High-yield overview

Lateral Hip Pain | Gluteal Tendinopathy | Not Just Bursitis

10-25%Prevalence in middle-aged population

F:M 4:1Female predominance

40-60Peak age range (years)

90%Have gluteal tendinopathy not just bursitis

PATHOLOGY SPECTRUM

Gluteal Tendinopathy

PatternMost common cause - gluteus medius/minimus degeneration

TreatmentPhysiotherapy, load modification, PRP

Trochanteric Bursitis

PatternIsolated in less than 10% - usually secondary to tendinopathy

TreatmentActivity modification, NSAIDs, injection

Gluteal Tears

PatternPartial or full thickness - rotator cuff of the hip

TreatmentPhysiotherapy vs surgical repair

Critical Must-Knows

Not just bursitis - 90% have gluteal tendinopathy; isolated bursitis is rare (less than 10%)
Rotator cuff of the hip - gluteus medius/minimus tears analogous to shoulder pathology
Lateral hip pain with side-lying - distinguishes from hip OA (groin pain) and lumbar radiculopathy
Trendelenburg gait/test - key examination finding indicating gluteal dysfunction
Load modification essential - crossing legs, stairs, sleeping on side all provocative

Clinical Pearls

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Point tenderness over greater trochanter with normal hip ROM suggests GTPS
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Single leg stance for 30 seconds reproduces lateral hip pain
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MRI shows tendinopathy in 90% but bursitis alone in less than 10%
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Female predominance is attributed to a wider pelvis increasing ITB tensile strain, but the mechanism is multifactorial

Overview and Epidemiology

Greater trochanteric pain syndrome (GTPS) is a clinical diagnosis: lateral hip pain with tenderness over the greater trochanter. It is one of the most common causes of hip pain in primary care. The older name, "trochanteric bursitis", is now considered outdated, because modern imaging shows that most patients have gluteal tendinopathy rather than primary bursitis. [1,2]

Who. Peak incidence falls at 40-60 years, women outnumber men 4:1, and the prevalence in the middle-aged population is 10-25%. It is common in runners and in people with sedentary occupations, and it is bilateral in 25-30% of cases.

Tendon, not bursa. On MRI about 90% of patients have gluteal tendinopathy, and isolated bursitis accounts for less than 10%. The landmark ultrasound prevalence study by Long et al. (AJR 2013), of 877 patients with GTPS, points the same way [1]:

49.9% had gluteal tendinosis
20.2% had trochanteric bursitis, so nearly 80% had no bursitis at all
28.5% had a thickened iliotibial band
Only 0.5% had a frank gluteal tendon tear, a figure that reflects how insensitive ultrasound was to tears in that dataset rather than how often tears occur

Risk factors. Beyond age, GTPS is associated with:

Female sex
Metabolic factors: obesity (BMI over 25), diabetes and hypothyroidism
Low back pathology, associated in 20-35%
Lower limb OA, ipsilateral knee or hip
Leg length discrepancy
Running, especially a sudden increase in mileage, or any sudden increase in load such as stairs
Sedentary occupation with prolonged sitting

Pathophysiology and Anatomy

The greater trochanter. Three facets receive the gluteal tendons, which lie deep to the iliotibial band, an arrangement that recalls the insertions of the shoulder cuff.

Anterior facet

Location: Most anterior aspect
Tendon Insertion: Gluteus minimus
Clinical Significance: First to tear, difficult to visualize

Lateral facet

Location: Lateral prominence
Tendon Insertion: Gluteus medius (main)
Clinical Significance: Most common site of tendinopathy

Superoposterior facet

Location: Superior-posterior
Tendon Insertion: Gluteus medius (secondary)
Clinical Significance: Extension tears may involve this

Greater Trochanter Facets and Insertions
Facet	Location	Tendon Insertion	Clinical Significance
Anterior facet	Most anterior aspect	Gluteus minimus	First to tear, difficult to visualize
Lateral facet	Lateral prominence	Gluteus medius (main)	Most common site of tendinopathy
Superoposterior facet	Superior-posterior	Gluteus medius (secondary)	Extension tears may involve this

