Treatment Options For Greater Trochanteric Pain Syndrome

Background

Patients who have lateral hip pain are frequently told that they have greater trochanteric bursitis. However, correct nomenclature now refers to the condition as greater trochanteric pain syndrome (GTPS) (Paul Barratt, 2017). This definition is inclusive of gluteus medius tendinopathy and snapping hip, which also contribute to the development of lateral hip pain (Paul Barratt, 2017). The paradigm has shifted and now gluteus medius tendinopathy is thought to be the driver of pain and not bursal inflammation (Mohammad Ali, 2018). In cases where bursitis is found, it is typically seen in conjunction with gluteus tendinopathy (John Furia, 2009). In a cohort of 877 patients with GTPS, only 8% were found to have isolated bursitis (Suzanne Long, 2013).

A study published in the Journal of Clinical Rheumatology looked at histopathological samples in patients who had been diagnosed with trochanteric bursitis. They found no evidence of inflammation in their bursa specimens (Fernando Silva, 2008). Another study published in Arthritis and Rheumatism looked at MRI results in 24 patients with the complaint of lateral hip pain with tenderness (P.A. Bird, 2001). What they found was that in 15 of the patients (62.5%) there was evidence of gluteus medius tendinopathy (P.A. Bird, 2001). Only 2 patients were found to have bursa distention on MRI (P.A. Bird, 2001).

There are three major bursa associated with the greater trochanter. These are the subgluteus maximus bursa, subgluteus medius bursa, and subgluteus minimus bursa (Fernando Silva, 2008). The largest bursa is the subgluteus maximus bursa and is also known as the trochanteric bursa (John Redmond, 2016)

Risk factors for GTPS are knee OA, IT band syndrome, and low back pain (Mohammad Ali, 2018). Women are four times more likely to have GTPS then men (Jane Fitzpatrick, 2018). Incidence of GTPS peaks within the fourth and sixth decades of life (Fernando Silva, 2008).

Clinical symptoms

Pain that localizes to the lateral hip is consistent with GTPS (Jane Fitzpatrick, 2018). Pain can also radiate down the leg and into the gluteus during the acute phase (Edward Mulligan, 2014). Pain typically worsens with walking and going up and down stairs (Jane Fitzpatrick, 2018). Patients also have pain when they try to sleep on that side.

Imaging studies

Simple radiographs can help identify irregularities of the greater trochanter surface suggesting underlying tendinopathy (Michael Mallow, 2014).

Multiple studies have looked at the presence of bursitis on MRI of the hip and its association with GTPS. In European Journal Radiology, they looked at 224 MRIs of the hip and evaluated them for bursitis or gluteus medius degeneration (Michaeil Klontzas, 2014). What they found was that in those patients who had no bursitis on MRI, the negative predictive value for GTPS was 97.14% (Michaeil Klontzas, 2014). The positive predictive value of GTPS in those patients who were found to have bursitis was only 23.53% (Michaeil Klontzas, 2014).

Treatment options

First line management for GTPS is conservative therapy. This includes rest, ice, physical therapy, and weight loss (WS Bolton, 2018). Typical physical therapy programs for GTPS begin with mechanical changes and controlled abduction and progress to abductor strengthening with eccentric exercises (Edward Mulligan, 2014). There is little evidence supporting different therapy modalities.

One of the challenges with GTPS is that physical therapy and NSIADs have not been shown to provide a long term benefit (Jane Fitzpatrick, 2018). Only 60% of patients who attempt conservative measures have pain relief within one year (WS Bolton, 2018).

Corticosteroid injection

In patients who fail conservative measures for GTPS, corticosteroid injections are frequently used. A study published in the American Journal of Sports Medicine looked at patients who had GTPS and assigned them to one of three treatment groups (Home PT, corticosteroid injection, and shockwave therapy) (Jan Rompe, 2009). What they found was that at one month, the corticosteroid injection group had the best pain relief. However, this improvement decreased over the course of the study (Jan Rompe, 2009). At 4 month and 15 month follow up, the patients who did home therapy and those who did shockwave therapy had improved pain compared to the corticosteroid group (Jan Rompe, 2009).

A study published in the Annals of Family Medicine looked at pain relief from corticosteroid injections verse patients who received standard care which included analgesics (NSAIDs and PT) (Aaltien Brinks, 2011). What they found was that there was an initial improvement in pain at the 6 week and 3 month follow up in the group who received a corticosteroid injection. However, at 6 months the benefit compared to usual care had disappeared (Aaltien Brinks, 2011).

Ultrasound guided injection

Ultrasound guided injections for greater trochanteric pain syndrome can be done into the greater trochanteric bursa or the subgluteus medius bursa (Jennifer McEvoy, 2013). These injections are done by placing the patient in the lateral decubitus position with the knees flexed. Then the location of the injection is at the site of maximum pain, which is typically found over the greater trochanter where the gluteus medius inserts on the trochanteric facet (Jennifer McEvoy, 2013).

A study published in the American Journal of Roentgenology in 2013 showed that injections in the greater trochanter bursa had greater pain relief than those in to the sub-glute medius bursa (Jennifer McEvoy, 2013).

Platelet Rich Plasma Injection

Due to the recent increase in use of PRP for tendinopathy, there has been interest in the use of PRP for GTPS. Fitzpatrick did a study in which she looked at pain relief in GTPS from PRP injections. She randomized patients into two groups. One group received a corticosteroid injection and the other received a PRP injection. Injections were given under ultrasound guidance in to the area of gluteal tendon that was affected (Jane Fitzpatrick, 2018). What they found was that at 12 weeks post injection, patients who had received a PRP injection had higher modified Harris Hip scores compared to the corticosteroid group (Jane Fitzpatrick, 2018). The modified Harris Hip score is a survey completed by the patient, where higher scores indicate better hip function and pain (Jane Fitzpatrick, 2018).

Extracorporeal Shockwave

There has also been an interest in the use of shockwave therapy in treating tendinopathy, which has led to studies investigating its role in GTPS. Furio published a study looking at pain scores in patients who underwent extracorporeal shockwave treatment for GTPS verse a control group (John Furia, 2009). He found that at 1, 3, and 12 months there was a statistically significant pain reduction in patients who received the shockwave therapy compared to the control group (John Furia, 2009).

Conclusion

When evaluating a patient with lateral hip pain, physicians must consider gluteal tendinopathy and degeneration in addition to trochanteric bursitis. Conservative measures can lead to successful outcomes in more than half our patients. However, in those patients who continue to have pain, options do exist. Ultrasound guided corticosteroid injections, shockwave treatment, and PRP have all been shown to provide pain relief. Ultimately, providers should begin with a conservative approach and progress as needed to the various other options now available.

Bibliography

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Paul Barratt, N. B. (2017). Conservative treatments for greater trochanteric pain syndrome: a systematic review. British Journal of Sports Medicine, 97-104.

Suzanne Long, D. S. (2013). Sonography of Greater Trochanteric Pain Syndrome and the Rarity of Primary Bursitis. American Journal of Roentgenology, 1083-1086.

WS Bolton, D. K. (2018). Do ultrasound guided trochanteric bursa injections of corticosteroid for greater trochanteric pain syndrome provide sustained benefit and are imaging features associated with treatment response? Clinical Radiology, 505.e9-505.e15.