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Therapist’s guide to Greater Trochanteric Pain Syndrome
My approach has evolved in how to treat and prescribe exercises to patients with lateral hip pain or greater trochanteric pain syndrome (GTPS). In the last two months, I have treated about a dozen patients with GTPS using a new approach and all of them have been helped greatly. GTPS is a fairly common condition with 15% of women and 8.5% of men suffering the condition at some point. GTPS is often treated with a corticosteroid injection, but is this wise?
Update: New evidence that gluteal tendinopathy is more common than trochanteric bursitis. A research review was published in 2015, they concluded, “There is a dearth of evidence for any treatments, so the approach we recommend involves managing the load on the tendons through exercise and education on the underlying pathomechanics.”
“The cause of GTPS is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.” 2013 study of 877 patients
GTPS is diagnosed with pain on palpation of the greater trochanter, and pain with passive external rotation plus abduction of the thigh. MRI and/or diagnostic ultrasound may reveal swelling, but often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS. Most commonly one or two of the four lateral hip bursae are injected, with often poor results. Injecting all four (gluteus medius, gluteus minimus, subgluteus medius and subgluteus minimus) bursae has been recommended by some.
After one year 36% (29% after five years) of GTPS cases are still symptomatic. A high prevalence of cases have leg length discrepancy, ITB syndrome or OA at the knee, suggesting a lower limb biomechanical link. Given the high recidivism rate and the biomechanical link, could it be that in many (or most) cases bursitis is a misdiagnosis and gluteal enthesopathy is the actual problem?
A 2015 study found that patients with glute tendinopathy on one side, had weakness of the hip abductors on both sides.
A 2016 study revealed, “Individuals with gluteal tendinopathy exhibit greater hip adduction moments and alterations in trunk and pelvic kinematics during walking. Findings provide a basis to consider frontal plane pelvic control in the management of gluteal tendinopathy.”
Gluteal enthesopathies (GE) are treated differently than a bursitis! An exercise approach of high load isometrics progressing to eccentrics, is recommended for GE. Because it is difficult to rule out a bursitis it is best not to load an elongated tendon isometrically (or with repeated thigh rotation). In general, it is probably not wise to stretch a tendon over an irritated bursa or bone. Stretching (and ill-advised exercises) were found to make proximal hamstring tendinopathies worse. The same applies when dealing with ischial-gluteal bursitis. Load the tendon, but not with it stretched over the underlying bursa or bone. Keep the isometrics in a “safer” range.
Of course, it is important to address any biomechanical issues of the foot and/or knee. I find myofascial release is an effective soft tissue method to increase the flexibility of the hips, and any lower limb biomechanical issues. Chiropractic works well to promote a neurophysiological response to maximize glute activation, and I recommend gentle myofascial release at the enthesis.
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