Labelled axial MRI showing the anterior and lateral trochanteric facets and the overlying iliotibial band — Axial MRI at the greater trochanter with printed labels: the anterior facet, insertion of gluteus minimus (orange), the lateral facet, main insertion of gluteus medius (green), the ridge between them, and the overlying iliotibial band, tensor fascia lata and gluteus maximus. This layered anatomy has to be checked before all lateral signal is attributed to a bursa.Credit: Grimaldi et al., Archives of Orthopaedic and Trauma Surgery (CC BY 4.0)

The abductor cuff. Gluteus medius and minimus form the hip abductor mechanism. Because their pathology mirrors shoulder rotator cuff disease, GTPS has been called the "rotator cuff of the hip". Like supraspinatus, gluteus medius is the tendon most commonly affected, and tears follow the same pattern: partial-thickness undersurface tears first, progressing to full thickness with retraction and fatty infiltration.

Origin

Gluteus medius: External surface of ilium between the anterior and posterior gluteal lines
Gluteus minimus: External surface of ilium between the anterior and inferior gluteal lines

Insertion

Gluteus medius: Lateral and superoposterior facets of the greater trochanter
Gluteus minimus: Anterior facet of the greater trochanter

Innervation

Gluteus medius: Superior gluteal nerve (L4-S1)
Gluteus minimus: Superior gluteal nerve (L4-S1)

Function

Gluteus medius: Primary hip abductor; stabilises the pelvis in single-leg stance
Gluteus minimus: Hip abduction, internal rotation, pelvic stabilisation

	Gluteus medius	Gluteus minimus
Origin	External surface of ilium between the anterior and posterior gluteal lines	External surface of ilium between the anterior and inferior gluteal lines
Insertion	Lateral and superoposterior facets of the greater trochanter	Anterior facet of the greater trochanter
Innervation	Superior gluteal nerve (L4-S1)	Superior gluteal nerve (L4-S1)
Function	Primary hip abductor; stabilises the pelvis in single-leg stance	Hip abduction, internal rotation, pelvic stabilisation

The bursae. Three bursae surround the greater trochanter:

Subgluteus maximus bursa - the largest, between gluteus maximus and the greater trochanter
Subgluteus medius bursa - between the gluteus medius tendon and the greater trochanter
Subgluteus minimus bursa - between the gluteus minimus tendon and the anterior facet

They may become inflamed secondary to tendinopathy, direct compression or friction from the overlying iliotibial band. Each occupies its own layer, so where the fluid lies changes the suspected pain generator, and symptoms labelled bursitis have to be localised against the adjacent gluteal tendon and ITB.

Transverse anatomy of iliopsoas and peritrochanteric hip bursae — Transverse drawing through the hip. Around the greater trochanter (GT) the subgluteus minimus bursa (green) lies deep to gluteus minimus (GMi), the subgluteus medius bursa (light blue) deep to gluteus medius (GMe) and the subgluteus maximus bursa (red) deep to gluteus maximus (GMx), each in its own layer; the iliopsoas bursa (dark blue) lies anteriorly.Credit: Corvino et al., Diagnostics (CC BY 4.0)

Three-dimensional locations of the three greater-trochanteric bursae — The three trochanteric bursae painted on the proximal femur from three aspects, coloured as in the transverse drawing: subgluteus maximus (red), visibly the largest, subgluteus medius (light blue) and subgluteus minimus (green).Credit: Corvino et al., Diagnostics (CC BY 4.0)

How the tendon fails. GTPS develops through a combination of tensile and compressive load, which together lead to tendon degeneration, as rotator cuff tendinopathy does in the shoulder.

Tensile overload - repetitive hip abduction loading in running, stair climbing and single-leg activities, and a sudden increase in activity level
Compressive load - the ITB pressing the tendons against the trochanter in hip adduction, direct compression when sleeping on that side, and crossing the legs (hip adduction and internal rotation)

Biomechanics. A wider female pelvis increases ITB tension and the compressive load on the gluteal tendon insertions, and an increased Q angle in women, valgus knee alignment and leg length discrepancy add to the load. These have been used to explain the female predominance, but that association is multifactorial and should not be reduced to a presumed wider pelvis or knee Q-angle.

Clinical Presentation

The pain. It sits over the greater trochanter and is aching or burning, sometimes sharp. It may radiate down the lateral thigh to the knee, but not below it. Onset is usually gradual and may follow an increase in activity.

