Review Article
Volume 4 Issue 1 - 2016
Greater Trochanteric Pain Syndrome- A Review Article
Akash Saraogi1, Naveen Lokikere1 and Videsh Raut2*
1Senior Clinical Research Fellow, Wrightington Hospital, United Kingdom
2Consultant Orthopaedic Surgeon, Wrightington Hospital, United Kingdom
*Corresponding Author: Videsh Raut, Consultant Orthopaedic Surgeon Wrightington Hospital, Hall Lane, Appley Bridge, WN6 9EP, United Kingdom.
Received: August 02, 2016; Published: August 22, 2016
Citation: Videsh Raut., et al. “Greater Trochanteric Pain Syndrome- A Review Article”. EC Orthopaedics 4.1 (2016): 429-434.
Greater trochanteric pain syndrome (GTPS), also known as “trochanteric bursitis” is a common clinical condition faced day to day by the practising physicians and orthopaedic surgeons. The important pre-disposing factors, clinical implication of its etio-pathology and the latest update on the management options have been discussed in this article. Not all GTPS require an MRI. Also, not all respond favourably to a steroid injection. The management of GTPS essentially relies on individualizing treatment option on a case to case basis.
Keywords: Trochanteric Pain; GTPS; MRI; Cortico-steroid injections; Arthroplasty
Greater trochanteric pain syndrome (GTPS), commonly known as “trochanteric bursitis” contributes to cause significant morbidity in industrialised societies. It was first described by Stegemann in 1923 as lateral hip pain [1]. The previous term trochanteric bursitis has been given up as 3 symptoms of inflammation namely, redness, swelling and raised local temperature are uncommon [2,3]. Though, conventionally defined as chronic, intermittent, pain and tenderness at lateral hip [2,4], GTPS covers a spectrum of presentation including, pain and reproducible tenderness at GT, buttock or lateral thigh. Due to its varied presentation, it has been described as a “great mimicker” [5]. It affects around 5.6 patients per thousand population [6] and is a self-limiting condition usually which responds to conservative measures.
Relevant Anatomy
Upto 21 bursae have been described around the hip joint. However, 3 - 4 bursae are most commonly present.
Figure 1 shows the anatomy of various primary and secondary bursae. The trochanteric bursa lies deep to the gluteus maximus muscle and superficial to the medius tendon. Other commonly involved bursae are the one deep to the gluteus medius tendon, and in relation to the gluteus minimus tendon [7]. The significance of knowledge of anatomy lies in the fact that there is differential response to steroid injections in patients of GTPS, hence the importance of injecting all the bursae when using ultra-sound guidance [8].

Figure 1: Anatomy of various primary and secondary bursae [Olive Chung].

Pre-disposing factors
Almost 10-20% of adults of more than 60 years’ age group experience some type of hip pain. However, GTPS is more common in the 4th-6th decade. It is 3-4 times more common in females than males. The pre-disposing factors include low backache, knee arthritis, iliotibial band tenderness, obesity, leg-length inequality and rheumatoid arthritis [9]. Interestingly, increased acetabular ante-version and wide trochanters in relation to iliac wings have been found increasingly associated with GTPS [10].
Contrary to common belief, bursitis is not always present in GTPS. Infact, in a study based on MRI, features of bursitis were present in only 8% of GTPS [11]. Nearly, all cases had abnormality of glutei in some form. It is hypothesized that frictional overuse of abductor apparatus, trauma or high tension of ilio-tibial band result in inflammation or tears of the gluteus medius/minimus tendons, which may ultimately progress to secondary bursitis. Other causes of lateral hip pain include trigger points (discrete, focal, hyperirritable spots located in a taut band of skeletal muscle), iliotibial band disorders, meralgia paresthetica, osteoarthritis, lumbar spine disorders. Histopathological study of proven cases of GTPS showed no changes of acute or chronic inflammation in the trochanteric bursae [12]. A word of caution exists while dealing with acute trauma, as pain of neck of femur fracture may mimick GTPS occasionally [13].
Clinical Features
Patients with GTPS present with lateral hip pain, usually intermittent. The pain is exacerbated by lying on the affected side, prolonged standing, transitioning to standing, sitting with affected leg crossed, climbing stairs, running or other high impact activities [5]. 50% patients experience pain radiating along lateral aspect of thigh to knee [14]. Ege Rasmussen KJ described a criterion for diagnosis of GTPS.
Clinical Features
Positive first two criteria along with one other criterion can be termed as GTPS. Examination reveals point tenderness (jump sign) postero-lateral to greater trochanter. Resisted active abduction along with external rotation and sometimes internal rotation typically reproduces the pain. Rarely, extension produces pain. Trendelenburg’s test was noted to be the most accurate test in detecting a tendon tear, with a sensitivity of 73% and a specificity of 77% [16].
Lateral hip pain
Distinct tenderness about the greater trochanter
Pain at the extreme of rotation, abduction, or adduction
Pain on hip abduction against resistance
Pseudo radiculopathy–pain radiating down the lateral aspect of the thigh
Patrick-FABERE (Flexion, abduction, external rotation, extension)

Table-1: Determination of GTPS [15].

