treatment options, which allows us to utilize the techniques you are comfortable with. For example, Dry needling can be effective in providing short term pain reduction but if you are not comfortable with this, then we will utilize other techniques such as muscle inhibition.

b) Home based modifications:
1. Avoid positions of tendon compression for a period. You will be able to tolerate these again in the future.
a. Direct Compression from laying on the effected side.
b. Indirect compression as a result of increasing the Q-Angle:
i. Laying on the unaffected side without anything between your knees.
ii. Sitting cross legged.
iii. Standing lazily.
iv. Stretching your gluteal muscles by bringing one leg across the other.
v. Some activities such as clams (these can be modified however)

HOT TIP: Instead of stretching your gluteal muscles, use a massage ball. Hold the ball on a sore part of the muscle for 1 minute and do this for all the sore points you find.

2. Modification of your activities.
a. Complete rest is not indicated. It rarely leads to an improved long term outcome.
b. We may need to modify a few things in the short term. For example, if walking is a trigger for your pain, a short-term reduction in walking distance can reduce the pain and allow us to commence loading exercises.

c. Be consistent in the amount of activity that you do.
i. Avoid suddenly introducing a long walk or run.
ii. Avoid long periods of rest and sporadic activity which can make your pain continually yoyo.
d. A painful tendon does not like high impact activities.
i. Our tendons are very resilient. However, when they become sensitized, they need to be handled with care. This is typical for the initial stages of our rehabilitation plan. Exercises that involve rapid stretching or shortening of the muscles should be limited during this time. We may limit activities like plyometrics, until we build up enough tissue tolerance to then re-introduce them down the track.

3. Calm the pain down using simple solutions like self-massage with a massage ball. Or the application of a heat pack, or cold pack.
a. Heat and cold applications can both have a neural desensitizing effect. We no longer us ice with the intention of reducing inflammation. They are both safer than pain medication, So why not try both and see which provides the best relief for you.
i. Just be aware that you should never place ice or a cold pack directly onto the skin, not should it be applied for longer than 15 minutes.
ii. We’re less stressed about warm packs, just don’t make them too hot.

Promote Resilience
1. If your hip stability is inadequate, we may see increased hip sway to the side when you walk, thus increasing the Q-angle and compressing your gluteal tendons between the ITB and the greater trochanter.
i. Improving hip stability by strengthening the muscles can be started quite early on, even during the pain settling phase of our recovery plan. These exercises can even help to reduce pain as well.

2. LOAD! Adequate loading helps to stimulate tissue repair and remodeling, which can improve the quality and strength of the gluteal tendons over time. This improves the ability of these structures to handle the demands of daily activities, such as walking, standing, and climbing stairs, without causing pain.

Are injections good for hip bursitis?

Sometimes corticosteroid injections are considered as a second line option for greater trochanteric pain syndrome when there is noteworthy bursitis present. However, this only provides short term relief (3-4 months). Cortisone injections make no difference to your outcome in the longe term (when reviewed 12 months later).[xi]

The decision to elect for a cortisone injection also needs to careful consideration of the side effects. Cortisone may reduce the tendon healing process and repeated cortisone injections may even lead to tendon weakness, increasing the chance of tearing. There is emerging clinical evidence that shows significant long-term harm to tendon tissue and cells associated with glucocorticoid injections.[xi]

What’s important here is that people who actively involved in their recovery, will fare better than people who cope passively and chase quick fixes.

Even though health professionals are aware that injections may not lead to better long-term outcomes for GTPS, they often feel pressured to offer this option. Since GTPS takes time to improve, people may feel discouraged after trying exercises for a short period of time. However, it’s essential to note that sufficient loading of the area through exercises is crucial for long-lasting improvement. The discouraged feeling is a whole lot stronger when the pain recurs months down the track.

Is Shockwave Therapy good for GTPS?

Radial Shockwave Therapy is a good pain-relieving option for persistent GTPS. It has minimal side effects besides localised pain at the time of the procedure, and bruising/slight skin damage such as blisters. Because it can be used to avoid cortisone injections, there is less risk of tendon damage.