Night pain. Difficulty sleeping on the affected side is a hallmark of GTPS, and patients often report waking at night when they roll onto the hip.

What makes it worse. Load and compression provoke the pain:

Lying on the affected side
Crossing the legs
Prolonged sitting, especially on hard surfaces, and prolonged standing
Stairs, especially descending
Standing up from a seated position
Single-leg activities such as putting on shoes and socks
Walking, especially uphill or on uneven ground

Associated symptoms. Patients describe the hip as weak or giving way, have difficulty with single-leg activities, feel stiff after prolonged sitting, and may have a limp or a Trendelenburg gait.

Look. Watch the gait for a Trendelenburg pattern, note any pelvic obliquity when the patient stands, and look for gluteal wasting in chronic cases.

Feel. Point tenderness over the greater trochanter is the key sign. Check for tenderness at the gluteus medius insertion on the posterosuperior trochanter and at the gluteus minimus insertion anteriorly. The groin is not tender, which distinguishes GTPS from hip OA.

Move. Hip range of motion is typically full and painless, which also separates GTPS from OA. End-range adduction hurts because it compresses the tendons, and end-range internal rotation with the hip flexed hurts too.

Single leg stance (30s)

Technique: Stand on affected leg for 30 seconds
Positive Finding: Reproduces lateral hip pain
Performance: Rule-IN test: specificity 100%, LR+ ~12 (Grimaldi, n=65)

Greater trochanter palpation

Technique: Palpate over the greater trochanter
Positive Finding: Point tenderness
Performance: Rule-OUT test: sensitivity ~80% (Grimaldi, n=65)

Trendelenburg test

Technique: Stand on affected leg, observe pelvis
Positive Finding: Contralateral pelvis drops
Performance: Sensitivity 72.7%, specificity 76.9% for a gluteus medius TEAR (Bird 2001, n=24)

FABER test

Technique: Flexion-abduction-external rotation
Positive Finding: Lateral hip pain (not groin)
Performance: Sensitivity 82%

Resisted hip abduction

Technique: Side-lying, resist abduction
Positive Finding: Pain and/or weakness
Performance: Variable

Side-lying provocation

Technique: Lie on affected side
Positive Finding: Reproduces lateral hip pain
Performance: Sensitivity high

Clinical Tests for GTPS
Test	Technique	Positive Finding	Performance
Single leg stance (30s)	Stand on affected leg for 30 seconds	Reproduces lateral hip pain	Rule-IN test: specificity 100%, LR+ ~12 (Grimaldi, n=65)
Greater trochanter palpation	Palpate over the greater trochanter	Point tenderness	Rule-OUT test: sensitivity ~80% (Grimaldi, n=65)
Trendelenburg test	Stand on affected leg, observe pelvis	Contralateral pelvis drops	Sensitivity 72.7%, specificity 76.9% for a gluteus medius TEAR (Bird 2001, n=24)
FABER test	Flexion-abduction-external rotation	Lateral hip pain (not groin)	Sensitivity 82%
Resisted hip abduction	Side-lying, resist abduction	Pain and/or weakness	Variable
Side-lying provocation	Lie on affected side	Reproduces lateral hip pain	Sensitivity high

Rule in, rule out. GTPS is a clinical diagnosis, and the two most useful bedside tests do different jobs. Grimaldi and colleagues (2017) examined 65 patients with lateral hip pain against MRI-confirmed gluteal tendinopathy: a positive single-leg stance moved a nominal 50% pretest probability to a 98% post-test probability and strongly confirms the diagnosis, while a patient who is not tender on trochanteric palpation is unlikely to have MRI-detected gluteal tendinopathy.

The limits. About a third of MRI-positive patients (20 of 65) were clinically negative, so a normal examination does not fully exclude tendinopathy in a persistently symptomatic patient, and imaging still has a role. Lequesne's 100% sensitivity for the single-leg stance comes from 17 patients who all had MRI disease; do not quote it.

Resisted external derotation. This loaded, confirmatory provocation test, validated by Lequesne et al. (2008), had a sensitivity of 88% and a specificity of 97.3% against MRI in refractory GTPS.

