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The term “greater trochanteric pain syndrome” (GTPS) describes a collection of overlapping conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, iliotibial band syndrome, and tendinopathy of the hip abductor muscles.  (1-4)

Tears of the gluteus medius or minimus tendon insertion at the greater trochanter commonly accompany or mimic GTPS. The relative frequency of these tears has given them the moniker “rotator cuff tears of the hip”. The Hip Lag Sign demonstrates high sensitivity (89.5%) and specificity (96.6%) for identifying hip abductor tears. (5)

Review the Hip Lag Sign Video Now

Strains of the gluteus medius tendon may be present in nearly one-fourth of the elderly population.  (6-8) Gluteal tears progress much like rotator cuff tears- beginning as interstitial partial anterior tears and progressing to full thickness tears.  (9,10) Successful management of GTPS and its associated pathology requires three steps.

 

1. Differentiate The Structural Problem

Gluteus Medius

Gluteus Minimus

The most classic physical finding of GTPS is tenderness to palpation over the greater trochanter. (11) Tenderness along the posterior aspect of the greater trochanter may indicate gluteus medius involvement, while discomfort at the anterior aspect may suggest a contribution from the gluteus minimus.  (12) Resisted testing can help distinguish contractile tissue involvement from simple bursitis.  (12) Resisted abduction is likely to reproduce GTPS complaints, particularly those associated with gluteus medius tendon involvement.  (13)

The FABER test may help differentiate hip from sacroiliac problems.  (14) The Thomas test can help identify excessive psoas hypertonicity. Ober’s test may be used to assess for iliotibial band contracture.

 

2. Assess for Hidden Functional Deficits

Clinicians should assess for biomechanical deficits that may contribute to GTPS, including leg length discrepancy, foot hyperpronation, and lower crossed syndrome. Most importantly, clinicians must assess for the presence of hip abductor weakness; which is central to GTPS as an etiologic factor and a source of ongoing symptoms.

The gluteus medius serves as a primary hip abductor with innervation from the superior gluteal nerve (L4-S1).  (15) The muscle originates from the posterior surface of the iliac crest and inserts at two sites on the greater trochanter – the lateral facet and the superior posterior facet.  (16) Hip abductor weakness manifests functionally by allowing the contralateral pelvis to drop during single leg stance activities, including ambulation. This causes excessive thigh adduction and medial rotation, creating significant biomechanical disadvantages at the knee and hip, particularly increased tension of the iliotibial band and compression of the greater trochanteric bursa.  (17)

Functional orthopedic testing for hip abductor weakness would include the Trendelenburg sign, overhead squat test, and single leg squat test.  The presence of an “uncompensated” pelvic drop upon Trendelenburg maneuver suggests gluteus medius weakness.  Long-standing weakness may result in a “compensated” response of lateral trunk flexion over the stance leg. Patients with significant gluteus medius tendinopathy or tearing may report pain on Trendelenburg testing. (18)

3. Restore Balance

The differentiation of specific structural contributors to GTPS is challenging.  (19) Fortunately, most of these problems arise from common functional deficits.  The goal of treatment should be correct faulty mechanics and to prevent future overload.  This process requires a focused home exercise program that aims to resolve underlying functional imbalances – like hip abductor weakness. With the right plan, conservative treatment of GTPS can exceed a 90% success rate.  (20)

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References

1. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral Hip Pain in an Athletic Population Differential Diagnosis and Treatment Options Sports Health. 2010 May; 2(3): 191–196.
2. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. May 2009;108(5):1662-70.
3. McGee DJ. Hip. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:333-71.
 Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. Dec 2008;24(12):1407-21.
5. Kaltenborn A et al. The Hip Lag Sign – Prospective Blinded Trial of a New Clinical Sign to Predict Hip Abductor Damage. PLOS One March 12, 2014
https://doi.org/10.1371/journal.pone.0091560
6. Bunker T, Esler C, Leach W. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79:618–620.
7. Lachiewicz PF (2011) Abductor tendon tears of the hip: evaluation and management. J Am Acad Orthop Surg 19: 385–391.
8. Jeanneret L, Kurmann PT, van Linthoudt D (2008) [Rotator cuff tear of the hip]. Rev Med Suisse 14: 1226–1229.
9. Connell DA, Bass C, Sykes CA, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003;13(6):1339-1347.
10. Kagan A., II Rotator cuff tears of the hip. Clin Orthop Relat Res. 1999;368:135-140
11. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. Sep 2001;44(9):2138-45.
12. Snider RK, Trochanteric bursitis. In: Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:299-303
13. . Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. Sep 2011;21(5):447-53.
14. Bartlett MD, Wolf LS, Shurtleff DB, Stahell LT. Hip flexion contractures: a comparison of measurement methods. Arch Phys Med Rehabil. 1985;66(9):620-625.
15. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. Aug 2007;88(8):988-92.
16. Robertson WJ, Gardner MJ, Barker JU, Boraiah S, Lorich DG, Kelly BT. Anatomy and dimensions of the gluteus medius tendon insertion. Arthroscopy. 2008;24(2):130-136.
17. Markley G. Greater Trochanteric Pain Syndrome. Presentation- Illinois Chiropractic Society National Convention. September 2013, Chicago, IL.
18. Smart GW, Taunton JE, Clement DB. Achilles tendon disorders in runners – a review. Med Sci Sports Exerc 1980;12(4):231-243
19. Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. Sep 2011;21(5):447-53.
20. Brooker AJ. The surgical approach to refractory trochanteric bursitis. Johns Hopkins Med J. 1979;145:98–100.

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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