Greater Trochanteric Pain Syndrome Teresa Huckaby, PT, DPT

Landmark Palpation Intra-rater and Inter-rater Comparisons Fig. 2. Means and standard deviations for palpation discrepancies in normal weight and overweight groups, for the intra-rater comparisons for both raters and for the inter-rater comparisons. Cristiane Shinohara Moriguchi, Letícia Carnaz, Luciana Cristina Cunha Bueno Silva, Luis Ernesto Bueno Salasar, Rodrigo Luiz Carregaro, Tatiana de Oliveira Sato, Helenice Jane Cote Gil Coury Reliability of intra- and inter-rater palpation discrepancy and estimation of its effects on joint angle measurements Manual Therapy, Volume 14, Issue 3, 2009, 299–305 http://dx.doi.org/10.1016/j.math.2008.04.002

Greater Trochanteric Pain Syndrome Coxa Saltans (External Snapping Hip) – anterior fibers of glute max and ITB migrate anteriorly over GT when hip moves from extended to flexed position Trochanteric Bursitis Gluteus medius and minimus tendinopathies ALL have prolonged, intermittent peritrochanteric pain with tenderness to palpation over the lateral aspect of the hip

Greater Trochanteric Pain Syndrome Historically this syndrome has been referred to as “Bursitis” Presentation rarely involves cardinal symptoms of inflammation including erthyema, edema, and rubor. Many contributors to the symptoms Neurological, soft tissue, skeletal, systemic, or referred

Greater Trochanteric Pain Syndrome Differential Diagnosis Fig. 1. GTPS classification by source. Meralgia paraesthetica: nerve entrapment resulting in pain, paresthesias, sensory loss within distribution of LFCN (anterolateral hip/thigh) RULE IN: Reproduction of symptoms with pelvic compression, neurodynamic assessment of adverse tension, positive Tinel sign Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

Soft Tissue Involvement Gluteus medius and minimus tendon trigger points, tendon degeneration, or tendon failure Deep trochanteric bursa has potential for inflammation Iliotibial band (ITB) at hip causing external impingement or compressive irritation MOST COMMON: Degenerative interstitial changes in the hip abductor tendons

Tendon Changes Impingement forces through external compression altered by faulty biomechanics and functional compensations Females more predisposed due to wider pelvis altering biomechanics of gluteal and ITB around the GT Imaging indicates calcific changes around the greater trochanter in 13-40% of patients with chronic GTPS

GTPS Concurrent or past history of LBP in 20-62% of patients ITB tenderness and knee OA positively related to GTPS No positive relationship based on obesity (>30 BMI) or limited hip internal rotation mobility

Possible but Unproven Extrinsic Risk Factors Asymmetrical shoe wear Running on cambered or crowned surface Unreasonably rapid progression of exercise intensity, frequency, duration Poor core stability Gluteal weakness Functional limb-length discrepancies Alterations in pronation-supination sequence Adduction of hip beyond midline when running

GTPS Presentation Lateral hip pain May extend laterally down the thigh or posteriorly into gluteal region in non-dermatomal pattern History Intermittent, persistent lateral hip pain Exacerbated by lying on affected side, sitting with legs crossed, prolonged weight bearing in unilateral stance Reduced tolerance for physical exercise Fig. 2. Area of pain for GTPS. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

GTPS Cluster Aching pain in lateral hip and distinct tenderness in proximity of GT And at least one of the following Pain at end range of motion for hip abduction and adduction or internal and external rotation Positive FABER test Pain with resisted hip abduction Non-radicular pattern of pain extending down the lateral thigh **Diagnostic accuracy of this cluster has not been established**

Gluteal Tendon Pathology Pain, weakness, or lag with resisted hip abduction testing Lag sign may indicate a gluteal tendon tear Pain with single leg stance with resistive rotation may signal tendinopathy Positive for tendinopathic changes: Lateral hip pain during 30 sec unilateral stance (Sensitivity: 100%, Specificity: 97%)

ROM and MMT GTPS most often aggravated by passive adduction and active abduction (resisted hip abduction sensitivity of 73% and specificity of only 46%...so the side lying abduction MMT is better at ruling out than ruling in the problem)

Gluteal Tendon Rupture or Gluteus Medius Weakness? Trendelenburg sign is reliable and accurate test for torn tendon (Sensitivity 73%, Specificity 77%) Fig. 3. Trendelenburg sign – a) excessive contralateral hip drop or b) ipsilateral trunk side bending during the stance phase of gait. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

External Derotation Test Supine with 90 deg flexion and maximal hip external rotation Reproduction during resisted hip internal rotation back to neutral is positive High correlation for presence of tendon change (Sensitivity 88%, Specificity: 97%) Fig. 4. External Derotation Test – reproduction of lateral hip pain during resisted hip internal rotation is indicative of gluteal tendinopathy. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

Hip Lag Test Examiner passively abducts the extended and internally rotated hip and asks patient to hold this position when examiner releases limb. Test is positive if foot drops more than 10 cm or the patient cannot hold internally rotated position. Sensitivity: 89%, specificity: 97% when used to detect gluteus medius tear Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

Ober’s Test ITB Tightness Test and may cause compressive pain over GT Has not been studied for accuracy as a predictor of GTPS

Interventions Few high level studies to support management of tendinopathies around the GT Tendon healing Correction of contributing lower extremity impairments Progressive return to routine and recreational activities Surgery

Acute Management Rest Thermotherapy Reduction in weight bearing load Active or relative rest preferred over complete immobilization Modalities such as ultrasound, laser, and e-stim may be considered for transient, palliative symptom relief and possible stimulation of healing process

Stretching? And STM ITB stretching, particularly foam rolling over the affected area may only increase compressive loads and contribute to pain STM below the greater trochanter may be beneficial Avoid positioning the hip in a flexed, adducted or internally rotated position for STM

STM Fig. 6. Soft tissue massage with roller massage stick. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

Fig. 7. Gluteus medius training exercise progression based on weight bearing status and muscular demand. a) standing hip rotation on swivel stool; b) bilateral bridging with bent knee fall out; c) side lying hip abduction; d) lateral band walks. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

Fig. 7. Gluteus medius training exercise progression based on weight bearing status and muscular demand. a) standing hip rotation on swivel stool; b) bilateral bridging with bent knee fall out; c) side lying hip abduction; d) lateral band walks. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette Evaluation and management of greater trochanter pain syndrome Physical Therapy in Sport, Volume 16, Issue 3, 2015, 205–214 http://dx.doi.org/10.1016/j.ptsp.2014.11.002

References Mulligan E, Middleton E, Brunette M. Evaluation and management of greater trochanter pain syndrome. Physical Therapy in Sport, Vol 16:3 (2015) 205–14. Moriguchi, C, et al. Reliability of intra-rater and inter-rater palpation discrepancy and estimation of its effects on joint angle measurements. Manual Therapy. 14(3) 299-305.