RSWT reduces pain in the short term and has also been found to improve long term outcomes[xiii]

RSWT does not remove the need for an adequate loading program.

Is walking good for greater trochanteric pain syndrome?

In general, low-impact exercise such as walking is recommended for people with greater trochanteric pain syndrome (GTPS). However, it is important to start with shorter distances and lower intensity and gradually increase as tolerated. Walking on flat surfaces may be more comfortable than walking uphill or on uneven terrain to begin with.

I hope that this information has been useful in providing a better understanding of hip pain and the various conditions that can contribute to it, including greater trochanteric pain syndrome. At YouMove Osteopathy, we are passionate about helping people with their hip pain and providing tailored treatment plans to improve their quality of life. If you or someone you know is experiencing hip pain, do not hesitate to reach out to us for help. Thank you for reading!

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References
[i] Reid, D. (2016). The management of greater trochanteric pain syndrome: A systematic literature review. Journal of Orthopaedics, 13(1), 15-28. https://doi.org/10.1016/j.jor.2015.12.006

[ii] Woodley, S. J., Nicholson, H. D., Livingstone, V., Doyle, T. C., Meikle, G. R., Macintosh, J. E., & Mercer, S. R. (2008). Lateral hip pain: findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy, 38(6), 313-328. https://doi.org/10.2519/jospt.2008.2685

[iii] Fredericson, M., Lin, C., & Chew, K. (2020). Greater Trochanteric Pain Syndrome. In Clinical Sports Medicine (pp. 781-791). Elsevier. https://doi.org/10.1016/B978-0-323-54947-9.00062-6

[iv]Musick SR, Varacallo M. Snapping Hip Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448200/

[v] Dzidzishvili, L., Parrón Cambero, R., Mahillo Fernández, I., & Llanos Jiménez, L. (2022). Prognostic factors of trochanteric bursitis in surgical-staged patients: a prospective study. Hip International: The Journal of Clinical and Experimental Research on Hip Pathology and Therapy, 32(4), 530-536. https://doi.org/10.1177/1120700020986136

[vi] Seidman AJ, Taqi M, Varacallo M. Trochanteric Bursitis. [Updated 2022 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538503/

[vii] Gabbett, T. J. (2016). The training–injury prevention paradox: should athletes be training smarter and harder?. British Journal of Sports Medicine, 50(5), 273-280. https://doi.org/10.1136/bjsports-2015-095788

[viii] Segal, N. A., Felson, D. T., Torner, J. C., Zhu, Y., Curtis, J. R., Niu, J., & Nevitt, M. C. (2007). Greater trochanteric pain syndrome: epidemiology and associated factors. Archives of Physical Medicine and Rehabilitation, 88(8), 988-992. https://doi.org/10.1016/j.apmr.2007.04.014

[ix]Blank, E. (2012). Incidence of greater trochanteric pain syndrome in active duty US military servicemembers. Orthopedics, 35(7), e1022-e1027. http://hdl.handle.net/10945/48004

[x] Thomopoulos, S., Parks, W. C., Rifkin, D. B., & Derwin, K. A. (2015). Mechanisms of tendon injury and repair. Journal of orthopaedic research : official publication of the Orthopaedic Research Society, 33(6), 832–839. https://doi.org/10.1002/jor.22806
[xi] Brinks, A., van Rijn, R. M., Willemsen, S. P., Bohnen, A. M., Verhaar, J. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2011). Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care. Annals of family medicine, 9(3), 226–234. https://doi.org/10.1370/afm.1232
[xii] Dean, B. J., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Seminars in arthritis and rheumatism, 43(4), 570–576. https://doi.org/10.1016/j.semarthrit.2013.08.00

[xiii] Rompe, J. D., Segal, N. A., Cacchio, A., Furia, J. P., Morral, A., & Maffulli, N. (2009). Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. The American journal of sports medicine, 37(10), 1981–1990. https://doi.org/10.1177/0363546509334374

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