Key points

Video of an injection of the greater trochanteric bursa accompanies this article at http://www.pmr.theclinics.com/

Introduction

The term greater trochanteric pain syndrome (GTPS) refers to pain originating from various structures in the lateral hip, including tendon and bursa. The latter structure is now thought to play a smaller role in this entity than previously thought, and the term trochanteric bursitis is somewhat of a misnomer because inflammation is not commonly found. Other implicated structures and entities include gluteal tears and snapping hip. This article reviews the epidemiology, anatomy, diagnosis, and treatment of GTPS with special attention in imaging and image-guided interventions.

Introduction

The term greater trochanteric pain syndrome (GTPS) refers to pain originating from various structures in the lateral hip, including tendon and bursa. The latter structure is now thought to play a smaller role in this entity than previously thought, and the term trochanteric bursitis is somewhat of a misnomer because inflammation is not commonly found. Other implicated structures and entities include gluteal tears and snapping hip. This article reviews the epidemiology, anatomy, diagnosis, and treatment of GTPS with special attention in imaging and image-guided interventions.

Epidemiology

Hip pain is a common complaint prompting visitation to a primary care provider or musculoskeletal medicine specialist. In a large national survey, 14.3% of individuals more than 60 years of age reported frequent hip pain. In the survey, women reported pain more frequently than men; in men, age was not a predictor of hip pain. In a large observational study by Segal and colleagues, unilateral GTPS was noted to have a prevalence of 8.5% in women and 6.6% in men. In patients referred to a spine practice for a complaint of back pain, the prevalence of GTPS was 20.2% and again more frequent in women. Noted in this study, greater that 50% of patients had already undergone magnetic resonance imaging (MRI) of the lumbar spine.

Based on the aforementioned data, GTPS is a common clinical entity in patients presenting with both hip pain and low back pain. Attention to the differential of GTPS in any patient with hip and back pain is essential.

Associated conditions and factors

Because the buttock and hip can be a common site of referred pain from the spine and other structures, as well as the biomechanical loads placed on structures in this region, there are a host of conditions that may coexist with GTPS. Iliotibial band (ITB) tenderness, knee osteoarthritis, and low back pain were positively related to the occurrence of GTPS in an observational study. Body mass index was not found to be associated with GTPS. In a prospective study, GTPS was found in 18% to 45% of patients with chronic low back pain.

Anatomy

Several muscles insert on or near the greater trochanter of the femur, the gluteus medius and minimus, piriformis, obturator externus, and obturator internus. The most superficial gluteal muscle, the gluteus maximus, has a broad origin including fibers from the ilium and sacrum and inserts onto the gluteal tuberosity of the femur and the iliotibial tract. Deep to this muscle lies the gluteus medius, a smaller muscle in surface area, which originates from the ilium and inserts onto the greater trochanter of the femur. Deep to the gluteus medius, the gluteus minimus is found and takes origin from the ilium and also inserts onto the greater trochanter.

The tensor fascia lata originates from the iliac crest and inserts onto the iliotibial tract in the lower limb. This fibrous band of tissue inserts distally onto the lateral condyle of the tibia. As mentioned earlier, the gluteus maximus muscle inserts onto the iliotibial tract and the femur.

The greater trochanter is associated with bursae that provide protection for the surrounding tendons, namely, the gluteus medius and minimus, ITB, and tensor fascia lata. The most superior bursa, the subgluteus medius bursa, sits superior to the greater trochanter under the gluteus medius tendon. The subgluteus maximus bursa sits between the tendons of the gluteus medius and maximus and lateral to the greater trochanter. The deep subgluteus maximus bursa is a division sometimes revered to as the trochanteric bursa . In some individuals, a superficial bursa exists within the gluteus maximus muscle. Dissection study supports the idea that bursa may be acquired as a result of friction between the greater trochanter and gluteus maximus. Bursal tissue from patients with GTPS undergoing total hip arthroplasty showed no signs of acute or chronic inflammation. This finding supports the understanding that inflammation, or bursitis, plays a limited role in GTPS.

