INJECTION THERAPY FOR GREATER TROCHANTERIC PAIN SYNDROME (GTPS)

What is Greater Trochanteric Pain Syndrome?

The discomfort on the outside (lateral) side of the hip is known as greater trochanteric pain syndrome. The irritation of the gluteal (buttock muscle) tendons as they join to the greater trochanter causes this condition (the bony bump you can feel on the outside of your hip). An irritated bursa (a friction-reducing sac) between the greater trochanter and the gluteal tendons can also cause greater trochanteric pain syndrome. Both structures may be involved in pain linked with greater trochanteric pain syndrome in some situations. This illness can affect either sexe and is unrelated to age, however it is most frequent in middle-aged women.
A course of physiotherapy for greater trochanteric pain syndrome usually works well. However, if your discomfort isn’t getting better or you’re having trouble sleeping, an ultrasound-guided steroid injection can help. We always recommend physiotherapy after an injection to guarantee that the discomfort does not return.

What are the symptoms of Greater Trochanteric Pain Syndrome?

  • On the outside of the hip, directly over the greater trochanter, there is pain.
  • Crossing your legs, sitting or standing for long periods of time, and exercising cause pain.
  • Nighttime pain, particularly when lying on the affected side.
  • Standing on one leg causes pain and instability (on the affected side).
 
 

What are some additional conditions that are similar to Greater Trochanteric Pain Syndrome?

 

  1. Femoroacetabular impingement
  2. Greater Trochanteric Pain Syndrome
  3. Hip osteoarthritis
  4. Osteitis pubis
  5. Iliopsoas tendinopathy/bursitis

Greater Trochanteric Pain Syndrome vs Femoroacetabular impingement:

Femoroacetabular impingement is a hip joint disease caused by a bony difference in the shape of the hip structure that most typically affects patients in their forties and fifties. The pain is felt in the hip crease and is exacerbated by hip flexion tasks (bringing the knee towards the chest). Greater trochanteric pain syndrome, on the other hand, is mostly a tendon problem that causes pain on the outside of the hip. Walking and activity aggravate both illnesses, but the location of the discomfort is a critical diagnostic factor.

Anatomy:

A prominent bony protrusion on the exterior of the top of the femur is known as the greater trochanter (long thigh bone). It is a muscular attachment point for the gluteus minimus and gluteus medius, two Real Brides gluteal muscles (see image below). These muscles aid in the stabilisation and regulation of hip motions. The vast gluteus maximus muscle sits on top of both muscles and is the only gluteal muscle that does not link to the greater trochanter.

 

The lateral (outside) hip musculature is formed of the gluteus minimus and gluteus medius, which both start on the crest of the hip (iliac crest). Both muscles have a tendon that attaches to the greater trochanter. Tendons are the connective tissue that connects the muscle to the bone.

The trochanteric sits between the gluteus minimus and gluteus medius tendon and the overlaying gluteus maximus muscle. Bursae are naturally occurring sacs that are lined with synovial fluid, a friction-reducing material. They are found all over the body (over a hundred in total) and are designed to create a protective cushion between neighbouring structures so that movement can be smooth and frictionless.

A common cause of lateral hip discomfort and pain radiating over the greater trochanter is greater trochanteric pain syndrome (GTPS). According to recent studies, up to 25% of the general population suffers from chronic pain (Strauss et al., 2010). Trochanteric bursitis and gluteus medius tendinopathy are other names for GTPS. This illustrates the various structures that may be involved in this problem, and it is one of the reasons why a thorough examination and ultrasound scan are required to determine which specific structures are impacted in your case. Depending on the anatomical structure implicated, therapeutic techniques can differ greatly.

Mellor et al. (2016) identified the following risk variables related with greater trochanteric pain syndrome (GTPS):

  • Gender – women between the ages of 40 and 60 have the highest incidence rate of GTPS.
  • Hip weakness, notably in the abductors (the gluteus minimus and gluteus medius), the adductors (the opposite muscles), and the gluteus maximus (the gluteus maximus). This condition might also be caused by a lack of abdominal strength. Weakness leads to a loss of pelvic and hip control and stability, which alters biomechanics and puts more pressure on the structures surrounding the greater trochanter. This is a regular occurrence in runners as a result of ineffective training methods.
  • Tight hip muscles, particularly hip flexors
  • A sedentary lifestyle is defined as one in which one does not engage in regular physical activity.
  • Crossing legs or standing with one hip hooked are examples of poor extended posing.
  • Obesity or a high Body Mass Index (BMI)
  • The lateral hip has been directly injured.

Which anatomical structure can be affected?

Pain from one of the two gluteal tendons or the adjacent bursa might induce symptoms associated with GTPS.

1. Pain originating from gluteus minimus/medius tendons:

If subjected to prolonged periods of increased compressive forces the gluteal tendons can become inflamed and irritated. Tendon inflammation is referred to as tendinitis. Repetitive episodes of tendinitis affect tendon healing parameters resulting in a compromised, thickened tendon. This process is known as tendinopathy.

