Greater trochanteric pain syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Greater trochanteric pain syndrome (GTPS), also known as trochanteric bursitis, is inflammation of the trochanteric bursa, a part of the hip.

This bursa is at the top, outer side of the femur, between the insertion of the gluteus medius and gluteus minimus muscles into the greater trochanter of the femur and the femoral shaft. It has the function, in common with other bursae, of working as a shock absorber and as a lubricant for the movement of the muscles adjacent to it.[citation needed]

Occasionally, this bursa can become inflamed and clinically painful and tender. This condition can be a manifestation of an injury (often resulting from a twisting motion or from overuse), but sometimes arises for no obviously definable cause. The symptoms are pain in the hip region on walking, and tenderness over the upper part of the femur, which may result in the inability to lie in comfort on the affected side.[citation needed]

More often the lateral hip pain is caused by disease of the gluteal tendons that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles.[1]

Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis.[2] It may also coexist with low back pain, arthritis, and obesity.[3]

Signs and symptoms

The primary symptom is hip pain, especially hip pain on the outer (lateral) side of the joint. This pain may appear when the affected person is walking or lying down on that side.[citation needed]

Diagnosis

A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpating the hip and leg may reveal the location of the pain, and range-of-motion tests can help to identify its source.[citation needed]

X-rays, ultrasound and magnetic resonance imaging may reveal tears or swelling. But often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS.[2]

Differential diagnosis

Greater trochanteric bursitis must be differentiated from other causes of bursitis

Type of Bursitis Differential diagnosis
Subacromial bursitis[4]
Olecranon bursitis[5][6]
Trochanteric bursitis[7][8]
Prepatellar bursitis[9][10][11]
Retrocalcaneal bursitis[12][13]

Prevention

Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.[citation needed]

Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.[14]

Treatment

The primary treatment is rest. This does not mean bed rest or immobilizing the area but avoiding actions which result in aggravation of the pain. Icing the joint may help. A non-steroidal anti-inflammatory drug may relieve pain and reduce the inflammation. If these are ineffective, the definitive treatment is steroid injection into the inflamed area.

Physical therapy to strengthen the hip muscles and stretch the iliotibial band can relieve tension in the hip and reduce friction. The use of point ultrasound may be helpful, and is undergoing clinical trials.[15]

In extreme cases, where the pain does not improve after physical therapy, cortisone shots, and anti-inflammatory medication, the inflamed bursa can be removed surgically. The procedure is known as a bursectomy. Tears in the muscles may also be repaired, and loose material from arthritic degeneration of the hip removed.[14] (At the time of bursal surgery, a very close examination of the gluteal tendons will reveal sometimes subtle and sometimes very obvious degeneration and detachment of the gluteal tendons. If this detachment is not repaired, removal of the bursa alone will make little or no difference to the symptoms.[citation needed])

The bursa is not required, so the main potential complication is potential reaction to anaesthetic. The surgery can be performed arthroscopically and, consequently, on an outpatient basis. Patients often have to use crutches for a few days following surgery up to a few weeks for more involved procedures.[citation needed]

There are numerous case reports in which surgery has relieved GTPS, but its effectiveness is not documented in clinical trials.[3]

See also

References

  1. Trochanteric Bursitis at eMedicine
  2. 2.0 2.1 Dougherty C, Dougherty JJ (August 27, 2008). "Evaluating hip pathology in trochanteric pain syndrome". The Journal of Musculoskeletal Medicine.
  3. 3.0 3.1 Williams BS, Cohen SP (2009). "Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment". Anesthesia & Analgesia. 108 (5): 1662–1670. doi:10.1213/ane.0b013e31819d6562. PMID 19372352.
  4. Walker‐Bone, Karen, et al. "Prevalence and impact of musculoskeletal disorders of the upper limb in the general population.
  5. Stell IM (1996). "Septic and non-septic olecranon bursitis in the accident and emergency department--an approach to management". J Accid Emerg Med. 13 (5): 351–3. PMC 1342774. PMID 8894865.
  6. Lockman L (2010). "Treating nonseptic olecranon bursitis: a 3-step technique". Can Fam Physician. 56 (11): 1157. PMC 2980436. PMID 21075998.
  7. Brinks A, van Rijn RM, Bohnen AM, Slee GL, Verhaar JA, Koes BW; et al. (2007). "Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice". BMC Musculoskelet Disord. 8: 95. doi:10.1186/1471-2474-8-95. PMC 2045096. PMID 17880718.
  8. Karpinski MR, Piggott H (1985). "Greater trochanteric pain syndrome. A report of 15 cases". J Bone Joint Surg Br. 67 (5): 762–3. PMID 4055877.
  9. Aaron, Daniel L., et al. "Four common types of bursitis: diagnosis and management." Journal of the American Academy of Orthopaedic Surgeons 19.6 (2011): 359-367.
  10. Huang, Yu-Chih, and Wen-Lin Yeh. "Endoscopic treatment of prepatellar bursitis." International orthopaedics 35.3 (2011): 355-358.
  11. Meyerding, Henry W., and ROBERT E. VanDEMARK. "POSTERIOR HERNIA OF THE KNEE:(BAKER'S CYST, POPLITEAL CYST, SEMIMEMBRANOSUS BURSITIS, MEDIAL GASTROCNEMIUS BURSITIS AND POPLITEAL BURSITIS)." Journal of the American Medical Association 122.13 (1943): 858-861.
  12. Fauci, Anthony S., and Carol Langford. Harrison's rheumatology. McGraw Hill Professional, 2010.
  13. Lyman, Jeffrey, Paul S. Weinhold, and Louis C. Almekinders. "Strain behavior of the distal Achilles tendon implications for insertional Achilles tendinopathy." The American Journal of Sports Medicine 32.2 (2004): 457-461.
  14. 14.0 14.1 Dougherty C, Dougherty JJ (November 1, 2008). "Managing and preventing hip pathology in trochanteric pain syndrome".
  15. Clinical trial number NCT01642043 for "Point-of-Care Ultrasound in Greater Trochanteric Pain Syndrome" at ClinicalTrials.gov

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