1. Greater Trochanteric Pain Syndrome
Teresa Huckaby, PT, DPT

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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**

12. 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%)

13. 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)

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)