Greater Trochanteric Pain Syndrome (GTPS)

GTPS is condition where the structures on the outside of the hip become sensitive and painful. These structures include the tendons of the gluteus medius and gluteus minimus muscles, the greater trochanteric bursa (a fluid filled sac that helps to reduce friction between the tendons) and also the iliotibial band which is a thick fibrous band running along the outside of the hip.

GTPS is typically a chronic condition which means it develops slowly over time and usually there is no specific event that triggers the onset of symptoms.

The gluteus medius and minimus muscles have a very important role in keeping your pelvis level when standing, walking and running. These muscles are used thousands of times everyday. When these muscles get worked more than they are used to, over a long period of time, the muscle tendons become tendinopathic, which means they weaken and are unable to absorb load as well as a normal tendon. They also become very painful due to increased blood flow and nerve growth. We know that these tendons get overloaded due to overuse (such as excessive walking/running) but also due to compression of the tendon over bone due to altered postural issues.

The typical symptoms of GTPS:

• Deep ache felt mostly on the outside of the hip which can radiate down the outside of the leg
• Pain made worse by walking up and down stairs or on soft surfaces
• Tenderness to touch on the bony aspect of the outside of the hip
• Difficulty sleeping on the painful side at night
• Symptoms are often made worse with physical activity
• Pain can be aggravated by sitting with crossed legs or in a low chair

GTPS is almost always treated conservatively which means there is very little role for surgery. With the correct treatment GTPS will improve significantly however it can take up to 6 months for symptoms to resolve. The treatment for GTPS needs a broad approach using several different treatments which are outlined below. Looking for a quick fix almost never works and leads to patient frustration. It is also essential to understand what causes GTPS so contributing factors can be modified or avoided.

It is import to address any lifestyle factors that may be contributing to the development of GTPS. We know that GTPS is caused by weakening of the gluteal tendons, compression of the gluteal tendons over the bone on the outside of the hip or a combination of both. In the early stages of GTPS adopting low-weight bearing exercises such as swimming and cycling can help reduce the load placed on the tendons. Compression of the tendon typically occurs when lying on the affected side, standing with your weight shifted more to the affected side and sitting with crossed legs. Avoiding these can reduce pain significantly. Walking or running with poor biomechanics/posture can also cause yours hips to drop laterally which causes compression of the tendons. These biomechanical and postural issues need to be addressed.

Exercise has some of the strongest evidence for the management of GTPS. Exercises that build the strength of the gluteal muscles help to create increased capacity of the gluteal tendons which means they can work more effectively and restore the tendons normal function while reducing pain. Physiotherapists are experts in providing exercise programs specific for GTPS. It is also important to maintain general cardiovascular fitness without exacerbating symptoms. Low weight bearing exercises such as swimming or cycling are ideal in the early stages of a rehabilitation program to help increase general fitness while avoiding overloading the tendons. Physiotherapists can also assess any biomechanical issues with walking and running that when addressed can also reduce the load through the gluteal tendons.

Reducing 5 to 10% body weight can help reduce the load placed on the gluteal tendons during walking and running and will make a significant difference to the successful recovery from GTPS. Weight loss should be achieved by eating a well-balanced diet with minimal amounts processed food. Good nutrition is also essential to the recovery of body. You can discuss weight loss with your Sports Doctor or Dietitian.

There are no specific medications required for GTPS. Anti-inflammatories and paracetamol can be used during acute flares of pain however due to the chronic nature of the condition inflammation plays a limited role. Icing may also help provide some pain relief but wont address the underlying problem.

Injection treatments are often used in the management of GTPS and can be very effective in managing the symptoms in conjunction with other treatments. Corticosteroid injections are often used to reduce the inflammation of the bursa overlying the tendons and can provide good pain relief. However, because GTPS also involves the underlying tendons which may be tendinopathic or even torn, PRP injections can be used to stimulate regeneration/healing of the tendons and there is good scientific evidence to support these injections. More information about PRP injections can be provided by your Sports Doctor.

It is very rare that someone would need surgery for GTPS. There are some situations where the gluteus medius or gluteus minimus tendons are completely torn and may require surgical repair and this can be confirmed with advanced imaging such as MRI scans.