Definition

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral extra-articular hip pain. GTPS is clinically characterized by peritrochanteric pain and focal tenderness [1]. GTPS describes a continuum of disorders with causes ranging from gluteus medius and minimus tears, tendinitis, or tendinopathy to trochanteric bursitis and external coxa saltans [2]. Previously, it was thought that excessive gluteal tendon friction at the greater trochanter attachment led to subgluteus maximus bursal inflammation; hence, it was called greater trochanteric bursitis [3]. However, histopathologic and imaging studies have not identified bursal inflammation as a consistent finding, thus leading to the current clinical description of this entity as GTPS [2].

The peak incidence of GTPS is between the fourth and sixth decades of life. It occurs four times more frequently in women than in men, which may be due to gender differences in pelvic and lower limb biomechanics [4,5]. It affects up to 10% of the general population and has been reported in up to 20% of patients with low back pain [5,6]. GTPS can result from direct macrotrauma after contusions from falls or contact sports [7]. However, it is more often due to cumulative microtrauma and abnormal loading forces on the gluteus medius and minimus tendons inserting on the greater trochanter. It has been suggested that gluteal tendon degeneration and tears at the greater trochanter attachment may induce secondary reactive inflammation in the bursae [4]. Contributing factors include hip or knee osteoarthritis, lumbar spine degenerative disorders, obesity, true or functional leg length discrepancies, gait abnormalities, and iliotibial band tightness [5,6,8]. GTPS can also occur after hip surgery, such as femoral osteotomy [9], hip joint replacement, or arthroscopic surgery, and from postoperative hip abductor weakness. Less common causes to consider in the differential diagnosis include infection and inflammatory arthritis if there are systemic symptoms and signs, lateral hip swelling, redness, or heat [10–12].

The greater trochanter of the femur is the insertion site of the gluteus medius, gluteus minimus, piriformis, and obturator internus muscles, and it is also the origin of the vastus lateralis muscle [13]. Three main bursae surround the greater trochanter, including the subgluteal maximus, medius, and minimus bursae [14]. The subgluteus maximus bursa is the largest bursa and lies lateral to the greater trochanter beneath the gluteus maximus and iliotibial tract. The subgluteus medius bursa lies deep beneath the gluteus medius tendon and posterosuperior to the lateral facet of the greater trochanter. The subgluteus minimus bursa lies beneath the gluteus minimus tendon at the anterosuperior edge of the greater trochanter. The subgluteus maximus bursa is most often involved in cases of trochanteric bursitis [3].

Symptoms

The main clinical symptom is lateral hip pain at the greater trochanteric region. The pain can radiate down the lateral aspect of the thigh as a pseudoradiculopathy that does not extend past the knee. Symptoms are exacerbated by hip movements, in particular external rotation and abduction. Pain may also be provoked by standing, walking, stair climbing, crossing the legs, running, or running on banked surfaces. Recent changes in physical activity or sports training programs may precede symptoms. Sleep may be affected with pain aggravated by lying in the lateral decubitus position directly on the affected side or from lying with the affected side up and in passive hip adduction.

Physical Examination

In GTPS, localized tenderness is found on direct palpation of the greater trochanter. Lateral hip pain may be reproduced on examination with resisted hip abduction with the patient in a side-lying position. Pain can also be elicited with active hip internal or external rotation at 45 degrees of hip flexion [15].

Evaluation for gait, hip, or spine disorders and leg length discrepancy is important as abnormal motion and joint loading in one region of the kinetic chain can contribute to the development of GTPS. The Trendelenburg sign can be seen in GTPS as a result of weakness or inhibition of the hip abductor muscles [16