Greater Trochanteric Pain Syndrome (GTPS)
Summary
Greater Trochanteric Pain Syndrome (GTPS), formerly known as Trochanteric Bursitis, is a common cause of lateral hip pain. The contemporary understanding is that the primary pathology is usually Gluteal Tendinopathy (of Gluteus Medius and Minimus insertion on the Greater Trochanter) rather than bursitis alone. It is most common in middle-aged to older women and is associated with overuse, biomechanical factors, and obesity. Pain is characteristically located over the lateral hip, radiates down the lateral thigh, and is worse lying on the affected side at night. Treatment is primarily conservative (physiotherapy, especially gluteal strengthening exercises) with steroid injections for refractory cases. [1,2]
Clinical Pearls
"The Name is Wrong": Despite the traditional name "Trochanteric Bursitis", bursitis is found in a minority of cases. The main pathology is Gluteal Tendinopathy. The term Greater Trochanteric Pain Syndrome (GTPS) is preferred.
Lateral Thigh Pain ≠ Hip Arthritis: True hip joint pathology (osteoarthritis, AVN) causes Groin Pain. GTPS causes Lateral Hip/Thigh Pain. This distinction is crucial.
Point Tenderness: Exquisite tenderness directly over the Greater Trochanter on palpation is the hallmark clinical sign.
Night Pain: Pain lying on the affected side is classic. Patients often cannot sleep on that side.
Demographics
- Prevalence: ~15-25% of adults experience lateral hip pain at some point. GTPS is the most common cause.
- Sex: Female > Male (4:1). Wider pelvis anatomy is a contributing factor.
- Age: Peak 40-60 years.
Risk Factors
| Factor | Mechanism |
|---|---|
| Female Sex | Wider pelvis alters biomechanics (Q angle, ITB tension). |
| Obesity | Increased load on gluteal tendons. |
| Low Back Pain / Lumbar Spine Pathology | Altered gait, referred pain, gluteal inhibition. |
| Iliotibial Band (ITB) Tightness | Friction over Greater Trochanter. |
| Unequal Leg Length | Gait abnormality stresses lateral hip. |
| Running / Sudden Increase in Activity | Overuse tendinopathy. |
| Hip Osteoarthritis | Altered biomechanics. |
Mechanism
- Biomechanical Stress: Repetitive hip abduction/adduction (walking, running, stair climbing) loads the gluteal tendons.
- Tendinopathy of Gluteus Medius/Minimus: Degenerative changes (collagen disarray, decreased vascularity) develop at the tendon insertion on the Greater Trochanter. This is analogous to rotator cuff tendinopathy in the shoulder.
- ITB Compression: The Iliotibial Band passes over the Greater Trochanter. Tightness or friction can compress the underlying tendons and bursa.
- Secondary Bursitis: Inflammation of the trochanteric bursa may occur secondary to tendon pathology or ITB friction.
- Chronic Pain State: Ongoing inflammation and failed healing leads to chronic lateral hip pain.
Key Structures
- Gluteus Medius Tendon: Inserts onto the superoposterior and lateral facets of the Greater Trochanter.
- Gluteus Minimus Tendon: Inserts onto the anterior facet of the Greater Trochanter.
- Bursa: Three bursae around the Greater Trochanter (Subgluteus Medius, Subgluteus Minimus, Subgluteus Maximus). These can become inflamed.
| Condition | Key Features |
|---|---|
| GTPS (Trochanteric Bursitis) | Point tenderness over Greater Trochanter. Lateral thigh pain. Worse lying on side. |
| Hip Osteoarthritis | Groin Pain. Reduced ROM (especially internal rotation). Pain on loading. X-ray changes. |
| Referred Pain from Lumbar Spine | Low back pain. Radiculopathy pattern. Positive SLR. |
| Iliotibial Band Syndrome | Lateral Knee Pain (especially runners). Tender over lateral femoral condyle. |
| Femoral Neck Stress Fracture | Groin pain. Recent increase in activity (athletes, military recruits). MRI shows fracture. |
| Avascular Necrosis (AVN) of Femoral Head | Groin pain. Risk factors: Steroids, Alcohol, SLE. MRI shows AVN. |
| Meralgia Paraesthetica | Lateral Thigh Numbness/Burning (LFCN entrapment). Sensory symptoms, not pain on palpation of trochanter. |
| Septic Hip / Septic Bursitis | Fever. Severe pain. Erythema. Raised WCC/CRP. |
Symptoms
History Taking
Inspection/Palpation
- Point Tenderness: Directly over the Greater Trochanter on palpation. This is the key sign.
- Gait: May be antalgic (Trendelenburg gait if gluteal weakness).
Special Tests
| Test | Technique | Positive Finding |
|---|---|---|
| Resisted Hip Abduction | Patient lies on side. Resist abduction of top leg. | Pain over Greater Trochanter. |
| FABER (Patrick's Test) | Flex, Abduct, Externally Rotate hip. | Lateral hip pain. (Groin pain suggests hip joint pathology). |
| Single Leg Stance (30 seconds) | Patient stands on affected leg. | Pain reproduced (demonstrates load on gluteals). |
| Ober's Test | Measures ITB tightness. | Positive if tight ITB (cannot adduct leg passively). |
Exclusion Testing
- Hip Range of Motion: Usually Full and Painless (unlike OA). Internal Rotation may provoke deep groin pain if hip joint pathology.
- Lumbar Spine: Assess for referred pain.
