Greater trochanteric pain syndrome is a common condition causing pain that is most often felt around the bony prominence on the outer part of the upper thigh (1). This bony prominence, which can be palpated through the skin, is known as the greater trochanter. It serves as a useful attachment point for the gluteal muscles. These are muscles that originate around the pelvis and insert into the greater trochanter. The role of these muscles is to primarily stabilise your leg when you place weight on it, particularly during walking (3). The muscles connect to the greater trochanter via tendons. Tendons are tough, fibrous bands of tissue that are designed to withstand stress and strain. In some cases, tendons become painful with use. When this happens, we call it “tendinopathy”. Greater trochanteric pain syndrome is a tendinopathy of the gluteal muscles that are commonly seen in primary care (3, 6).
Tendinopathy occurs because of an alteration in the rate that the tendon regenerates in response to daily load (7). Our tendons undergo changes in response to stress and strain that help to keep them healthy. In some cases, the amount of stress and strain we place our tendons under can exceed their capacity to cope. After a time, the tendon can become painful and weakened when placed under stress. This results in pain with day-to-day activities such as walking, climbing stairs and sitting. It used to be felt that tendinopathy developed due to inflammation of the tendons. However, we now understand tendinopathy to be more of a failed healing response within the tendon, where it cannot manage the day-to-day stress and strain it is subjected to (8). Pleasingly, tendinopathy usually recovers well with the right treatment and advice and is not a sign of a more serious medical condition.
Greater trochanteric pain syndrome can develop because of sudden, unexpected changes in the amount of activity the gluteal tendon(s) is/are subjected to (5,8). This may be, for example, after a walking holiday or after starting a new type of sport or activity. However, in some patients, these changes can be subtle and are not obvious. We also know now that there are certain risk factors that increase the chances of those patients who are relatively inactive developing the condition. Being overweight, diabetic or having higher cholesterol can result in tendons that are more susceptible to smaller changes in load. It is also thought hormonal influences play a role in the development of greater trochanteric pain syndrome. Therefore, it is more often seen in female patients (2,3).
This is not an exhaustive list. These factors could increase the likelihood of someone developing greater trochanteric pain syndrome. It does not mean everyone with these risk factors will develop symptoms.
Greater trochanteric pain syndrome is responsible for up to 20% of people presenting to their doctor with pain in the hip or pelvic region. It is seen in females more than males. It is most seen in female patients who are over the age of 50 (1,2).
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRIs or ultrasound scans are usually not required to achieve a working diagnosis of greater trochanteric pain syndrome, but in unusual presentations, they may be warranted.
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help recover from greater trochanteric pain syndrome. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix but if done consistently over weeks and months then they will, in most cases, make a significant difference.
Research is very clear that modifying the load that goes through the gluteal tendons is the key element that stimulates recovery. Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body. Avoiding activities that cause compression of the gluteal tendons such as walking and squatting can help modify pain, and specific exercise can help stimulate strength and recovery of the tendon itself. Try to avoid lying directly on the affected side, as well as activities that involve crossing your affected leg over the other.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing muscular imbalances associated with greater trochanteric pain syndrome. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
This programme focuses on early, appropriate loading of the affected tendon and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows, this should not exceed any more than 3/10 on your perceived pain scale.
This is the next progression. More focus is given to progressive loading of the gluteal tendons and lower limb strengthening. This should not exceed any more than 3/10 on your perceived pain scale.
This programme is a further progression with challenging progressive loading of the affected tendon complex. This is often in more challenging positions that replicate day to day activities. This should not exceed any more than 3/10 on your perceived pain scale.
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting, and sprinting exercises (5, 7).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
Podiatry referral to address gross bio-mechanical alignment issues may be helpful in the short term. However, there is a lack of quality evidence in regard to long-term value when it comes to tendon related injuries.
Corticosteroid injections should only be considered as a last resort if appropriate and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement, careful consideration is heavily encouraged as in some cases repeated injections can exacerbate and delay the recovery in greater trochanteric pain syndrome compared to exercise and education alone (9).
Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.
We have Pure Physiotherapy clinics across the country including Norwich, Ipswich, Manchester, Bolton, Wakefield and Sheffield. Please view our clinics to find the closest physiotherapy clinic for you.
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