Frustrated by Lateral Hip Pain? Is it Trochanteric Bursitis or Tendinopathy? Start Here People!

Pain over the lateral hip is common particularly among distance runners and women over the age of 40. There was a time when lateral hip pain was thought to be due to trochanteric bursitis only. Research, clinical experience and advances in technology we understand that tendinopathy of the gluteus medius and/or minimus can cause lateral hip pain and potentially coexists with bursa pathology. Greater Trochanter Pain Syndrome (GTPS) it now used instead of Trochanteric Bursitis to describe lateral hip pain. The gluteus medius bursa lies beneath the tendon of the gluteus medius and the trochanteric bursa is lateral and superficial to the greater trochanter. Gluteus medius tendinopathy - tenderness on palpation of the gluteus medius muscle. Triggered by falls, prolonged weight-bearing on one leg. The most at risk populations for greater trochanteric pain syndrome are novice runners. Patients report pain over the greater trochanter which may extend into the lateral thigh, and even the lateral leg. Frequently, pain lying on the affected side at night also causes problems, also pain during or after weight-bearing activities is very common. Palpation of the greater trochanter produces the jump sign – as it’s usually pretty sore when you push on the area. Active Hip Range of movement tests for flexion, adduction, abduction, and the rotations in 0° and 90° flexion are normal or slightly increased, although muscle spasm may affect these. The FABER test is frequently positive, while Ober’s test may or may not be positive. passive hip joint examination helps assess for the presence of fpathology such as osteoarthritis. Resisted external rotation and abduction muscles tests can test for muscle weakness, and any obvious difference between the painful and non-painful side can potentially help with forming a diagnosis….. and give some clues as what should be targeted during the treatment/rehabilitation phase. Step up and step down test may help differentiate between tendinopathy, tears, and hip osteoarthritis. Those with more severe GTPS reports high levels of pain with stepping up forwards onto the step, and down sideways off the step. Those with less severe presentation have pain with the hip hitch with external and/or internal rotation. Reports of groin pain with these activities is likely if the person has hip joint pathology (e.g. chondropathy, osteoarthritis) in addition to lateral hip pain. A Trendelenburg gait, and weakness may be present - this is an inhibition or weakness of the gluteus medius and/or minimus muscles. Differentiating between pain inhibition and true weakness is important. The symptoms specifically affect runners, possibly due to the tilting of the pelvis with running. Diagnostic ultrasound can be performed to determine if fluid is present in the bursa or thickening exists about the bursa, and to look for echogenic changes that are consistent with tendinopathy and tears. Magnetic resonance imaging (MRI) demonstrates tendinopathy and tears of the gluteus medius. The principles of treating GTPS or similar to the treatment of other tendinopathy is: -Control pain by minimising the compression on the greater trochanter and managing the load on the tendons. -Strengthen and improve function of the gluteal muscles. -Treat comorbidities. It’s all about keeping the loads to a level where the injured tissues are not further aggravated, whilst aiming to strengthen the tendons and muscles to make them better prepared to handle to daily loads we place upon them. We can manipulate the load by either changing the duration of the activity, the intensity of the activity, or the frequency of the activity. Patients should be checked for hip abduction and rotation control in activities of daily living. Look for hip adduction during stepping, standing etc which Increases the risk of developing GTPS. As the patient improves we can increase the load and bring in sports specific activities such as running, jumping, and hopping. Shockwave therapy has been shown to be effective in the treatment of GTPS. Ultrasound guided corticosteroid injection has been shown to be an effective treatment for gluteus medius tendinopathy. A corticosteroid injection is only one part of the treatment – to enable the patient to commence a rehabilitation program. Resistance band exercises need to be introduced very carefully, and the response monitored carefully. Furthermore, referred pain from the spine should be assessed and treated as appropriate.