Next to osteoarthritis, greater trochanteric pain syndrome is the most frequently encountered hip injury, estimated to eventually affect between 10 percent and 25 percent of the population.1 The patient typically complains of pain with single-leg stance, and the discomfort is often aggravated by side-lying on the affected hip. The lateral hip pain may be reproduced by palpating the lateral and posterior aspects of the greater trochanter, and/or by resisted contraction of the hip abductor / external rotator musculature.
The female to male ratio for this condition is 4:1, and 40- to 60-year-olds are especially vulnerable. This common condition is surprisingly difficult to treat, and symptoms may last months to years. While it was originally believed the lateral hip pain resulted from chronic inflammation in one of the three greater trochanter bursae (Fig. 1), recent research confirms bursal inflammation correlates poorly with the presence of lateral hip pain. As a result, the term greater trochanteric bursitis has been abandoned in favor of greater trochanteric pain syndrome.
To identify the specific tissues responsible for the development of lateral hip pain, Woodley, et al.,2 performed MRI evaluations of the symptomatic and asymptomatic hips in 40 patients presenting with unilateral greater trochanteric pain syndrome. After having the MRIs read by three radiologists, the researchers discovered that although bursal inflammation had no correlation with the presence of lateral hip pain, gluteus medius tendinopathy and atrophy of the gluteus minimus muscle were relatively common and occurred almost exclusively on the side of the symptomatic hip. Because these findings are consistent with other research confirming hip abductor tendinopathy correlates with the presence of greater trochanteric pain syndrome,3 treatment interventions should emphasize restoration of tendon function, not reduction of bursal inflammation.
Research-Based Considerations
In an important study comparing the efficacy of different treatment protocols, Rompe, et al.,3 assigned 229 patients with refractory unilateral greater trochanteric pain syndrome to one of three treatment protocols: a single local corticosteroid injection (25 mg prednisolone); a repetitive low-energy shockwave treatment; or a home training program that included specific hip abductor / rotator stretches and exercises as follows, performed twice daily, seven days a week for 12 weeks:
Subjects were re-evaluated at one, four and 15 months to evaluate the degree of recovery and severity of pain.
Study findings were interesting in that corticosteroid injection produced significant short-term improvements, while shockwave treatment and home stretches / exercises produced better long-term results.
For example, at the one-month mark, 75 percent of the subjects receiving corticosteroid injections reported significant reductions in pain, whereas only 13 percent of the shockwave group and 7 percent of the home exercise group showed significant pain reductions. However, at the four-month follow-up, 68 percent of the individuals receiving radial shockwave presented with significant pain reductions, compared to 51 percent of the corticosteroid group and 41 percent of the home stretches / exercises group. By the 15-month follow-up, the home stretching / exercise group had the best outcomes, with 80 percent reporting significant pain reductions, compared to 74 percent of the shockwave group and 48 percent of the corticosteroid injection group.
The authors state that because the significant short-term superiority of a single corticosteroid injection reversed after one month, "The role of corticosteroid injection for greater trochanter pain needs to be reconsidered."
Your Best Treatment Option
Given the economic cost of shockwave therapy, the simplest and most effective method of treating greater trochanteric pain syndrome is with strengthening exercises and stretches. Because the typical greater trochanteric pain syndrome is associated with tendinopathy of the gluteus medius and atrophy of the gluteus minimus, it is important to isolate these muscles with specific stretches and eccentric exercises. (Fig. 2) These exercises are especially helpful when treating individuals with coxa valgum (Fig. 3), since an increased femoral neck angle reduces the mechanical efficiency of the hip abductors and a strong gluteus medius is necessary for injury prevention.
In addition to these exercises, clinical outcomes are often improved by performing deep-tissue massage on the hip abductor and external rotator tendons. To access these tendons, it is often necessary to position the supine patient with the hip abducted 45 degrees. In order to produce the best possible outcomes, the practitioner must be able to isolate each specific tendon near its attachment on the greater trochanter. (Fig. 1)
In my experience, by coupling eccentric exercises with specific deep-tissue massage of the involved tendons, significant reductions in pain occur within the first four months of treatment.
References
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