Research has revealed that gluteal tendon pathology occurs due to increased compression forces sustained by these tendons due to one or more of the above risk factors (Mellor et al., 2016). Gluteal tendinopathy is believed to be the primary cause of GTPS and has been observed in 23% of women and 8.5% of men aged between 40 and 60 years of age (Lee et al. 2016).

2. Pain originating from the bursa:

The presence of greater trochanteric bursitis has been linked to hip pathologies such as osteoarthritis and femoral acetabular impingement (FAI) (Schapira et al., 1986 cited by Strauss et al., 2010). When testing for GTPS, it is critical to do a full assessment of the entire hip.

Under normal circumstances, the bursa allows muscles and tendons to move freely and without friction. The gluteal bursae might become inflamed when demand increases owing to one or more of the preceding risk factors. Bursitis is a common cause of considerable musculoskeletal discomfort caused by bursal inflammation. Bursitis is frequently associated with gluteal tendinopathy and was once thought to be the primary cause of GTPS for a long time.However, with to advancements in imaging techniques such as magnetic resonance imaging (MRI) and diagnostic musculoskeletal ultrasound imaging, it is now known to be less common than previously thought (Mellor et al., 2016).

How do you now if you have GTPS?

Greater trochanteric pain syndrome usually develops gradually and insidiously, with no clear cause or occurrence. A fall onto the outside of the hip can occasionally cause pain. Intermittent episodes of pain are common, and they usually go away after a brief time of relaxation. As GTPS advances, these sporadic bouts become more common.

The following are some of the most common GTPS symptoms:

  • At the level of the greater trochanter, there is pain on the lateral side of the hip.
  • Standing, walking, or running for long periods of time might cause pain.
  • Crossing legs or standing with one hip hooked causes pain (for example when carrying a child on your hip)
  • Sleeping on that side is painful and difficult.
  • Standing on one leg and having poor balance are frequently linked to pain.

How do we diagnose GTPS?

A correct and accurate diagnosis is critical in determining the most effective treatment strategy for you with your doctor. A mix of clinical tests and diagnostic imaging is used to make a diagnosis.

The following items are included in the clinical evaluation of GTPS:

  • Direct questioning aimed at eliciting information about how, when, and why your suffering began.
  • Muscle strength evaluation
  • Flexibility testing of muscles
  • Range of motion of the hip joint
  • Walking, running, crouching, and balancing are all evaluated during functional testing.

For the examination of the gluteal tendons, diagnostic musculoskeletal ultrasound imaging has been proved to be an excellent diagnostic technique (Connell et al., 2003). Diagnostic musculoskeletal ultrasonography generates real-time, dynamic pictures that can assess tendon anatomy as well as inflammation and edoema associated with tendinopathy and bursitis.

How do we treat GTPS?

The great majority of GTPS patients benefit from conservative treatment. The most common kind of conservative treatment is physiotherapy, which includes:

  • Techniques for reducing compressive strain through the lateral hip through activity modification
  • Gluteal muscle groups, adductor muscles, and abdominals: progressive strengthening workouts
  • Stretching exercises for the hips
  • Poorly regulated movement habits, such as squatting, are re-educated biomechanically.
  • A physiotherapist may use soft tissue manipulation and/or acupuncture to reduce pain and discomfort in some circumstances.

Here are a few pointers that you might want to try:

  • Pay attention to how you sit and stand. Compression on your lateral hip structures can be increased by crossing your legs or standing with one hip hitched.
  • Try glutes bridging and other Pilates exercises (see below)
  • At night, avoid sleeping on your affected side. While sleeping, place a pillow between your knees to assist keep your legs aligned.
  • Avoid activities that aggravate your discomfort, but try to stay as active as possible.
  • Apply a topical anti-inflammatory gel like Voltarol to the affected area. First, seek counsel from a pharmacist.

What if conservative management does not work?

If you’ve completed a course of physiotherapy, including rehabilitative exercise, but are still experiencing symptoms, injectable therapy may be a good option for you.

Clinically, injection treatment is indicated in the following situations:

  • Pain is interfering with your capacity to conduct daily tasks such as work and recreational activities. Pain is interfering with your ability to sleep at night.
  • Your capacity to accomplish your physiotherapy rehabilitation is being hampered by pain.
  • For more than three months, I’ve been in pain.
  • For the treatment of GTPS, there were two clinically successful, evidence-based injectable alternatives.

Corticosteroid injections is the common approach to treat GTPS.  All musculoskeletal injections should be guided by ultrasonography, according to current studies. Ultrasound-guided injections have been found to be much more accurate than landmark-guided injections. Increased precision has been demonstrated to prevent post-injection problems and reduce pain levels in patients. Real-time imaging is provided by a diagnostic ultrasound machine, which allows for precise needle insertion into the target region.

Ultrasound-guided steroid injections:

A corticosteroid is a powerful anti-inflammatory medication that is commonly used in musculoskeletal medicine and is an excellent way to relieve pain caused by inflammation. Corticosteroids have been demonstrated to be a clinically effective medicine for dramatically lowering pain associated with GTPS in studies (Mellor et al., 2016). Corticosteroid medicine is frequently coupled with a short-acting local anaesthetic to improve procedure comfort.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all hip, foot, hand and wrist disorders, including Greater Trochanteric Pain Syndrome. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.