Greater trochanteric pain syndrome

Greater trochanteric pain syndrome (GTPS) is a clinical syndrome characterised by chronic lateral hip pain localised to the greater trochanter region. It encompasses gluteal tendinopathy (tendinopathy of the gluteus medius and minimus at their greater trochanteric insertions) and trochanteric bursitis, with gluteal tendinopathy now recognised as the primary pathology in the vast majority of cases. GTPS predominantly affects middle-aged to older women and is one of the most common lower limb musculoskeletal presentations in Australian general practice. It is frequently misdiagnosed as hip OA or lumbar radiculopathy, leading to inappropriate management.

GTPS is primarily a tendinopathy of the gluteus medius and gluteus minimus tendons at their insertion on the greater trochanter, with the trochanteric bursa playing a secondary role. Understanding the compressive and tensile load mechanisms that drive tendinopathy is essential for guiding evidence-based rehabilitation.

Gluteal Tendinopathy: Primary Pathology

• Tendon anatomy — gluteus medius inserts on the lateral and posterosuperior facets of the greater trochanter; gluteus minimus inserts on the anterosuperior facet; both act as hip abductors and are essential for single-leg stance pelvic stability; the trochanteric bursa lies superficial to these insertions
• Compressive load mechanism — hip adduction (crossing legs, sitting with legs together, walking with an adducted gait) compresses the gluteal tendons against the greater trochanter; this compressive load, rather than tensile overload, is the primary driver of gluteal tendinopathy; postural habits (hip adduction in standing, sleeping with adducted hips) perpetuate the condition
• Reactive tendinopathy — acute overload of the tendon triggers reactive oedema and cell proliferation without structural failure; the tendon is thickened and mechanosensitive but structurally intact; appropriate load management during this phase prevents progression to degenerative tendinopathy
• Degenerative tendinopathy — chronic compressive and tensile overload leads to disorganised collagen, matrix disruption, and neovascularisation; partial or full-thickness tears of the gluteal tendons can occur; tendon tears are more common in older women and are associated with more severe symptoms and poorer response to injection

Risk Factors

• Female sex — women are 4 times more likely to develop GTPS; broader pelvis increases hip adduction angle during gait; postmenopausal hormonal changes reduce tendon collagen synthesis and increase tendon vulnerability
• Obesity — increased compressive load on greater trochanteric region; altered gait biomechanics with increased hip adduction during walking
• Hip OA and lumbar spine disease — gait alterations secondary to hip OA or lumbar radiculopathy alter hip abductor loading; GTPS frequently coexists with hip OA
• Sedentary to active transitions — rapid increase in walking or running load without adequate conditioning; training load spikes are a common precipitant

GTPS presents with lateral hip pain over the greater trochanter, characteristically provoked by lying on the affected side and by postures involving hip adduction. Clinical examination with a combination of palpation and provocation tests confirms the diagnosis in most cases.

History

• Lateral hip pain — pain localised to the greater trochanter, often described as a deep aching or burning; may radiate down the lateral thigh (pseudo-radiculopathy); rarely radiates below the knee (consider lumbar cause if so)
• Provocative activities — lying on the affected side (classic nocturnal pain); crossing legs; prolonged sitting with legs crossed or thighs adducted; walking up or down stairs; standing on one leg; sitting with hip in adduction (car seat, low chair)
• Postural aggravators — walking with an adducted gait (Trendelenburg-type); standing habitually with hip resting in adduction; sleeping in foetal position with knees together
• Onset — typically insidious; may follow a sudden increase in activity level; bilateral GTPS occurs in approximately 20–25% of cases

Examination Findings

• Point tenderness over greater trochanter — palpation directly over the greater trochanter reproduces pain; the most sensitive examination finding; tenderness at the lateral facet (gluteus medius insertion) and posterosuperior facet (gluteus medius and minimus); distinguish from hip joint tenderness (groin)
• Single leg stance (Trendelenburg) — pain or inability to maintain single leg stance for 30 seconds on the affected side; indicates gluteal tendon mechanosensitivity; contralateral pelvic drop (positive Trendelenburg sign) indicates gluteus medius weakness
• FABER test (Flexion, ABduction, External Rotation) — lateral hip pain reproduced in FABER position; the hip adduction component compresses the gluteal tendons against the trochanter; a positive FABER reproducing lateral hip pain is more specific for GTPS than for hip OA (which causes groin pain)
• Resisted hip abduction — pain with resisted abduction at 0° or with the hip in adduction (ABER position); indicates gluteus medius tendinopathy; weakness on manual testing suggests partial or complete gluteal tendon tear
• Hip range of motion — preserved in GTPS; significantly restricted internal rotation with groin pain suggests concurrent hip OA; hip ROM should always be assessed to exclude hip joint pathology

GTPS is primarily a clinical diagnosis. Investigations are used to confirm the diagnosis in atypical presentations, exclude hip joint pathology, guide injection therapy, and assess for gluteal tendon tears before surgical decision-making.

