Greater Trochanteric Pain Syndrome

REVIEW ARTICLE Greater Trochanteric Pain Syndrome Eric J. Strauss, MD,* Shane J. Nho, MD, MS,* and Bryan T. Kelly, MDw GTPS in patients with musculoskeletal low back pain and Abstract: Originally defined as ‘‘tenderness to palpation over the an increased prevalence in women compared with men.4,9–12 greater trochanter with the patient in the side-lying position,’’ Secondary to the relative paucity of information available greater trochanteric pain syndrome (GTPS) as a clinical entity, has on the diagnosis and management of components of GTPS, expanded to include a number of disorders of the lateral, peritro- the presence of these pathologic entities may be under- chanteric space of the hip, including trochanteric bursitis, tears of recognized, leading to extensive workups and delays in the gluteus medius and minimus and external coxa saltans (snap 4,13 ping hip). Typically presenting with pain and reproducible appropriate treatment. This article aims to review the tenderness in the region of the greater trochanter, buttock, or lateral present understanding of the lesions that comprise GTPS, thigh, GTPS is relatively common, reported to affect between 10% discussing the relevant anatomy, diagnostic workup and and 25% of the general population. Secondary to the relative recommended treatment for trochanteric bursitis, gluteus paucity of information available on the diagnosis and management medius and minimus tears, and external coxa saltans. of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment RELEVANT ANATOMY for trochanteric bursitis, gluteus medius and minimus tears, and The greater trochanter arises from the junction of the external coxa saltans. femoral neck and shaft. It is the site of attachment for 5 muscles, the gluteus medius and gluteus minimus tendons Key Words: abductor tears, trochanteric bursitis, gluteus medius, laterally and the piriformis, obturator externus and obtura- gluteus minimus tor internus more medially. As recently noted by Robertson (Sports Med Arthrosc Rev 2010;18:113–119) et al,14 the gluteus medius tendon has 2 distinct and consistent insertion sites on the greater trochanter, one on the lateral facet and the other on the superoposterior facet. The tendinous portion inserted on the superoposterior facet was he evaluation and management of patients who present noted to be stout with a circular shape, while that inserted Twith hip pain can be difficult, as the differential diag- on the lateral facet was larger and rectangular in shape. nosis of pain about the hip joint is broad, including intra- Anterior to the gluteus medius insertion lies the insertion of articular pathology, extraarticular pathology and referred 1,2 the capsular and long heads of the gluteus minimus tendon symptoms from the lumbar spine and pelvis. Advances in on the anterior facet of the greater trochanter.15 Superficial magnetic resonance imaging (MRI) and knowledge gained to the gluteus medius and minimus tendons lies a fibro- from improvements and experience with hip arthroscopy, muscular sheath composed of the gluteus maximus, tensor have led to an improved understanding of the functional fascia lata, and iliotibial band (ITB). anatomy about the hip joint and the ability to identify soft 1,3 Three bursas have been described to be consistently tissue causes of hip pain. Originally defined as ‘‘tender- present around the lateral aspect of the greater trochanter, ness to palpation over the greater trochanter with the patient 4–7 believed to function as cushioning for the gluteus tendons, in the side-lying position,’’ greater trochanteric pain the ITB, and the tensor fascia latae.2,16 They are the sub- syndrome (GTPS) as a clinical entity, has expanded to gluteus maximus bursa, the subgluteus medius bursa and include a number of disorders of the lateral, peritrochan- the gluteus minimus bursa. The subgluteus maximus bursa teric space of the hip, including trochanteric bursitis, tears is lateral to the greater trochanter, between the tendons of the gluteus medius and minimus and external coxa 3 of gluteus maximus and medius. Although variable, the saltans (snapping hip). subgluteus maximus is typically subdivided into up to 4 Typically presenting with pain and reproducible separate bursas. The deep subgluteus maximus bursa is the tenderness in the region of the greater trochanter, buttock, largest and most consistent of these subdivisions, often or lateral thigh, GTPS is relatively common, reported to 2,4,8 referred to as the ‘‘trochanteric bursa’’ and is often implica- affect between 10% and 25% of the general population. ted in cases of symptomatic