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Greater Trochanteric Pain Syndrome (GTPS) is a common condition affecting the soft tissue on the outside of the hip. It is particularly prevalent in peri- and post-menopausal females, a demographic that experiences significant hormonal changes that impact soft tissue health. GTPS can significantly affect quality of life, limiting mobility and causing persistent pain. In this blog, I will discuss the signs and symptoms of GTPS, its treatment and management, and the underlying reasons why it is more common in peri- and post-menopausal females. This discussion will include the relevance of hormones on soft tissue health and the significance of changes in load on soft tissues.
What is Greater Trochanteric Pain Syndrome?
Greater Trochanteric Pain Syndrome (GTPS) is a condition characterised by pain and tenderness over the lateral aspect of the hip, specifically the greater trochanter, which is the bony prominence on the outer side of the hip. GTPS is often associated with inflammation of the gluteal tendons, bursa, or both. The condition was traditionally referred to as trochanteric bursitis, but the term GTPS is now preferred as it encompasses a broader spectrum of disorders, including tendinopathies of the gluteus tendons.
Signs and Symptoms
The hallmark symptom of GTPS is pain over the lateral hip, which can radiate down the outer thigh. Common symptoms include:
Lateral Hip Pain: This pain is usually exacerbated by lying on the affected side, walking, running, sitting in low chairs or cross legged and prolonged standing. Patients often describe it as a deep, aching pain.
Tenderness over the Greater Trochanter: Palpation of the greater trochanter typically elicits tenderness, and this is often the most prominent clinical finding.
Pain with Activity: Activities that involve repetitive hip movement, such as climbing stairs or running, can exacerbate the pain. Please note, generally it does not appreciate being stretched.
Night Pain: Patients often report pain at night, particularly when lying on the affected side, which can disrupt sleep.
Weakness or Stiffness in the Hip: Some patients may experience weakness or stiffness in the hip, which can affect their gait and mobility.
Why is GTPS Most Common in Peri- and Post-Menopausal Females?
GTPS is significantly more common in peri- and post-menopausal females, and several factors contribute to this prevalence.
Hormonal Changes and Soft Tissue Health
The hormonal changes that occur during menopause, particularly the reduction in oestrogen levels, have a profound impact on soft tissue health. Oestrogen plays a critical role in maintaining the strength and integrity of tendons, ligaments, and muscles. Reduced oestrogen levels can lead to:
Decreased Collagen Production: Oestrogen is vital for collagen synthesis, which is essential for the strength and elasticity of tendons and ligaments. Reduced collagen production can weaken these structures, making them more susceptible to injury and inflammation.
Increased Tendon Stiffness: Lower oestrogen levels have been associated with increased tendon stiffness, which can lead to a higher risk of tendinopathies, including those affecting the gluteal tendons in GTPS.
Altered Pain Perception: Hormonal fluctuations can also affect pain perception, making peri- and post-menopausal women more sensitive to pain, which may exacerbate the symptoms of GTPS.
Changes in Load and Soft Tissue Health
In addition to hormonal changes, alterations in mechanical load on the hip joint and surrounding soft tissues can contribute to the development of GTPS. These changes may include:
Increased Load on the Hip: Weight gain, which is common during menopause, increases the load on the hip joint and surrounding structures, contributing to the development of tendinopathies and bursitis.
Reduced Physical Activity: Peri- and post-menopausal women may reduce their physical activity levels due to pain or other health issues. This reduction in activity can lead to muscle weakness and altered biomechanics, increasing the strain on the gluteal tendons and exacerbating GTPS symptoms. A period of decreased activity followed by a significant increase in load will also enhance the likelihood of developing GTPS.
Altered Gait: Changes in gait, often due to compensating for pain, can place additional stress on the hip and the greater trochanter, further contributing to the development of GTPS. Developing GTPS as a result of an ongoing lower back issue, knee injury or ankle pain could cause altered biomechanics in the kinetic chain.