Patient supine, hip and knee flexed to 90 degrees
The examiner passively externally rotates the hip to end range
The patient actively derotates (internally rotates) the leg back to neutral against resistance
Reproduction of the patient's lateral trochanteric pain is a positive result

A prone variant with the hip extended is also described.

Evidence

Grimaldi A, Mellor R, Nicolson P, et al. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med. 2017;51(6):519-524

Level II

Key Findings:

Single-leg stance = rule-in (specificity 100%, LR+ ~12)
GT palpation = rule-out (sensitivity ~80%)
31% of MRI-positive patients had a clinically negative exam

Finding: 65 patients with lateral hip pain assessed with compressive/tensile gluteal provocation tests against MRI (increased intratendinous T2 signal) as the reference standard. Lateral hip pain within 30 seconds of single-leg standing had specificity 100% and positive likelihood ratio ~12 (50% pretest to 98% post-test probability). Palpation over the greater trochanter had ~80% sensitivity. 20 of 65 (31%) had MRI tendinopathy despite a clinically negative examination.

Clinical implication: Pair a high-specificity rule-in test (single-leg stance) with a sensitive rule-out test (GT palpation), but recognise that a normal examination does not exclude tendinopathy in a persistently symptomatic patient - reserve imaging for these cases.

Limitation: THE REFERENCE STANDARD IS AN MRI SIGNAL CHANGE THAT ALSO OCCURS IN PAINLESS HIPS - gluteal tendinopathy was defined as increased intratendinous T2 signal, which is prevalent in asymptomatic people of this age, so some of the 'disease' being detected was never the source of the patient's pain. That cuts both ways: it inflates apparent false positives for the clinical tests, and it means a positive MRI does not license treatment on its own. The authors are unusually honest about power - 65 participants, and they warn the sample is 'possibly underpowered for indices of diagnostic utility with low precision', so the headline specificity of 100% carries a confidence interval that certainly includes values well below 100 and must not be read as a test that never misfires. The finding that should change practice is the one this page already carries: 20 of 65 (31%) had MRI tendinopathy with a clinically negative examination, so a normal examination does not exclude the diagnosis. Note finally that Grimaldi, Mellor, Bennell, Hodges and Vicenzino are the same investigator group as the LEAP trial below, so the diagnostic criteria and much of the treatment evidence on this page come from one team.

Verify on PubMed (PMID 27633027)

Mnemonic

GTPSGTPS Examination - STEPS

Single leg stance

30 seconds reproduces lateral hip pain

Trendelenburg test

Positive indicates abductor weakness

External rotation strength

Test in prone - often weak

Palpation over GT

Point tenderness over greater trochanter

Side-lying provokes

Pain lying on affected side

Hook:Take STEPS to examine GTPS - systematic approach to lateral hip pain

Exclude Serious Pathology

The following features warrant further investigation:

Night pain unrelated to position (may indicate tumour)
Rest pain unrelieved by avoiding compression
Systemic symptoms (weight loss, fever)
History of malignancy
Groin pain (suggests intra-articular hip pathology)
Pain below the knee (suggests lumbar radiculopathy)

Investigations

GTPS is primarily a clinical diagnosis. Investigations exclude other pathology and confirm the diagnosis in unclear or recalcitrant cases.

Radiographs. An AP pelvis and lateral hip view are usually normal in GTPS. Their purpose is to exclude hip OA, avascular necrosis and stress fracture, and they may show calcification at the trochanteric insertion (calcific tendinopathy).

AP pelvis radiograph with arrows marking gluteal tendon calcification at the iliac crests and around the greater trochanters — AP pelvis radiograph with arrows on tendon calcification at three sites: the gluteus medius origin on the iliac crests (blue), the gluteal tendons at the superolateral greater trochanter (dotted pink), and calcification extending inferiorly from the greater trochanters (orange). Radiography identifies mineralisation that can modify prognosis and procedural targeting.Credit: Grimaldi et al., Archives of Orthopaedic and Trauma Surgery (CC BY 4.0)

Ultrasound is the first-line imaging for GTPS. It shows tendon thickening, hypoechoic change and tears, a bursal fluid collection of more than 2mm, and ITB pathology, and it is useful for guiding injection.

