Greater trochanteric pain syndrome

Greater trochanteric pain syndrome is a condition that causes pain in the outer part of your hip and upper thigh. It is usually caused by injury to or inflammation of the muscles and other tissues that lie over the bony bump (the greater trochanter) on the outer part of your hip.

Greater trochanteric pain syndrome is a common condition that affects around one in 300 people each year. It is more common among women and those aged between 40 and 60, although it can also affect younger people, especially runners, footballers, and dancers.

Most cases of greater trochanteric pain syndrome improve with time, self-care, and physiotherapy. Steroid injections and, in some cases, surgery, may be needed.

Pain over the outer thigh and hip area is the most common symptom of greater trochanteric pain syndrome. The pain may start suddenly or build up more gradually over time.

The pain may also:

• come and go from time to time
• feel like an ache or burning sensation
• get worse over time
• get worse when you are lying on your side, especially at night
• get worse when you move around or stand for a long time
• get worse when you get up from a chair or climb the stairs or walk up a hill
• move down your thigh(s) or into your bottom

You may find that you walk with a limp.

Most cases of greater trochanteric pain syndrome are caused by injury to or inflammation of the muscles, tendons (tough bands of tissue) or connective tissue (fascia) in the upper, outer thigh area.

Exactly how greater trochanteric pain syndrome develops is currently unclear, but it may be caused by damage to and inflammation of the muscles and tissues that lie in and around the hip.

Greater trochanteric pain syndrome may develop from:

• a direct injury to your hip, such as a fall
• repetitive hip movements, such as running or walking a lot
• prolonged or excessive pressure to your hip area, such as from sitting in a bucket (individual) car seat
• certain infections and diseases, such as tuberculosis, gout and arthritis
• previous hip surgery, implants, or surgical wire

There are some medical conditions that are associated with greater trochanteric pain syndrome such as:

• osteoarthritis of the hip or knee
• rheumatoid arthritis
• spine conditions such as degenerative disc disease or scoliosis
• obesity
• foot disorders like plantar fasciitis
• having different leg lengths

Greater trochanteric pain syndrome used to be called trochanteric bursitis. This was because the pain was thought to be caused by inflammation of a fluid-filled sac (called a bursa) that lies over the greater trochanter.

Research now suggests that an inflamed bursa is just one of several causes of greater trochanteric pain syndrome.

It is important to see your doctor if you have pain in your hip, especially if the pain comes on suddenly or if it occurs after a direct injury or a fall. Your doctor may suspect greater trochanteric pain syndrome after asking you about your symptoms, how you injured yourself, and your medical history.

Your doctor is also likely to examine your hips and legs. This usually involves feeling for any tenderness over the greater trochanter (bony prominence) and asking you to make certain movements to help reach a diagnosis.

If the diagnosis is unclear or the pain is not getting better with treatment, your doctor may organise the following tests:

• an MRI scan
• ultrasound
• CT scan
• x-ray - an x-ray usually cannot diagnose greater trochanteric pain syndrome, but it can help to exclude other causes of hip pain

Your doctor will also want to exclude infection of the bursae. If he or she suspects an infection, you may need a minor procedure (aspiration) which involves taking a small sample of the fluid from the bursa with a needle, to send for laboratory testing.

If you have, or suspect you may have, greater trochanteric pain syndrome, see your doctor. They will be able to advise you on the best treatment for your symptoms.

Self-care

In most cases, greater trochanteric pain syndrome gets better on its own over time. This can take weeks, months, or sometimes years.

You can help to speed up your recovery with the following self-care measures:

• rest the affected hip - avoid or minimise activities that trigger the pain
  • minimise stair climbing and walking up hills
  • avoid lying on the painful hip
  • avoid crossing your legs while sitting
  • stand with your weight evenly spread across both legs
• apply ice to your hip for 15-20 minutes every two to three hours - wrap the ice or a bag of frozen peas in a damp towel. Do not place the ice directly onto your skin because it could cause a cold burn
• lose weight - if you are overweight or obese, losing weight may help to improve your symptoms
• painkillers – non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help relieve pain and inflammation

Some guidelines suggest you should avoid taking NSAIDs for the first 48 hours after an injury and that you should only take them for a short time period. This is because it is thought that NSAIDs may slow down the healing process. However, this theory needs further research. At present, there is no conclusive evidence that proves that NSAIDs should not be taken soon after an injury.

It may not be safe to take NSAIDs if you have certain conditions (such as asthma, high blood pressure, kidney failure, indigestion or heart failure) or if you are allergic to NSAIDS. Always check with your doctor or pharmacist before taking new medicines after an injury.

Steroid injections

If you are in a lot of pain, the pain is keeping you up at night, or the pain does not improve with self-care, your doctor may offer an injection of a steroid into the area that is painful. This can help to relieve the pain, although there is no strong evidence that steroid injections provide better pain relief than NSAIDs in the short term.

While these injections can provide short-term pain relief, it is common for pain to come back in the long term.

Physiotherapy

If you have greater trochanteric pain syndrome, your doctor may refer you to a physiotherapist. Your physiotherapist will typically be able to teach you an exercise programme to help strengthen your leg hip and leg muscles, and manage your symptoms in the long term. The nature of the exercise programme will depend on how severe your symptoms are and how long you’ve had them for.

Your physiotherapist may also recommend ways to avoid reinjuring yourself in the future.

Surgery

Not all cases of greater trochanteric pain syndrome need surgery. However, your doctor may refer you to a bone specialist (orthopaedic surgeon) if:

• your symptoms have not improved after six to 12 months of treatment
• you have torn one of your buttock (gluteal) muscles (usually detected on MRI scans)
• your symptoms may be related to previous hip surgery or a broken thigh bone (femur)

The type of surgery you need will often depend on what caused you to develop greater trochanteric pain syndrome. However, surgery may involve open surgery (open wound) or a keyhole procedure (arthroscopy) to repair any damaged tendons or tissue in your hip.

Greater trochanteric pain syndrome is a common cause of outer hip pain in adults. In the majority of cases, the condition gets better over time with self-care, physiotherapy, and, sometimes, steroid injections.

In a small percentage of people, the symptoms of greater trochanteric pain syndrome can persist after treatment. However, this does not always mean there is a serious ongoing problem or damage in the hip joint.

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