Differential Diagnosis
Differentiating GTPS from other causes of lateral hip pain forms mainstay in management of the patient. Neuropathic symptoms due to damage to superior or inferior gluteal nerve can mimic GTPS [17]. Painful flexion and extension along with groin pain may indicate osteoarthritis. Avascular necrosis must be differentiated from GTPS by noting history of waxing and waning of symptoms, associated etiology (corticosteroids, smoking, alcohol, and childhood illnesses) and differential hip rotation on examination. Ilio-tibial band syndrome must be considered with positive Ober’s test (Patient positioned in side-lying with hips and knees flexed, aligning the shoulders with the hips and ankles, with the legs stacked on top of each other. The clinician then holds the patient’s top leg with the forearm in supination, supporting the lower leg and knee (90°), while his or her other hand stabilizes the pelvis. Finally, the clinician takes the leg back into hip external rotation and extends to 0°, then allows the leg to passively adduct from a position of neutral hip extension and rotation, without allowing pelvis motion and maintaining the femur in neutral) [18]. Also, it is important to ask the patient about history of snapping while walking, jogging, cycling etc. Meralgia Paresthetica can be well differentiated by presence of burning sensation over antero-lateral thigh aggravated by extension of hip. Lumbar disorders are the most important and difficult to differentiate due to co-existence in many cases. However, symptoms of radiculopathy and positive nerve stretch signs points towards spinal etiology. Sacro-iliac joint involvement present as a more posterior based pain with positive sacro-iliac tests like Gaenslen’s test, pump handle test etc.
GTPS is essentially a soft-tissue disorder. However, a plain radiograph of pelvis with both hips is important. It helps in exclusion of important pathologies like osteoarthritis, femoro-acetabular impingement, stress or avulsion injuries, and fractures. Chronic GTPS may show findings of trochanteric exostoses or osteophytes. Insertional tendinopathic calcification (than bursal) may be seen in Upto 40% of cases [19]. Ultrasound depicts tendinous pathology in the form of loss of fibrillar architecture, hypo echogenicity, thickening within- tendinopathy, intratendinous hypoechoic or anechoic foci- partial tear, ‘bald’ facet- full-thickness tear. Also, calcific gluteal tendinopathy is seen better than MRI. Bursitis may be visualised in the form of crescent-shaped hypoechoic/anechoic collection deep to gluteus maximus tendon. Dynamic ultrasound helps in diagnosing snapping hip syndrome (externa coxa saltans) [20]. MRI is a highly sensitive imaging modality. It helps in detection of soft-tissue elements like gluteal insertion tears/ abnormalities. However, owing to presence of such findings in asymptomatic individuals, it is not a very specific modality [21]. It is useful in cases of uncertain diagnosis, recalcitrant cases and in cases whom specialist referral is required.
GTPS is a self-limiting condition and usually responds to conservative measures. A wide spectrum of treatment modalities is available. However, no modality can claim to cure this condition. Recent hypothesis suspects presence of degenerative enthesopathy as cause than inflammation, hence no curative treatment. Oral analgesics, physical therapy, weight reduction and ice application have all shown to benefit in controlling symptoms due to GTPS and form the mainstay of treatment [22]. Low energy shock wave therapy has been shown to improve patient outcomes as well [23]. Cortico-steroid injections seem to be the most attractive treatment modality at present. Response rates vary from 60 to 100% with prospective studies claiming 77% success rate [5]. There is no role of fluoroscopic guidance, however ultra-sound guidance helps in injecting all 4 bursae around the greater trochanter. Most common causes for failures include other bursae involvement, tendonitis, misdiagnosis, inaccurate needle placement and recurrence of symptoms [5]. Injection technique includes using 40 - 80 mg of methylprednisolone combined with 4–6 ml of 1% lignocaine. Half of the mixture is injected at the point of maximal tenderness with the rest infiltrated in the surrounding tissues. Complications, although rare, include sterile abscess, nerve injury, granulomatous reaction and skin atrophy [2]. Dry needling is a recent treatment modality in GTPS. It involves electrical stimulation-2 Hz, 250 microseconds with the help of needles [24]. Peri-articular hip endoscopy [25] involves suture-anchor repair of tendinous tears (gluteus medius/ minimus) to greater trochanter, bursectomy for recalcitrant trochanteric bursitis and iliotibial band release (diamond shape resection) for external snapping.

Figure 2: Bursectomy for recalcitrant trochanteric bursitis and iliotibial band release [24].