Axial ultrasound anatomy of gluteus minimus medius and trochanteric bursa — Axial ultrasound over the greater trochanter showing the cuff-like insertions: gluteus minimus tendon (yellow circle) anteriorly, gluteus medius tendon (asterisk) in the middle and gluteus maximus (GMx) covering the trochanter. The red and light-blue lines trace the subgluteus maximus and subgluteus medius bursae. This is the orientation needed to tell tendinopathy, tear and secondary bursitis apart.Credit: Corvino et al., Diagnostics (CC BY 4.0)

Short-axis ultrasound of traumatic subgluteus-maximus bursal distension — Short-axis ultrasound of traumatic subgluteus maximus bursitis: the distended bursa (arrow) lies deep to gluteus maximus (GMx) and superficial to the greater trochanter and the gluteus medius tendon (asterisk). Internal clot distinguishes traumatic haemorrhagic bursitis from simple anechoic fluid.Credit: Corvino et al., Diagnostics (CC BY 4.0)

MRI is the gold standard for soft tissue assessment. It shows tendinopathy as increased T2 signal, demonstrates partial and full-thickness tears, and assesses muscle quality through fatty infiltration. It is 91% accurate in diagnosing abductor tears (Cvitanic 2004) [4].

The MRI signs. The single most useful sign of a tear is a focus of T2 hyperintensity superior to the greater trochanter (sensitivity 73%, specificity 95%). Other findings include disruption of tendon continuity, tendon elongation and, in chronic cases, fatty infiltration of the gluteal muscles, directly analogous to rotator cuff assessment.

Coronal MRI showing high signal at the greater trochanter (arrow) in GTPS — Coronal fluid-sensitive MRI with increased signal at the greater trochanter (arrow). It supports the diagnosis but must be interpreted with tendon morphology and the clinical pain pattern, not used as a stand-alone diagnosis.Credit: Sunil Kumar et al., Knee Surgery, Sports Traumatology, Arthroscopy (CC BY 4.0)

MRI spectrum from gluteus medius tendinosis to partial tear — Four MRI panels (A-D), each with an arrow. A: mild intrasubstance signal and peritendinous oedema in gluteus medius, tendinosis. B: marked signal and ill-definition of the gluteus medius tendon at its lateral-facet insertion, an insertional partial tear: the line between tendinopathy and structural failure. C and D are axial images.Credit: Seo et al., PLOS ONE (CC BY 4.0)

Axial and coronal MRI of combined gluteus medius and minimus tears — Axial and coronal MRI (printed labels), arrows at the trochanteric insertion, in a patient with gluteus medius and minimus tears on a background of severe tendinopathy. Reading both planes establishes the extent of the tear and the quality of the background tissue for surgical planning.Credit: Grimaldi et al., Archives of Orthopaedic and Trauma Surgery (CC BY 4.0)

Grading. MRI findings are graded from 1 to 5, and each grade carries its own management implication.

Grade 1

MRI Findings: Bursitis with minimal tendon changes
Management Implication: Conservative - physio, activity modification

Grade 2

MRI Findings: Tendinopathy - increased T2 signal
Management Implication: Conservative - physio, may consider injection

Grade 3

MRI Findings: Partial thickness tear
Management Implication: Prolonged conservative trial, PRP consideration

Grade 4

MRI Findings: Full thickness tear without retraction
Management Implication: Consider surgical repair if conservative fails

Grade 5

MRI Findings: Complete tear with retraction, fatty atrophy
Management Implication: Surgical repair vs reconstruction

MRI Grading of Gluteal Tendinopathy
Grade	MRI Findings	Management Implication
Grade 1	Bursitis with minimal tendon changes	Conservative - physio, activity modification
Grade 2	Tendinopathy - increased T2 signal	Conservative - physio, may consider injection
Grade 3	Partial thickness tear	Prolonged conservative trial, PRP consideration
Grade 4	Full thickness tear without retraction	Consider surgical repair if conservative fails
Grade 5	Complete tear with retraction, fatty atrophy	Surgical repair vs reconstruction

Blood tests. These are not routinely required, but consider them in atypical presentations:

ESR and CRP if infection or inflammatory arthritis is suspected
Rheumatoid factor if inflammatory arthritis is suspected
HbA1c to screen for diabetes in recurrent cases