• Essential
  X-ray pelvis (AP) and hip (lateral)

  Mandatory at first presentation to exclude hip OA, femoral neck stress fracture, Paget's disease, and bony lesions. GTPS: X-ray usually normal; may show trochanteric calcification in chronic cases. Hip OA: joint space narrowing, osteophytes, subchondral sclerosis. Weight-bearing AP pelvis for accurate joint space assessment. If FABER and hip ROM testing suggest hip joint involvement, X-ray is essential before further management.
• Recommended
  Musculoskeletal ultrasound

  First-line soft tissue imaging for GTPS. Identifies gluteal tendinopathy (tendon thickening, hypoechogenicity, intratendinous calcification), trochanteric bursitis (anechoic fluid collection), and gluteal tendon tears (partial or full-thickness). Essential for guiding corticosteroid or PRP injection into the trochanteric bursa or peritendinous region. Identifies gluteal tendon tears that would alter management (surgical consideration). Available with bulk-billing at most Australian radiology practices.
• Specialised
  MRI hip

  Gold standard for gluteal tendon tear assessment (partial and full-thickness), bone marrow oedema, labral tears, and avascular necrosis. Indicated when ultrasound findings are equivocal, clinical examination suggests significant gluteal weakness (possible tear), or when surgical management is being considered. Also indicated when hip OA, labral pathology, or osteonecrosis is suspected and X-ray is inconclusive. Not required for typical GTPS managed conservatively.

Severity stratification in GTPS guides the balance between load management, physiotherapy, corticosteroid injection, and specialist referral.

Pharmacological management of GTPS provides symptomatic pain relief to enable participation in rehabilitation. Corticosteroid injection provides superior short-term relief but does not alter the natural history of gluteal tendinopathy and has inferior long-term outcomes compared to physiotherapy-led loading programs.

Physiotherapy-led gluteal tendon loading is the definitive treatment for GTPS, with superior long-term outcomes compared to corticosteroid injection or wait-and-see. Education about compressive load avoidance is a critical and often underemphasised component of management.

Physiotherapy: Gluteal Loading Program

• Education (load management) — this is the single most important intervention; patients must understand that hip adduction (crossing legs, sleeping with knees together, standing with hip hitched) compresses the gluteal tendons and perpetuates pain; avoiding compression postures allows the tendon to recover; most patients have never been told about these positions and experience rapid symptom improvement with posture correction alone
• Isometric hip abduction (reactive phase) — sustained isometric hip abduction against resistance (wall, theraband) in a neutral hip position (not adduction); 5 repetitions of 45–second holds; performed daily; reduces tendon pain immediately and for hours after; suitable when pain is high (≥4/10) or during reactive flare; does not compress the tendon
• Isotonic loading (rehabilitation phase) — progressive hip abduction, hip extension, and squat exercises; single leg squat progression from partial to full range; 3 sets of 15 repetitions; progressive load over 8–12 weeks; must avoid hip adduction range throughout exercises; physiotherapist supervision required to ensure correct technique
• Running and walking modification — running with hip adduction (crossing midline) is a major load driver; gait retraining (reduce crossover, increase step width, increase cadence) significantly reduces compressive trochanteric load; walking on cambers (roadside camber produces hip adduction on the uphill side) should be avoided initially

Interventional Procedures

• Platelet-rich plasma (PRP) injection — ultrasound-guided injection into the gluteal tendon; emerging evidence for efficacy in refractory GTPS; MAST trial shows superior outcomes to corticosteroid at 12 months; not PBS-funded; cost $300–600 AUD; indicated after failure of physiotherapy loading program and corticosteroid injection; referred to sports medicine or musculoskeletal medicine specialist
• High-volume injection — large-volume (10–40 mL) saline with steroid injection peritendinously; may disrupt neovascularisation; limited GTPS-specific evidence; used in some sports medicine practices

Surgical Management

• Gluteal tendon repair — endoscopic or open surgical repair of partial or full-thickness gluteal tendon tears; indicated for significant tears with severe abductor weakness that have failed 6 months of conservative management; high success rates (80–90%) for appropriately selected cases; orthopaedic hip arthroplasty specialist referral
• Iliotibial band release — endoscopic release of the IT band over the greater trochanter; may reduce compressive load; less commonly performed; considered when IT band tightness is a significant contributing factor

Non-pharmacological management is central to GTPS recovery. Load management education, posture correction, and progressive exercise form the evidence-based core of treatment. Sleep modification and activity adaptation address the most disabling aspects of the condition.