bursitis.2 Other reported Some investigators have shown an increased incidence of components of the subgluteus maximus bursas include the secondary deep, superficial, and gluteofemoral bursas. Deep to the gluteus medius tendon up to 3 separate bursas From the *Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of have been identified in anatomic studies, with the largest Rush University, Chicago, IL; and wHospital for Special Surgery, typically being present on the anterior surface of the greater Weill Medical College of Cornell University, New York, NY. trochanter, near its apex.17 The gluteus minimus bursa is a No funding was obtained in connection with this manuscript. minor bursa located deep to the minimus insertion on the Reprints: Bryan T. Kelly, MD, Hospital For Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, anterior aspect of the greater trochanter. New York, NY 10021 (e-mail: [email protected]). The increased popularity of hip arthroscopy and Copyright r 2010 by Lippincott Williams & Wilkins advances in technique have improved the understanding Sports Med Arthrosc Rev Volume 18, Number 2, June 2010 www.sportsmedarthro.com | 113 Strauss et al Sports Med Arthrosc Rev Volume 18, Number 2, June 2010 of the anatomy of the peritrochanteric space.3,18 The tion, and extension). Additionally, the Ober test for ITB borders of the arthroscopic lateral, peripheral, or peritro- tightness is often positive. Selective anesthetic/cortico- chanteric compartment consist of the tensor fascia lata steroid injections can be used for both diagnostic and and ITB laterally, the abductor tendons superomedially, therapeutic purposes, injecting at the point of maximal the vastus lateralis inferomedially, the gluteus maxi- tenderness or under fluoroscopic guidance.23 Secondary to mus muscle superiorly and its tendon posteriorly. Typically, the number of pathologic conditions presenting with similar the peripheral compartment is viewed with the operative leg symptoms and physical exam findings, besides point tender- off traction through the anterior portal, which is created ness at the greater trochanter and symptom relief from 1-cm lateral to the anterior superior iliac spine in the trigger point injection there are few signs with a high interval between the sartorius and the tensor fascia lata.3,18 specificity for trochanteric bursitis.2 The cannula is directed toward the greater trochanter with Although not required to make a diagnosis of trochan- the leg in full extension, neutral adduction/abduction and teric bursitis, imaging studies used in the workup of 10 to 15 degree of internal rotation. The initial arthroscopic patients usually begin with plain radiographs of the affected view includes the insertion of the gluteus maximus into the hip, looking for intraarticular sources of the presenting posterior border of the ITB, the longitudinal fibers of the symptomatology. Although calcifications may occasionally vastus lateralis and bursal tissue overlying the greater tro- be evident within the bursal space around the greater chanter. In cases of severe trochanteric bursitis, this tissue trochanter, plain x-rays are often negative.1 In a review of may be hypertrophied, thick, and very vascular. Subsequent 15 cases of trochanteric bursitis diagnosed based on clinical to the clearing of the bursal tissue with a motorized shaver presentation and point tenderness at the greater trochanter, and/or radiofrequency probe (through a distal posterior Karpinski et al24 reported that 12 patients had completely portal placed halfway between the tip of the greater normal hip radiographs whereas 3 had evidence of minimal trochanter and the vastus tubercle along the posterior soft tissue calcification present. Dynamic ultrasound may one-third of the greater trochanteric midline), continued be another imaging modality with utility in the evaluation inspection will identify the fibers of the gluteus medius as it of trochanteric bursitis. In addition to ruling out other inserts onto the greater trochanter. This insertion is components of greater trochanteric pain syndrome, includ- carefully examined for evidence of full or partial-thickness ing gluteus medius and minimus tears and evidence of tears. Finally, the ITB is assessed, particularly the posterior snapping hip, ultrasound can help identify an inflamed one-third, looking for evidence of abrasive wear consistent trochanteric bursa.1 Similarly, an MRI for the evaluation of with external coxa saltans. trochanteric bursitis can be used as an exclusionary tool while potentially showing inflammation in the region of

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