Treatment and Management of Greater Trochanteric Pain Syndrome
The management of GTPS involves a combination of conservative treatments, physiotherapy, and, in some cases, more invasive interventions. The National Institute for Health and Care Excellence (NICE) guidelines emphasise a stepwise approach to managing musculoskeletal pain, including GTPS, with a focus on non-invasive treatments first.
1. Conservative Management
Rest and Activity Modification: Patients are advised to reduce and adapt activities that exacerbate their symptoms, such as prolonged standing or lying on the affected side. Using a pillow between the knees while sleeping can help reduce pressure on the greater trochanter.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can be effective in managing pain and inflammation associated with GTPS. They are often recommended as part of the initial management plan.
2. Physiotherapy
Physiotherapy is a cornerstone of GTPS management and focuses on:
Strengthening Exercises: Strengthening the hip abductors, particularly the gluteus medius and minimus muscles, can help improve hip stability and reduce the strain on the tendons and bursa. A study published in Physical Therapy in Sport (2011) showed that targeted exercise programs significantly improve pain and function in patients with GTPS.
Manual Therapy: Techniques such as deep tissue massage and myofascial release can help reduce muscle tightness and facilitate pain relief in the short term which can facilitate engagement in a robust rehabilitation program.
Education and Advice: Physiotherapists play a crucial role in educating patients about the condition, including advice on activity modification, load management, and a gradual, progressive loading program. If this has been tried for an adequate period with minimal change in symptoms they will also be able to discuss alternative options with you.
3. Shockwave Therapy
Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment option that has been shown to be effective in some patients with GTPS. ESWT works by delivering shockwaves to the affected area, promoting tissue healing and reducing pain. A study in The American Journal of Sports Medicine (2007) reported positive outcomes for patients treated with ESWT for GTPS.
4. Corticosteroid Injections
For patients who do not respond to conservative management and physiotherapy, corticosteroid injections into the trochanteric bursa may be considered. These injections can provide temporary relief by reducing inflammation. However, repeated injections should be avoided due to the potential for decreasing tendon integrity.
5. Surgery
Surgery is considered a last resort for patients with GTPS who have not responded to other treatments. Surgical options may include bursectomy (removal of the inflamed bursa) or tendon repair. However, surgery is rarely required and is typically reserved for severe cases.
Conclusion
Greater Trochanteric Pain is a common condition that predominantly affects peri- and post-menopausal females. The interplay between hormonal changes and mechanical load on the hip joint and surrounding soft tissues is crucial in understanding why this condition is more prevalent in this population. Effective management of GTPS requires a comprehensive approach, including conservative treatments, physiotherapy, and, in some cases, more invasive interventions. Early intervention and a tailored treatment plan can help alleviate symptoms, improve function, and enhance the overall quality of life for those affected by this condition.
References
NICE guidelines [CG177]: Osteoarthritis: care and management. National Institute for Health and Care Excellence. (2014).
Fearon, A. M., Cook, J. L., & Scarvell, J. M. (2014). Greater trochanteric pain syndrome: defining the syndrome. British Journal of Sports Medicine, 48(10), 647-653. doi:10.1136/bjsports-2012-091565.
Rompe, J. D., Segal, N. A., Cacchio, A., Furia, J. P., Morral, A., & Maffulli, N. (2007). Home training, local corticosteroid injection, or radial shockwave therapy for greater trochanter pain syndrome. The American Journal of Sports Medicine, 37(10), 1981-1990. doi:10.1177/0363546509335544.
Ganderton, C., Pizzari, T., Harle, T., & Cook, J. (2017). The gluteal tendinopathy rehabilitation program: case reports of 3 patients with greater trochanteric pain syndrome. Physical Therapy in Sport, 25, 92-98. doi:10.1016/j.ptsp.2016.07.005.
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. doi:10.2519/jospt.2015.5829.
Allison, K., & Purdam, C. (2009). Eccentric loading for Achilles tendinopathy: strengthening or stretching? British Journal of Sports Medicine, 43(4), 276-279. doi:10.1136/bjsm.2008.052332.
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