Posture and Load Modification

• Sleeping position — avoid lying on the affected side without hip support; if side lying is unavoidable, place a pillow between the knees to prevent hip adduction; sleeping on the back with legs in neutral is ideal during the acute phase; many patients experience near-immediate nocturnal pain reduction with pillow positioning
• Sitting posture — avoid crossing legs; sit with thighs parallel or slightly apart; avoid low chairs that produce hip adduction; avoid sitting with one hip hitched higher (crossed leg position at the knee); car seat adjustment to ensure hips are in neutral abduction
• Standing posture — avoid standing with weight through one leg in hip adduction (hip hitching); stand with weight evenly distributed; avoid leaning against a wall or bench with the hip in relative adduction
• Walking modification — increase step width; avoid crossover gait; wear supportive footwear with cushioned soles; avoid walking on road cambers initially; trekking poles can reduce trochanteric load on walking

Patient Education

• Condition explanation — explain that GTPS is a tendinopathy driven by compressive load from hip adduction, not a bursitis from inflammation; this reframes the condition and empowers patients to actively modify posture; reassure that the condition is self-limiting with appropriate management but requires patience (recovery over months)
• Expected course — with physiotherapy-led loading program and posture education, 80–90% improve significantly over 12 weeks; injection provides faster short-term relief but does not change the 12-month outcome; patients who continue adduction postures will relapse regardless of treatment

Monitoring focuses on pain response, functional improvement, and compliance with load management education. Failure to improve despite appropriate management should prompt reassessment of diagnosis and imaging review.

Indications for Specialist Referral

• Orthopaedics — confirmed gluteal tendon tear with significant weakness and functional impairment after 6 months conservative management; failed corticosteroid injection and physiotherapy program
• Sports medicine / musculoskeletal medicine — refractory GTPS for PRP injection consideration; complex biomechanical assessment; gait retraining
• Rheumatology — if bilateral GTPS with systemic features raises concern for inflammatory arthritis (PMR, spondyloarthritis); polymyalgia rheumatica can present with bilateral hip girdle pain and may coexist with GTPS

Special considerations apply to postmenopausal women, athletes, and patients with concurrent hip OA or lumbar spine disease.

Postmenopausal Women

• Oestrogen deficiency — postmenopausal oestrogen decline reduces tendon collagen synthesis and increases tendon stiffness and vulnerability; GTPS incidence peaks in the perimenopausal period; hormone replacement therapy (HRT) has been associated with lower rates of tendinopathy in observational studies but is not recommended solely for GTPS
• Weight management — postmenopausal weight gain increases trochanteric compressive load; dietary and exercise-based weight management is an important adjunct to GTPS rehabilitation; waist circumference reduction improves gait biomechanics

Athletes and Active Individuals

• Running athletes — crossover gait is a modifiable risk factor; gait retraining (increase step width, avoid crossover) significantly reduces trochanteric compressive load and is superior to rest alone; reduce running volume by 50% during acute phase; avoid hill running and road cambers during rehabilitation
• Return to sport — progressive loading protocol; single leg squat symmetry (>90%) before return to full running; hip abductor strength symmetry; functional hop tests

Concurrent Hip OA

• Coexistence — GTPS and hip OA frequently coexist; altered gait from hip OA increases trochanteric compressive load; both conditions should be treated simultaneously; hip OA management (physiotherapy, weight loss, analgesia) may reduce GTPS severity by normalising gait; intra-articular hip injection may benefit both conditions in some cases

Stewardship in GTPS focuses on avoiding repeated corticosteroid injections without physiotherapy engagement, intratendinous injection (which causes tendon weakening), and overreliance on injection as the primary treatment without addressing the compressive load mechanism.

With appropriate physiotherapy-led rehabilitation and posture modification, the majority of patients with GTPS improve significantly over 12 weeks to 6 months. Prevention focuses on maintaining hip abductor strength, weight management, and avoidance of compressive postures.

Prevention

• Long-term posture habits — permanent avoidance of hip adduction postures (crossing legs, hip hitching) substantially reduces GTPS recurrence; patients should be reminded of these habits at follow-up appointments, particularly during periods of increased activity or weight gain
• Hip abductor strengthening — ongoing hip abductor and external rotator strengthening reduces compressive load on the greater trochanter during gait; 2–3 sessions per week of hip strengthening as part of a long-term exercise program; GLAD program (osteoarthritis program) includes hip abductor strengthening and is suitable for patients with concurrent hip OA
• Weight management — BMI reduction reduces trochanteric compressive load and improves gait biomechanics; structured weight loss program with dietitian and exercise physiologist referral for overweight patients

• Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662. (LEAP trial)
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