Greater Trochanteric Pain Syndrome

History: lateral hip pain is the cardinal symptom, localised to the greater trochanter and lateral hip, sometimes radiating down the lateral thigh. NOT groin pain - the distinction from hip OA is constantly tested. Pain when lying on the affected side at night is one of the commonest and most distressing symptoms. Aggravated by weight-bearing (walking, stairs especially ascending, standing from sitting, prolonged standing) and by compressive postures (crossing legs, sitting cross-legged, hip-hitched standing).

Onset may be insidious or follow a change in activity. Ask about lumbar symptoms, contralateral hip or knee pathology, previous surgery, menopausal status, and running history.

Examination:

• •Tenderness over the greater trochanter is the most reliable clinical finding. Palpate lateral, superoposterior, and anterior facets
• •Pain on resisted hip abduction reproduces lateral hip pain
• •Pain on passive adduction stretches and compresses the gluteal tendons. The FADER test (Flexion, ADduction, External Rotation) loads the gluteal insertion
• •FABER may reproduce lateral hip pain (trochanteric), groin pain (hip joint), or posterior pain (SIJ) - interpret the location carefully
• •Single-leg stance test for 30 seconds reproduces lateral hip pain in a useful functional provocation. True Trendelenburg sign (pelvic drop) suggests advanced tendon pathology or tear
• •Examine the lumbar spine for L5 radiculopathy (a cause of secondary GTPS via gluteus medius weakness) and the hip for OA (reduced painful internal rotation - GTPS and hip OA commonly coexist)

GTPS is best diagnosed from a cluster of findings: lateral hip pain, trochanteric tenderness, and pain on abductor loading.

Red flags: night pain unrelieved by position change with weight loss (malignancy); acute onset with inability to weight-bear after trauma (fracture); fever (septic bursitis or osteomyelitis); rapidly progressive abductor weakness (tendon rupture, L5 radiculopathy, or motor neurone disease).

Differentials: hip OA (groin not lateral, reduced internal rotation), lumbar referred pain or L5 radiculopathy (dermatomal pattern, back symptoms), meralgia paraesthetica (sensory only, no trochanteric tenderness), femoral neck or trochanteric stress fracture, gluteal tendon tear (severe end of spectrum), ITB syndrome (lateral knee not hip), SIJ dysfunction.

Per NICE CKS, GTPS is usually a clinical diagnosis. Imaging is not routinely required.

• •Plain radiographs (AP pelvis): not routinely needed. Consider if hip OA is suspected or fracture is a concern. May show enthesopathy. AP pelvis allows comparison with the contralateral side
• •Ultrasound: useful when diagnosis is uncertain or gluteal tendon tear is suspected. Demonstrates tendinopathy, tears, and bursal fluid. Mild tendinopathy or bursal fluid is also seen in asymptomatic individuals - interpret with caution
• •MRI: not first-line. Indicated when gluteal tendon tear is suspected, diagnosis uncertain, or other pathology needs exclusion. Demonstrates tendon pathology, fatty infiltration, and bone marrow oedema. Same asymptomatic-findings caveat
• •Bloods: not routinely indicated
• •Diagnostic injection: USS-guided peritrochanteric local anaesthetic can confirm the trochanteric region as the pain source

Conservative-first. Per NICE CKS, management includes education, exercise, and load modification. The LEAP trial (Mellor et al., 2018) is the landmark RCT informing UK practice.

LEAP trial summary: education plus exercise outperformed both corticosteroid injection and a wait-and-see approach in patient-reported global improvement at 52 weeks. Corticosteroid injection provided short-term benefit (at 8 weeks) but was inferior to exercise long-term - mirroring lateral epicondylalgia evidence. This trial has shifted UK practice away from injection-first approaches.

Conservative management (first-line):

• •Education: explain GTPS is a tendinopathy, not bursitis. Explain the compressive mechanism and the importance of load modification
• •Load modification (unique to GTPS and equally important to strengthening): avoid crossing legs, avoid lying on the affected side (sleep on the opposite side with a pillow between knees, or supine), avoid hip-hitched standing, avoid sustained single-leg stance on the affected side, modify walking and running load
• •Analgesia: oral NSAIDs for short-term symptomatic relief
• •Physiotherapy-led rehabilitation: progressive gluteal strengthening combined with education and load modification

Corticosteroid injection: per LEAP, education plus exercise produces better long-term outcomes. May be considered selectively for short-term symptom reduction when pain prevents rehabilitation. Usually peritrochanteric under landmark or USS guidance. Repeated injections are not recommended. Warn diabetic patients about hyperglycaemia.