Other options for recalcitrant cases include ITB Z-lengthening, open reduction trochanteric osteotomy and platelet-rich plasma injections. There is increasing trend of use of platelet-rich plasma injections in treatment of GTPS; however, there is no good evidence in literature available to our knowledge, about its efficacy.
Trochanteric pain in post-hip arthroplasty
15% of bursae are involved when observed while doing the primary hip replacement for osteoarthritis. There is increasing trend of recognition of problem of trochanteric pain following total hip replacement. Though the management of these cases is similar to those of conventional GTPS, there is an inherent fear among surgeons of injecting Cortico-steroid in a clinic setting owing to the risk of infection and most surgeons prefer to inject in sterile operating room.
Due to overlapping presentation of various pathologies, excluding GTPS from other causes is the main challenge in management of GTPS. MRI is gold standard for difficult, recalcitrant cases not responding to conservative measures. Conservative management forms mainstay of treatment. Corticosteroids have proven role in management of symptoms, however, must be used judiciously and only when conservative measures fail.
  1. Stegemann H. “Die chirurgische bedevtung paraartikularer kalkablagerungen”. Archives of Klinical Chiroplasty 125 (1923): 718–738.
  2. Shbeeb MI and Matteson EL. “Trochanteric bursitis (greater trochanter pain syndrome)”. Mayo Clinic Proceedings 71.6 (1996): 565-569.
  3. Paluska SA. “An overview of hip injuries in running”. Sports Medicine 35.11 (2005): 991-1014.
  4. Alvarez-Nemegyei J and Canoso JJ. “Evidence-based soft tissue rheumatology: III: trochanteric bursitis”. Journal of Clinical Rheumatology 10.3 (2004): 123-124.
  5. Williams BS and Cohen SP. “Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment”. Anaesthesia Analogues 108.5 (2009): 1662-1670.
  6. Brinks A., et al. “Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice”. BMC Musculoskeletal Disorders 8(2008): 95.
  7. Hugo D and de Jongh HR. “Greater trochanteric pain syndrome”. South African Orthopaedics Journal. [Internet]. 11.1 (2012): 28-33.
  8. McEvoy JR., et al. “Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: greater trochanter bursa versus subgluteus medius bursa”. American Journal of Roentgenology 201.2 (2013): 313-317.
  9. Christmas C., et al. “How common is hip pain among older adults?” The journal of family practice 51.4 (2002): 345-348.
  10. Viradia NK., et al. “Relationship between width of greater trochanters and width of iliac wings in tronchanteric bursitis”. American Journal of Orthopaedics 40.9 (2011): 159-162.
  11. Bird PA., et al. “Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome”. Arthritis and Rheumatism 44.9 (2001): 2138-2145.
  12. Silva F., et al. “Trochanteric bursitis: refuting the myth of inflammation”. Journal of Clinical Rheumatology 14.2 (2008): 82-86.
  13. Margo K., et al. “Evaluation and management of hip pain: an algorithmic approach”. Journal of Family Practise 52.8 (2003): 607-617.
  14. Gordon EJ. “Trochanteric bursitis and tendinitis”. Clinical Orthopaedics 20 (1961): 193-202.
  15. Ege Rasmussen KJ and Fano N. “Trochanteric bursitis. Treatment by corticosteroid injection”. Scandinavian journal of rheumatology 14.4 (1985): 417-420.
  16. Dunn T., et al. “Anatomical study of the trochanteric bursa”. Clinical Anatomy 16.3 (2013): 233-240.
  17. Kendall FP., et al. “Muscles: testing and function with posture and pain”. Philadelphia: Lippincott Williams & Wilkins (2005).
  18. Ho GW and Howard TM. “Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction”. Current Sports Medical Reports 11.5 (2011): 232-38.
  19. Connell DA., et al. “Sonographic evaluation of gluteus medius and minimus tendinopathy”. European Radiology 13.6 (2003): 1339-1347.
  20. Blakenbaker DG., et al. “Correlation of MRI findings with clinical findings of trochanteric pain syndrome”. Skeletal Radiology 37 (2008): 903-909.
  21. Butcher JD., et al. “Lower extremity bursitis”. American Family Physician 53.7 (1996): 2317-2324.
  22. Lustenberger DP., et al. “Efficacy of treatment of trochanteric bursitis: a systematic review”. Clinical Journal of Sport Medicine 2011 Sep; 21(5): 447-453.
  23. Pavkovich R. “Effectiveness of dry needling, stretching, and strengthening to reduce pain and improve function in subjects with chronic lateral hip and thigh pain: a retrospective case series”. International Journal of Sports Physical Therapy 10.4 (2014): 540-551.
  24. Byrd JWT. “Peri trochanteric Access and Gluteus Medius Repair”. Arthroscopy Techniques 2.3 (2013): e243-e246.
  25. Verhelst L., et al. “Extra-articular hip endoscopy: A review of the literature”. Bone and Joint Research 1.12 (2012): 324-332.
Copyright: © 2016 Videsh Raut., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PubMed Indexed Article

EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005

EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777

EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347

EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478

EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253

EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033

EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992

EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505

EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793

EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211

EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047

EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560

EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318

EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819

EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840

EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344

EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476

EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658

EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489

EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278

EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108

EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571

EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333

EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883

EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001

EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937

EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723

EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726

EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603

EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646

EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616

EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290

EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226

EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812

EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268

News and Events

November Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the November issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for Upcoming Issue

ECronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before December 09, 2022.

Certificate of Publication

ECronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

ECronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.