Greater trochanteric pain syndrome (GTPS), a form of

bursitis Bursitis is the inflammation of one or more bursae (synovial sacs) of synovial fluid in the body. They are lined with a synovial membrane that secretes a lubricating synovial fluid. There are more than 150 bursae in the human body. The bursae (bu ...

, is inflammation of the trochanteric

bursa Bursa () is a city in northwestern Turkey and the administrative center of Bursa Province. The fourth-most populous city in Turkey and second-most populous in the Marmara Region, Bursa is one of the industrial centers of the country. Most of ...

, a part of the

hip In vertebrate anatomy, the hip, or coxaLatin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) (: ''coxae'') in medical terminology, refers to either an anatomical region or a joint on t ...

. This bursa is at the top, outer side of the

femur The femur (; : femurs or femora ), or thigh bone is the only long bone, bone in the thigh — the region of the lower limb between the hip and the knee. In many quadrupeds, four-legged animals the femur is the upper bone of the hindleg. The Femo ...

, between the insertion of the

gluteus medius The gluteus medius, one of the three gluteal muscles, is a broad, thick, radiating muscle. It is situated on the outer surface of the pelvis. Its posterior third is covered by the gluteus maximus, its anterior two-thirds by the gluteal aponeuros ...

and

gluteus minimus The gluteus minimus, or glutæus minimus, the smallest of the three gluteal muscles, is situated immediately beneath the gluteus medius. Structure It is fan-shaped, arising from the outer surface of the ilium, between the anterior and infe ...

muscles into the

greater trochanter The greater trochanter of the femur is a large, irregular, quadrilateral eminence and a part of the skeletal system. It is directed lateral and medially and slightly posterior. In the adult it is about 2–4 cm lower than the femoral head.Sta ...

of the femur and the femoral shaft. It has the function, in common with other bursae, of working as a shock absorber and as a lubricant for the movement of the muscles adjacent to it. Occasionally, this bursa can become inflamed and clinically painful and tender. This condition can be a manifestation of an injury (often resulting from a twisting motion or from overuse), but sometimes arises for no obviously definable cause. The symptoms are pain in the hip region on walking, and tenderness over the upper part of the femur, which may result in the inability to lie in comfort on the affected side. More often the lateral

hip pain Pain in the hip is the experience of pain in the muscles or joints in the hip, hip/ pelvic region, a condition commonly arising from any of a number of factors. Sometimes it is closely associated with lower back pain. Causes Causes of pain aro ...

is caused by disease of the gluteal

tendons A tendon or sinew is a tough band of dense fibrous connective tissue that connects muscle to bone. It sends the mechanical forces of muscle contraction to the skeletal system, while withstanding tension. Tendons, like ligaments, are made of ...

that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length,

iliotibial band syndrome Iliotibial band syndrome (ITBS) is the second most common knee injury, and is caused by inflammation located on the lateral aspect of the knee due to friction between the iliotibial band and the lateral epicondyle of the femur. Pain is felt most ...

, and weakness of the hip abductor muscles. Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis. It may also coexist with

low back pain Low back pain or wiktionary:lumbago#Etymology, lumbago is a common musculoskeletal disorders, disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can var ...

arthritis Arthritis is a general medical term used to describe a disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, Joint effusion, swelling, and decreased range of motion of ...

, and

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

Signs and symptoms

The primary symptom is hip pain, especially hip pain on the outer (lateral) side of the joint. This pain may appear when the affected person is walking or lying down on that side.

Diagnosis

A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpating the hip and leg may reveal the location of the pain, and range-of-motion tests can help to identify its source. X-rays,

ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

and

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

may reveal tears or swelling. But often these imaging tests do GTPS.

Prevention

Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures. Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.

Treatment

Conservative treatments have a 90% success rate and can include any or a combination of the following: pain relief medication, NSAIDs, physiotherapy, shockwave therapy (SWT) and

corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...

injection. Surgery is usually for cases that are non-respondent to conservative treatments and is often a combination of bursectomy, iliotibial band (ITB) release, trochanteric reduction osteotomy or gluteal tendon repair. A 2011 review found that traditional nonoperative treatment helped most patients, low-energy SWT was a good alternative, and surgery was effective in refractory cases and superior to corticosteroid therapy and physical therapy. There are numerous case reports in which surgery has relieved GTPS, but its effectiveness is not documented in clinical trials as of 2009. The primary treatment is rest. This does not mean

bed rest Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...

or immobilizing the area but avoiding actions which result in aggravation of the pain. Icing the joint may help. A

non-steroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

may relieve pain and reduce the inflammation. If these are ineffective, the definitive treatment is steroid injection into the inflamed area. Physical therapy to strengthen the hip muscles and stretch the iliotibial band can relieve tension in the hip and reduce friction. The use of point ultrasound may be helpful, and is undergoing clinical trials. In extreme cases, where the pain does not improve after physical therapy,

cortisone Cortisone is a pregnene (21-carbon) steroid hormone. It is a naturally-occurring corticosteroid metabolite that is also used as a pharmaceutical prodrug. Cortisol is converted by the action of the enzyme corticosteroid 11-beta-dehydrogenase ...

shots, and anti-inflammatory medication, the inflamed bursa can be removed surgically. The procedure is known as a

bursectomy A bursectomy is the removal of a bursa, which is a small sac filled with synovial fluid that cushions adjacent bone structures and reduces friction in joint movement. This procedure is usually carried out to relieve chronic inflammation (bursitis ...

. Tears in the muscles may also be repaired, and loose material from arthritic degeneration of the hip removed. At the time of bursal surgery, a very close examination of the gluteal tendons will reveal sometimes subtle and sometimes very obvious degeneration and detachment of the gluteal tendons. If this detachment is not repaired, removal of the bursa alone will make little or no difference to the symptoms. The bursa is not required, so the main potential complication is potential reaction to anaesthetic. The surgery can be performed

arthroscopically Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the jo ...

and, consequently, on an outpatient basis. Patients often have to use crutches for a few days following surgery up to a few weeks for more involved procedures.

References

External links

''wexnermedical.osu.edu'': Greater trochanteric pain syndrome

Ohio State University The Ohio State University (Ohio State or OSU) is a public university, public Land-grant university, land-grant research university in Columbus, Ohio, United States. A member of the University System of Ohio, it was founded in 1870. It is one ...

{{Soft tissue disorders Synovial bursae Soft tissue disorders Syndromes