Shockwave therapy (ESWT): NICE IPG511 supports ESWT for refractory GTPS. An option in selected refractory cases in some UK specialist or MSK pathways, typically after 3-4 months of failed structured rehabilitation.

Referral: refer if symptoms persist despite 3-6 months of structured rehabilitation, a gluteal tendon tear is suspected, or there is diagnostic uncertainty.

Surgical options: gluteal tendon repair for confirmed tears causing significant functional limitation. Trochanteric bursectomy and ITB release are less commonly performed now. Gluteal tendon reconstruction is considered for chronic irreparable tears.

Two pillars: reduce tendon compression and progressively strengthen gluteus medius and minimus with pelvic control.

Phase 1 (pain-dominant, 0-6 weeks): load modification is the priority. Long-hold isometric gluteal activation in non-compressive positions (isometric hip abduction standing with back against a wall - 5 repetitions of 30-45-second holds at moderate intensity; bilateral bridging). Isometrics provide an analgesic effect and are the starting point. Maintain cardiovascular fitness with non-provocative activities (stationary cycling with a wider seat, swimming - avoid breaststroke kick).

Phase 2 (loading, 6-12 weeks): progressive resistance training targeting gluteus medius and gluteus maximus. Transition from isometric through isotonic to functional. Key exercises: side-lying hip abduction (short to long lever), standing hip abduction with resistance band, single-leg bridging, lateral band walks, and hip hitch exercise. Exercises should initially minimise compression. Some discomfort is acceptable (up to approximately 4/10) provided it settles within 24 hours.

Phase 3 (functional, 12+ weeks): progressive single-leg loading - step-ups, lunges, single-leg squat progression. Running-specific rehabilitation if applicable. Sport-specific work. Continue gluteal strengthening as maintenance. Address kinetic chain deficits.

Long-term maintenance: ongoing gluteal strengthening 2-3 sessions per week. Recurrence is common if strengthening stops. Ongoing self-management of compressive positions.

• •LEAP trial (Mellor et al., BMJ 2018): landmark UK RCT showing education plus exercise was superior to corticosteroid injection at 52 weeks in patient-reported global improvement. Shifted UK practice away from injection-first approaches.
• •NICE CKS Greater trochanteric pain syndrome: UK primary-care framework recommending clinical diagnosis, education, exercise, and load modification first-line.
• •NICE IPG511 Extracorporeal shockwave therapy for refractory greater trochanteric pain syndrome: supports ESWT in selected refractory cases.
• •Grimaldi and Fearon (BJSM 2015) gluteal tendinopathy clinical assessment: trochanteric tenderness, pain on abductor loading, and lateral hip pain reproduction form the diagnostic cluster.
• •BHS gluteal repair guidance: surgical thresholds and outcomes for gluteal tendon repair.
• •Lateral epicondylalgia injection RCTs (parallel evidence): consistent finding of corticosteroid being inferior to exercise long-term in compressive tendinopathy.

• •GTPS = lateral hip pain. Hip OA = groin pain. The most-tested distinction. If the question describes lateral trochanteric tenderness, the answer is GTPS, not hip OA.
• •GTPS is primarily gluteal tendinopathy (gluteus medius with or without minimus), NOT trochanteric bursitis. "Rotator cuff tear of the hip" is the standard analogy.
• •LEAP trial (Mellor et al., BMJ 2018): education plus exercise was superior to corticosteroid injection at 52 weeks. Know it by name.
• •Compressive loading is the mechanism. Reducing compressive loads (no crossed legs, no lying on the affected side, no hip-hitched standing) is as important as strengthening.
• •L5 radiculopathy causes gluteus medius weakness and can produce secondary GTPS. Always examine the lumbar spine in a patient with lateral hip pain. GTPS and hip OA commonly coexist in older patients.
• •Gluteal tendon tears are the severe end of the spectrum. Progressive abductor weakness with Trendelenburg warrants MRI and specialist referral. NICE IPG511 supports ESWT for refractory cases.