Greater Trochanteric Pain Syndrome (GTPS) is a clinical diagnosis for pain on the side of the hip, with possible causes including:
- trochanteric bursitis (swollen structure near the tendon) associated with tendinopathy (problematic tendon)¹ ² ³
- tendinopathy of two of the outer hip muscles³ ⁴ ⁵ ⁶
- tears of the outer hip muscle tendons
- snapping hip syndrome
- iliotibial band (ITB – a tight long band which runs from the hip to the knee) abnormalities
This condition used to be referred to as trochanteric bursitis, but recent research has shown that the bursitis is not the main problem, but rather a consequence of existing tendinopathy.² ⁷ Tendinopathy has been found to be the most prevalent cause of GTPS⁷ ⁸ ⁹ ¹⁰ and should always be treated first. GTPS is far more common in women (up to four times more common than in men) ⁸ between the ages of 40 and 60.² ⁶ ¹⁰
GTPS is characterised by intense, aching pain in the outer hip. Some other characteristics of this condition include:
• pain when lying on the problematic side⁸ ⁹ ¹⁴
• pain when pressing on the muscles of the outer hip, especially over the tendon near the hip bone ⁵ ⁸ ⁹ ¹⁴
• increased symptoms after sitting for a long time ⁸ ¹⁶
• weight-bearing activities such as walking, climbing stairs and running cause pain ² ⁸ ⁹ ¹⁴
• pain when standing with more weight on the problematic side’s leg (hanging on one leg) ⁸
• pain when sitting with leg’s crossed or with knees together ⁸
• the pain can refer down the outer thigh sometimes ² ⁵ ⁸ ¹⁴
Why does Greater Trochanteric Pain Syndrome occur?
There are a few reasons why this condition can occur:
- The tendon can become a problem because of overuse⁶, loading the tendon too much⁶ ¹⁰ or due to an incomplete healing process after injury¹
- Weak hip muscles can cause the ITB to press against the tendons in the outer hip³. Weak hip muscles can also prevent the best position of the hp which in turn can compress the tendons against the hip bone more than normal, causing pain³.
- Although the bursa is not the main cause of the problem, if it becomes swollen (bursitis), it can contribute to the pain in the side of the hip.¹¹
- Snapping hips are an uncommon cause of the pain but they are also something to consider. There are multiple tendons that can cause a snapping hip, but the most relevant one is when the one hip/glute muscle or the ITB snaps over the hip bone¹² ¹³
- Not all snapping hips are painful, but when they are, they fall under the GTPS diagnosis. Please have a look at this video for a demonstration of a snapping hip.
In athletes, weak hip muscles, running on cambered roads, incorrect shoes and/or incorrect training can contribute towards GTPS developing.¹⁴
Treatment of GTPS
There are a few options for conservatively managing this condition. Conservative, (in other words, a treatment that does not involve surgery), is the preferred choice of treatment initially.
Education regarding what positions and activities to avoid. This includes stretching of the hip muscles;⁸ sitting with your legs crossed or knees together; ⁸ ¹⁵ lying on the painful side⁸ ¹⁵ and standing with more weight on one leg.⁸ ¹⁵ Avoiding these things together with the correct exercise/strengthening has been shown to be very effective. When lying on your unaffected side, place a pillow or two between your knees and shins¹⁵ to prevent irritation of the tendon on the affected side.
Exercise: Strengthening of the outer hip muscles is a very important part of treating the condition. The exercises are progressed in a certain way to allow the tendon to learn to take load again⁹ and to provide better stability at the hip, which in turn reduces compression at the tendons in the outer hip area. There are also certain exercises called isometric exercises that are very effective in reducing pain¹⁵ ¹⁶ and lead to pain relief for between 4 to 8 hours after doing them.¹⁶
There are a number of studies mentioning cortisone injections as an effective way of reducing pain, but exercise combined with avoidance of painful positions/activities has been shown to be more effective than cortisone.¹⁷ A Cortisone injection is definitely helpful in scenarios where pain limits treatment, but unfortunately it only has a short-term effect¹⁰ ¹⁷ and it is more beneficial for pain caused by the bursa than the pain caused by the tendon.¹⁴ Anti-inflammatory tablets may be helpful in the very early phase of GTPS, but if the problem has been present for a long time, these tablets are not advised as usage may negatively impact tendon healing¹⁴.
