GTPS is short for Greater Trochanteric Pain Syndrome. Say that 5 times fast! The term “greater trochanteric pain syndrome” (GTPS) describes a collection of overlapping conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, iliotibial band syndrome, and strain or tendinopathy of the hip abductor muscles (1-4).
Bursitis and GTPS
The typical hip has six bursa, which are positioned beneath tendons to reduce friction over the bone (5). Any of these bursae may become painfully inflamed (6). Bursitis, or bursa inflammation may occur in response to acute trauma, but more commonly develops from repetitive mechanical overloading.
What are the risk factors for GTPS?
Tensor fascia lata hypertonicity and iliotibial band tightness generate excessive lateral hip compression and are predisposing factors for greater trochanteric pain syndrome. Hip abductor weakness, foot hyperpronation, pes planus, or leg length inequality are also contributing factors (8,9). Approximately 1/3 of patients with GTPS demonstrate leg length discrepancies (8).
Hip Abductors and GTPS
The hip abductors (i.e. gluteus medius and minimus) are central to GTPS as a source of ongoing symptoms. Weakness in the abductors causes excessive thigh adduction and medial rotation, creating biomechanical disadvantages at the knee and hip, particularly increased tension of the iliotibial band and compression of the greater trochanteric bursa (8).
Who is affected by GTPS?
Greater trochanteric pain syndrome affects a wide spectrum of people, but is most common in middle-aged to elderly adults (8,17). The condition affects both active and sedentary populations (10). GTPS is two to four times more common in females, affecting up to 15% of women (10,17). The condition is present on both sides in up to one-third of GTPS patients (10). 20-35 percent of patients affected with GTPS suffer with concurrent lower back pain (8).
How long can GTPS last?
The chronicity of GTPS is impressive, unfortunately. Thirty-six percent of patients will be symptomatic at one year, and 29% have ongoing complaints after five years. (17) Those with lower extremity osteoarthritis as well as GTPS have nearly a five times greater risk of persistent symptoms (17).
What are the symptoms of GTPS?
Greater trochanteric pain syndrome presents as chronic, persistent pain in the lateral hip, buttock, and thigh (8,19). Tif there is numbness or pain radiating significantly beyond the knee, alternate diagnosis is likely (20). Groin crease pain could indicate acetabular pathology, particularly osteoarthritis (21).
What aggravates GTPS?
GTPS symptoms are often provoked by sitting with the affected leg crossed, transitioning to a standing position, prolonged standing, climbing stairs, and high-impact activities, such as running (8,22). Patients may limit activity as a result of pain, and an antalgic gait is possible. Sleep disturbances are common, since lying on the affected side often increases symptoms.
Are X-rays or imaging necessary for GTPS?
In many cases, X-rays are unnecessary for the initial assessment of GTPS (30). Radiographs may be warranted in cases of trauma or when needed to rule out other pathology. Radiographs should be performed on all patients presenting with significant loss of motion or the inability to bear weight. Children and pre-pubescents with hip pain will likely require radiographs to exclude Legg-Calve-Perthes disease and slipped capital femoral epiphysis (SCFE), respectively. Cases that are unresponsive to a trial of conservative care require further diagnostic work-up. In cases where the diagnosis cannot be confirmed clinically, MRI is the current standard of imaging for GTPS and hip abductor tendon tears (32,52).
Most of the problems with GTPS are from common biomechanical deficits. The goal of treatment should be correct faulty mechanics and to prevent future overload. Conservative treatment of GTPS can exceed a 90% success rate (33).
Rest, activity modification and pain relief are the first lines of defense(34). Patients with acute pain may need to temporarily limit or discontinue aggravating activities. Anti-inflammatory treatments include ice, ultrasound, or electrical stimulation. Patients may apply ice or use ice massage at home. The use of counter-irritant creams (Biofreeze, icy hot, etc.) may provide symptomatic relief.
Stretching and myofascial release techniques such as A.R.T. may be needed for the TFL/ ITB, external hip rotators, hip flexors, gluteus maximus, quadriceps, and hip abductors (8,27). Performing deep soft tissue massage and myofascial release prior to stretching may improve treatment outcomes (36-38).
The addition of IASTM may stimulate remodeling of the gluteus medius and gluteus minimus tendons (39,40).
A specific emphasis should be placed on strengthening the hip abductors and external rotators (41,45,46). Patients should be taught proper squatting and hip hinge techniques to limit hip internal rotation.
While isolated hip stretching and strengthening exercises may be necessary to improve mobility and strength, those exercises and their associated gains do not necessarily translate to improved functional movement patterns. For lasting improvement, patients must be subsequently taught to ‘groove” new movement patterns, via activity-specific exercises (48).
Other insights on GTPS
Athletes should avoid running on a banked surface, like the crown of a road or indoor track. Running on a small circular track causes the inner leg’s ITB to work harder to prevent it from swinging medially. Runners should reverse directions on a circular track each mile.
Patients should avoid running on wet or ice surfaces, as these require greater TFL activation for stabilization. Patients with a “lazy” narrow-based running gait should be encouraged to increase step width to minimize stress on the iliotibial band. (42)
Runners may need to consider new training shoes, particularly if the current shoes have in excess of 300 miles or show any signs of wear on the lateral heel. Cyclists should make certain that their seat is not positioned “too high”.
Overweight or obese patients should consider weight reduction programs to decrease overall biomechanical tension on the area.
Other treatment options for GTPS
The medical co-management of GTPS includes NSAIDs and the injection of local anesthetics or corticosteroids (43). Some researchhas shown benefit for combined corticosteroid and lidocaine injections (44,47).
At Creekside Chiropractic & Performance Center, we are highly trained to treat GTPS. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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