As a result, the term greater trochanteric pain syndrome was adopted to describe a cluster of signs and symptoms that presented with localised pain around the outside of the thigh. Imaging has determined that pain caused by greater trochanteric pain syndrome is most often caused by gluteal tendinopathy (Connell et al. 2003), which is defined as pain and dysfunction in the tendons; however, the term gluteal tendinopathy was not agreed to amongst tendon researchers in a 2019 consensus statement aiming to reach agreement on terminology in tendinopathies (Scott et al. 2020).
The terms greater trochanteric pain syndrome or gluteal tendinopathy are often used to describe localised pain around the outside of the thigh. Isolated trochanteric bursitis, or trochanteric bursitis with greater trochanteric pain syndrome/gluteal tendinopathy is rare and a thorough history and physical examination can accurately differentiate the cause of localised pain around the outside of the thigh and guide appropriate treatment.
Aetiology
Greater trochanteric pain syndrome/gluteal tendinopathy is hypothesised to be caused by increased load on the gluteal tendon due to poor lumbo-pelvic hip control (Grimaldi 2015, & Grimaldi & Fearon 2015).
When walking, ascending stairs, or descending stairs the gluteus medius and gluteus minimus muscles contract to keep the pelvis level while standing on one leg.
Patients with greater trochanteric pain syndrome often walk with a pelvic drop during that increases the load on the gluteal tendons causing greater trochanteric pain syndrome/gluteal tendinopathy.
Assessment
Assessment of greater trochanteric pain syndrome/gluteal tendinopathy should include a detailed assessment of the location of pain (Plinsinga et al. 2022), as well as provocative activities or movements, hip mobility, lumbo-pelvic hip control, and gluteal muscle strength (Grimaldi et al. 2015, Grimaldi & Fearon 2015, Grimaldi et al. 2016, Plinsinga et al 2020).
A Physiotherapist may also ask women with greater trochanteric pain syndrome/gluteal tendinopathy about their menopausal status.
Treatment
Best practice for greater trochanteric pain syndrome/gluteal tendinopathy includes education on the biomechanical cause, sleeping positions to reduce the load on the gluteal tendons, as well as exercises to strengthen the gluteus medius and minimus muscles, which prevent a pelvic drop.
Ganderton et al. (2017a & 2017b) investigated exercises to address greater trochanteric pain syndrome using fine wire electromyography and determined that the most common exercise used by Physiotherapists to strengthen the gluteus medius and gluteus minimus muscles, clamshell exercises, do not effectively activate and strengthen the gluteus minimus and medius muscles.
Exercises that challenge patients to maintain a level pelvis while standing on one leg achieve the greatest activation and strengthening of the gluteus medius and gluteus minimus muscles. Once a patient can effectively maintain a level pelvis while standing on one leg, a Physiotherapist can then progressively challenge the patient’s ability to maintain a level pelvis in movements that reflect their activities or sport.
Isolated strength exercises for the gluteal muscles can also be prescribed. Most patients with greater trochanteric pain syndrome will have a positive outcome from education and exercise alone (Ganderton et al. 2018, & Mellor 2022) and education and exercise has been shown to be superior and more cost effective than corticosteroid injections (Wilson et al. 2023).
Patients who do not respond to education and exercise as anticipated may be appropriate for focused extracorporeal shockwave therapy (Ramon et al. 2020). Post-menopausal women with greater trochanteric pain syndrome may benefit from hormone replacement therapy; however, hormone replacement therapy requires further research on the optimal dose per kilogram of bodyweight before it is adopted in clinical practice (Cowan et al. 2022).
A consensus statement of tendon researchers concluded pain at night, time to pain onset with single leg stance, pain with stairs and walking, and gluteal muscle strength should be used to assess patient outcomes from treatment for greater trochanteric pain syndrome/gluteal tendinopathy (Fearon et al. 2024).
References:
Connell, D. A., Bass, C., Sykes, C. J., Young, D., & Edwards, E. (2003). Sonographic evaluation of gluteus medius and minimus tendinopathy. European radiology, 13, 1339-1347
Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R. J., Fu, S.N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S. P., Malliaras, P., McAuliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., Speed, C., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885
Grimaldi, A., Mellor, R., Hodges, P. et al. Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Med 45, 1107–1119 (2015). https://doi.org/10.1007/s40279-015-0336-5
Grimaldi, A., & Fearon, A. (2015). Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy, 45(11), 910-922
Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2016). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine
Plinsinga, M. L., Coombes, B. K., Mellor, R., & Vicenzino, B. (2020). Individuals with persistent greater trochanteric pain syndrome exhibit impaired pain modulation, as well as poorer physical and psychological health, compared with pain-free individuals: a cross-sectional study. Pain Medicine, 21(11), 2964-2974
Plinsinga, M., Boudreau, S., Coombes, B., Mellor, R., Hayes, S. & Vicenzino, B. (2022). Comparing what the clinician draws on a digital pain map to that of persons who have greater trochanteric pain syndrome. Scandinavian Journal of Pain, 22(3), 506-514. https://doi.org/10.1515/sjpain-2021-0135
Ganderton, C., Pizzari, T., Harle, T., Cook, J., & Semciw, A. (2017a). A comparison of gluteus medius, gluteus minimus and tensor facia latae muscle activation during gait in post-menopausal women with and without greater trochanteric pain syndrome. Journal of Electromyography and Kinesiology, 33, 39-47
Ganderton, C., Pizzari, T., Cook, J., & Semciw, A. (2017b). Gluteus minimus and gluteus medius muscle activity during common rehabilitation exercises in healthy postmenopausal women. journal of orthopaedic & sports physical therapy, 47(12), 914-922
Ganderton, C., Semciw, A., Cook, J., Moreira, E., & Pizzari, T. (2018). Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial. Journal of women’s health (2002), 27(6), 815–829. https://doi.org/10.1089/jwh.2017.6729
Mellor, R., Kasza, J., Grimaldi, A., Hodges, P., Bennell, K., & Vicenzino, B. (2022). Mediators and Moderators of Education Plus Exercise on Perceived Improvement in Individuals With Gluteal Tendinopathy: An Exploratory Analysis of a 3-Arm Randomized Trial. Journal of Orthopaedic & Sports Physical Therapy, 52(12), 826-836
Wilson, R., Abbott, J. H., Mellor, R., Grimaldi, A., Bennell, K., & Vicenzino, B. (2023). Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial. Journal of Physiotherapy, 69(1), 35-41
Ramon, S., Russo, S., Santoboni, F., Lucenteforte, G., Di Luise, C., de Unzurrunzaga, R., … & Vulpiani, M. C. (2020). Focused shockwave treatment for greater trochanteric pain syndrome: a multicenter, randomized, controlled clinical trial. JBJS, 102(15), 1305-1311.
Cowan, R. M., Ganderton, C. L., Cook, J., Semciw, A. I., Long, D. M., & Pizzari, T. (2022). Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome? A 2 × 2 Factorial Randomized Clinical Trial. The American journal of sports medicine, 50(2), 515–525. https://doi.org/10.1177/03635465211061142
Fearon, A. M., Grimaldi, A., Mellor, R., Nasser, A. M., Fitzpatrick, J., Ladurner, A., … & COS-GT consensus group. (2024). ICON 2020—International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy. British Journal of Sports Medicine.