Ultrasound is not effective for managing this condition, whilst icing and heat have limited supporting evidence.¹⁹
This article was submitted by Wendy Snyders, Practice Manager at the Tygervalley, Cape Town branch of Lamberti Physiotherapy. You can contact her to discuss any symptoms you may be experiencing, by completing an online form.
1. Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology. 2013 Nov;201(5):1083-6.
2. CJB, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. British Journal of General Practice. 2017;67:479-480.
3. Jacobson JA, Yablon CM, Henning PT, Kazmers FS, Urquhart A, Hallstrom B, Bedi A, Parameswaran A. Greater Trochanteric Pain Syndrome: Percutaneous Tendon Fenestration Versus Platelet-Rich Plasma Injection for Treatment of Gluteal Tendinosis. J Ultrasound Med. 2016;35:2413–2420
4. Khoury AN, Brooke K, Helal A, Bishop B, Erikson L, Palmer IJ, Martin HD. Proximal iliotibial band thickness as a cause for recalcitrant greater trochanteric pain syndrome. Journal of Hip Preservation Surgery. 2018;5(3):296–300.
5. Domb BG, Carreira DS. Endoscopic Repair of Full-Thickness Gluteus Medius Tears. Arthroscopy Techniques. 2013;2(2):e77-e81
6. Reid D. The management of greater trochanteric pain syndrome: A systematic literature review. Journal of Orthopaedics. 2016;13:15-28.
7. Ali M, Oderuth E, Atchia I, Malviya A. The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review. Journal of Hip Preservation Surgery. 2018;5(3):209–219
8. Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. JOSPT. 2015;45(11):910-924.
9. Klauser AS, Martinoli C, Tagliafico A, Bellmann-Weiler R, Feuchtner GM, Wick M, Jaschke WR. Greater Trochanteric Pain Syndrome. Seminars in Musculoskeletal Radiology. 2013;17(1):43-48.
10. Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Med. 2015;45(8):1107-1119.
11. Fearon AM, Twin J, Dahlstrom JE, Cook JL, Cormick W, Smith PN, Scott A. Increased substance P expression in the trochanteric bursa of patients with greater trochanteric pain syndrome. Rheumatol Int. 2014; 34(10):1441–1448.
12. Lewis CL. Extra-articular snapping hip: a literature review. Sports health. 2010 May;2(3):186-90.
13. Yen YM, Lewis CL, Kim YJ. Understanding and treating the snapping hip. Sports medicine and arthroscopy review. 2015 Dec;23(4):194.
14. Lin CY, Fredericson M. Greater Trochanteric Pain Syndrome: An Update on Diagnosis and Management. Curr Phys Med Rehabil Rep. 2015;3(1);60-66.
15. Ganderton C, Semciw A, Cook J, Moreira E, Pizzari T. Gluteal loading versus sham exercises to improve pain and dysfunction in postmenopausal women with greater trochanteric pain syndrome: a randomized controlled trial. Journal of Women’s Health. 2018 Jun 1;27(6):815-29
16. Cook J. Lower Limb Tendinopathy. Lower Limb Tendinopathy course; 2020 Mar 9-10; Cape Town, South Africa. P1-102.
17. Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: a prospective, single, blinded, randomised clinical trial. BMJ. 2018;360:1-9.
18. Koulischer S, Callewier A, Zorman D. Management of greater trochanteric pain syndrome: a systematic review. Acta Orthop Belg. 2017 Jun;83:205-14.
19. Wyss J, Patel A. Therapeutic Programs for Musculoskeletal Disorders. United States of America: Bradford & Bigelow Printing, 2013.