Do you have lateral hip & thigh pain? It could very well be Greater Trochanteric Pain Syndrome!
What is greater trochanteric pain?
GTPS, often referred to as Hip bursitis or gluteal tendinopathy, is characterised by pain and tenderness experienced over the greater trochanter (hip joint) and can elicit pain from the hip + glutes, down the lateral thigh often interfering with sleep and physcial function. It has a prevalence of 10-25% and experienced by 1 in 4 women aged over 50.
What causes GTPS?
Causes can be due to trauma to the bursa due to a direct blow eg. falls etc, sedentary lifestyle causing weakness of the hip abductors and glutes, muscle imbalances, rubbing/shearing forces over the tendons leading to secondary irritation of the bursa.Studies have indicated gluteal tendinopathy as the most common underlying pathology.
What is bursitis? Or a bursa?
A bursa is fluid filled sacs which serve as cushions between bone and soft tisse structures to lubricate the joint during movement, reducing friction. This can easily become inflammed leading to symptoms of pain/throbbing, night pain, morning stiffness, tenderness, weakness and reduced physical function.
So if GTPS underlying pathology is glute tendinopathy – what is tendinopathy?
Tendons are strong rope like structures attaching muscle to bone, made up of collagen and protein. Tendinopathy is the degeneration of the collagen due to overuse, tendon stress, inactive lifestyles, direct trauma and lack of muscle activation leading to muscle/tendon degeneration.
Can you experience GTPS and low back pain simultaneously?
YES!, GTPS is very commonly associated with with low back pain.
You may ask…why? Well The L5/S1 nerve roots in the Lower Back innervate the hip abductors. L5/S1 is most commonly associated with chronic disc pathology. Therefore a chronic nerve root dysfunction leads to an inability to fire the muscles that are innervated by those nerve roots, causing progressive weakening of the hip abductors (glute tendinopathy). The SIJ (Sacroilliac joint, known as the the tailbone) can be a secondary problem with GTPS. Weakness in the surrounding muscles can cause shearing forces/irritation at SIJ. The deeper muscles under the spine and glutes may compensate to maintain pelvic stability. a common muscle that compensates is the Piriformis muscle located under the glutes, however it’s small and can’t keep up therefore tightens, spasms, fatigues and becomes painful, causing unilateral glute pain. The same group of people with GTSP can present with piriformis syndrome.
Another structure that runs laterally down the hip + thigh is the ITB (illiotibial band). The ITB can also compensate and move anterior or posterior due to abductor weakness, rubbing and shearing at the joint, which can irritate the bursa. 
What evidence based literature has to say?
With GTPS less than 20% of the time would you truly have a bursitis. Most research suggest that even as little as 10% of people presenting with GTPS have a true bursitis. Women and female athletes are more susceptible to getting GTPS due to a wider pelvic structure and Q angle, causing strain and weakness in the hip abductors.
A common treatment for GTPS/gluteal tendinopathy is Corticosteroid injections. Although early outcomes are promising, its not long term and caution should be taken due to the significant health risks associated with it.
A RCT study was conducted to make comparisons between 3 groups of people with a diagnosed GTPS. The three groups were categorised into “education and exercise strenghtening”, “corticosteroid group” and “wait and see approach” group. At 8 weeks, the exercise group + coricosteroid use” reported better improvements then the wait and see approach group. At the 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use group.
There are numerous amounts of evidence to suggest that most should avoid the potential Systemic harmful effects of corticosteroid injections such as bone weakening, hypertension, edema, immune suppression, hyperglycemia, increased appetite, sleep and behaviour alterations
Repeated use can cause hormonal imbalances and bone density weaknening which can make the tendinopathy even worse then it aready is.
Treatment and management:
Evidence based treatment include:
A progressive hip strengtheningstrengthening programme to activate/strengthenstrengthen the muscles that have been inhibited such as hip abductors, hip extensors and back extensors. Stretching of the ITB and piriformis muscles due to tightening, spasming and overcompensation.
Education is of high importance and should be taught to the patients to manage tendon loading/reducing faulty movement patterns. Manuel therapy/soft tisse work for acute low Back/hip pain.
In Conclusion- medical literature states that GTPS is not a bursitis and is best done by addressing biomechanical and muscular imbalances that may be at play.