Presentation

Patients with GTPS will present with hip pain, but this verbal symptom must be carefully discussed and a full history taken. Patients should be asked about the associated presence of low back pain, groin pain, as well as more distal complaints of knee or ankle pain. Recent increases or decreases in activity should be discussed as well as questions about recent or past trauma. Groin pain often points one in the direction of hip osteoarthritis or perhaps lumbar spine disorders, whereas pain felt laterally, just distal to the waistline, prompts further consideration of GTPS.

Acutely, patients with GTPS will complain of lateral hip pain that is worse with pressure on that side of the body, such as while lying down. They often complain of pain with walking and may admit that pain is worse while standing on the affected leg. There may be associated lateral thigh pain radiation but rarely below the knee. A dermatomal distribution of pain should prompt investigation of alternative causes, such as lumbar radiculopathy. This evaluation, however, can be challenging as the two conditions may coexist.

Some patients with advanced cases can demonstrate tears of the gluteus medius or minimus on ultrasound or MRI. These tears maybe analogous to rotator cuff tears, usually present similarly to GTPS and benefit from a period of conservative treatment, covered later.

External snapping hip syndrome is caused by tightness of the ITB as it overlies the greater trochanter. When the hip is flexed, the ITB may snap over the greater trochanter and can be painful at times in younger, active patients. This syndrome can also be treated with conservative measures.

Differential diagnosis

Various disorders and clinical entities can cause lateral hip pain. A comprehensive differential diagnosis is presented here :

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  GTPS

  
  
  
  
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    Gluteus medius dysfunction, gluteus medius or gluteus minimus tendinopathy

    
    
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    Piriformis tendinopathy

    
    
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    Iliotibial tract friction syndrome

    
    
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    Trochanteric bursitis

  
  
  
  
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  Traction enthesopathy

  
  
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  Piriformis syndrome

  
  
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  Other snapping hip syndrome

  
  
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  Meralgia paresthetica

  
  
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  Other peripheral compressive neuropathy

  
  
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  Hip (femoroacetabular) osteoarthrosis

  
  
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  Slipped capital femoral epiphysis

  
  
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  Femoroacetabular impingement

  
  
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  Acetabular labral tear

  
  
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  Femoral head avascular necrosis

  
  
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  Femoral neck fracture

  
  
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  Femoral neck stress fracture

  
  
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  Iliopsoas tendinopathy

  
  
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  Sports hernia

  
  
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  Fibromyalgia

  
  
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  Myofascial trigger points

  
  
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  Complex regional pain syndrome

  
  
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  Lumbosacral spine disorders

  
  
  
  
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    Intervertebral disk disease

    
    
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    Facet joint arthropathy

    
    
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    Lumbosacral radiculopathy

    
    
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    Lumbosacral spine sprain or strain

    
    
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    Lumbosacral spondylolisthesis

    
    
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    Pars interarticularis injury

    
    
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    Sacroiliac joint injury or dysfunction

  
  
  
  
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  Referred pain from intra-abdominal processes

  
  
  
  
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    Endometriosis

    
    
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    Prostate disease

    
    
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    Gastroenteritis

    
    
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    Inflammatory bowel disease

    
    
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    Irritable bowel syndrome

    
    
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    Inguinal hernia

    
    
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    Ovarian cysts

    
    
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    Ureteral stone or dysfunction

  
  

Examination

A complete neuromusculoskeletal examination should be performed, including observation of swelling or skin breakdown and gait observation. Proper manual muscle testing cannot be overemphasized because neurologic conditions, such as lumbar radiculopathy, can present as lateral hip pain. It is important to identify any weakness, sensory loss, and or diminished reflexes because these findings may direct the clinician to an alternative workup. Gluteus medius weakness, however, is often present with GTPS.

Pain in GTPS may be reproduced by direct palpation and often by resisted abduction and external rotation. In a series of 24 patients, Bird and colleagues showed that the Trendelenburg sign was most sensitive for the detection of gluteus medius tears confirmed by MRI. It should be noted that evidence of bursitis was rare in these patients versus the finding of gluteus medius tendinopathy.