Management Algorithm
LATERAL HIP PAIN + TROCHANTERIC TENDERNESS
↓
CLINICAL DIAGNOSIS: GTPS
(Imaging rarely needed initially)
↓
FIRST LINE: CONSERVATIVE
(Success rate >90%)
┌─────────────────────┴─────────────────────┐
↓ ↓
PHYSIOTHERAPY LIFESTYLE
(Core treatment) MODIFICATION
- Gluteal strengthening - Weight loss
- ITB stretching - Activity modification
- Core stability - Avoid lying on affected side
- Load management (Pillow between knees)
↓
ANALGESIA
- Simple: Paracetamol
- NSAIDs: Oral or Topical
- Ice pack to lateral hip
↓
POOR RESPONSE (>8-12 WEEKS)?
↓
SECOND LINE: CORTICOSTEROID INJECTION
(Into bursa / around tendons)
- Very effective short-term
- Can be USS guided
↓
STILL REFRACTORY?
↓
THIRD LINE OPTIONS:
- Extracorporeal Shockwave Therapy (ESWT)
- Platelet-Rich Plasma (PRP) - emerging
- Surgical debridement / bursectomy (rare)
Conservative Treatment (First Line)
- Physiotherapy: Gluteal strengthening exercises (Gluteus Medius, Minimus) are the cornerstone of treatment. Improves pelvic/hip stability. Evidence-based programme.
- ITB/Hip Flexor Stretching: If tight.
- Weight Loss: Reduces load on tendons.
- Activity Modification: Avoid aggravating activities. Avoid lying on affected side.
- Sleeping Position: Place pillow between knees.
- Analgesia: Paracetamol, NSAIDs (oral or topical).
Corticosteroid Injection
- Technique: Local anaesthetic + Steroid (e.g., Depo-Medrone 40mg) injected into the bursa or around the tendons. Ultrasound guidance improves accuracy.
- Efficacy: Provides good short-term pain relief (~50-75% at 4 weeks). Effect often wanes by 12 months. Best combined with physiotherapy.
- Repeat Injections: Can be repeated but caution with multiple injections (tendon weakening).
Advanced/Refractory Options
- Extracorporeal Shockwave Therapy (ESWT): Emerging evidence for benefit.
- Platelet-Rich Plasma (PRP): Some evidence, not widely available.
- Surgery: Rarely needed (less than 5%). Options include ITB release, bursectomy, gluteal tendon repair. Reserved for failures of extensive conservative management.
Of Condition
- Chronic Pain: Can persist for months to years if untreated or poorly managed.
- Sleep Disturbance: Significant impact on quality of life.
- Gluteal Tendon Tear: Progressive tendinopathy can lead to partial or full-thickness tears.
- Functional Impairment: Difficulty walking, climbing stairs, exercising.
Of Treatment
- Steroid Injection: Infection (rare), Skin/Subcutaneous Atrophy, Fat Necrosis, Tendon Weakening with repeated injections.
- Conservative Treatment: ~80-90% improve significantly with physiotherapy and lifestyle measures over 12 months.
- Injection: Provides ~50-75% short-term relief. Long-term benefit less clear without concurrent physiotherapy.
- Chronicity: Some patients develop chronic symptoms requiring ongoing management.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| GTPS Management | NICE CKS | Conservative first (Physio, Weight loss). Steroid injection if failure. |
| Tendinopathy Principles | BJSM | Load management and progressive loading exercise is key. Avoid complete rest. |
Landmark Evidence
1. LEAP Trial (Mellor et al, BMJ 2018)
- Question: Education + Exercise vs Corticosteroid Injection vs Wait-and-See for GTPS?
- Result: Education + Exercise was superior to both other groups at 8 weeks and 52 weeks.
- Impact: Established physiotherapy as the cornerstone of treatment. Injections provide short-term benefit but not superior long-term.
What is GTPS (Trochanteric Bursitis)?
It is a common cause of pain on the outer side of your hip. The tendons that attach your buttock muscles to the hip bone become irritated and inflamed.
Why does it hurt to lie on my side?
The painful area is exactly where you lie when you sleep on that side. The pressure on the inflamed tendons and bursa causes pain.
Will I need surgery?
Very unlikely. Most people get better with physiotherapy exercises and simple painkillers. Sometimes an injection into the area helps.
What are the best exercises?
Strengthening your buttock muscles (Gluteal exercises) is the key treatment. A physiotherapist can teach you a specific programme.
Tip for Sleeping
Put a pillow between your knees if sleeping on your side. This takes pressure off the sore hip.
Primary Sources
- Mellor R, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (LEAP). BMJ. 2018;361:k1662. PMID: 29720371.
- Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther. 2015;45(11):910-22. PMID: 26381484.
Common Exam Questions
- Anatomy: "What tendons insert on the Greater Trochanter?"
- Answer: Gluteus Medius and Gluteus Minimus.
- Diagnosis: "Point tenderness over the Greater Trochanter, lateral thigh pain, worse at night lying on side?"
- Answer: Greater Trochanteric Pain Syndrome (GTPS).
- Distinguishing Feature: "Groin pain vs Lateral hip pain - what does it suggest?"
- Answer: Groin pain = Hip Joint pathology (OA, AVN, Fracture). Lateral hip pain = GTPS.
- Treatment: "First-line management?"
- Answer: Physiotherapy (Gluteal strengthening exercises).
Viva Points
- LEAP Trial: Be able to discuss that physiotherapy is superior to corticosteroid injection at long-term follow-up.
- ITB Role: Explain how Iliotibial Band tightness contributes to compression over the Greater Trochanter.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.