Differential Diagnosis

GTPS

Pain Location: Lateral hip over GT
Key Distinguishing Features: Point tenderness GT, normal ROM, side-lying pain

Hip OA

Pain Location: Groin (C-sign)
Key Distinguishing Features: Reduced ROM, crepitus, start-up stiffness, X-ray changes

Lumbar radiculopathy

Pain Location: Lateral thigh to below knee
Key Distinguishing Features: Back pain, dermatomal distribution, neurological signs

External snapping hip

Pain Location: Lateral hip, audible snap
Key Distinguishing Features: Palpable/visible snap with hip flexion, usually painless

Meralgia paraesthetica

Pain Location: Anterolateral thigh
Key Distinguishing Features: Sensory symptoms, no motor weakness, LFCN territory

Stress fracture (femoral neck)

Pain Location: Groin, lateral hip
Key Distinguishing Features: Activity-related, worse with weight bearing, high index of suspicion

Differential Diagnosis of Lateral Hip Pain
Condition	Pain Location	Key Distinguishing Features
GTPS	Lateral hip over GT	Point tenderness GT, normal ROM, side-lying pain
Hip OA	Groin (C-sign)	Reduced ROM, crepitus, start-up stiffness, X-ray changes
Lumbar radiculopathy	Lateral thigh to below knee	Back pain, dermatomal distribution, neurological signs
External snapping hip	Lateral hip, audible snap	Palpable/visible snap with hip flexion, usually painless
Meralgia paraesthetica	Anterolateral thigh	Sensory symptoms, no motor weakness, LFCN territory
Stress fracture (femoral neck)	Groin, lateral hip	Activity-related, worse with weight bearing, high index of suspicion

The C-Sign

Ask where it hurts. The patient with hip OA demonstrates the "C-sign", cupping the hand around the hip with the thumb posteriorly and the fingers anteriorly in the groin; the patient with GTPS points directly to the lateral hip. This is a key distinguishing feature in the exam setting.

Axial and coronal MRI showing quadratus femoris oedema in ischiofemoral impingement — Ischiofemoral impingement on axial (A) and coronal (B) MRI: oedema in quadratus femoris with a narrowed ischiofemoral space (arrows). The pain it causes is posterior and deep-gluteal rather than lateral trochanteric, and it should not be misclassified as GTPS.Credit: Yoon et al., Diagnostics (CC BY 4.0)

Management

Management follows a stepwise approach, with conservative measures first-line. Surgical intervention is reserved for recalcitrant cases or significant tears. [5,6]

Patient education about pathology and prognosis
Avoid sleeping on affected side (pillow between knees)
Avoid crossing legs and prolonged standing
Limit stair climbing (use handrail, lead with unaffected leg)
Activity modification - reduce running, single leg loading
Weight loss if BMI over 25

Gluteal strengthening (isometric progressing to isotonic)
Hip abductor exercises (non-provocative positions)
Core stability and lumbar spine assessment
Gait retraining
ITB stretching (controversial - may increase compression)
Graduated return to activity

NSAIDs (topical or oral) for 2-4 weeks
Corticosteroid injection
PRP injection
Shockwave therapy (ESWT)

Exercise. The programme avoids provocative positions, hip adduction and compression, at first, and then progresses the load in phases.

Initial (0-2 weeks)

Exercises: Isometric hip abduction in neutral
Key Points: Pain-free range, avoid compression

Early (2-6 weeks)

Exercises: Bridging, clamshells, side-lying abduction
Key Points: Progress load gradually, monitor symptoms

Intermediate (6-12 weeks)

Exercises: Standing hip abduction, step-ups
Key Points: Single leg loading with good control

Advanced (12+ weeks)

Exercises: Running, stairs, sport-specific
Key Points: Full return to activity

Exercise Progression for GTPS
Phase	Exercises	Key Points
Initial (0-2 weeks)	Isometric hip abduction in neutral	Pain-free range, avoid compression
Early (2-6 weeks)	Bridging, clamshells, side-lying abduction	Progress load gradually, monitor symptoms
Intermediate (6-12 weeks)	Standing hip abduction, step-ups	Single leg loading with good control
Advanced (12+ weeks)	Running, stairs, sport-specific	Full return to activity

When. An injection is indicated for:

Failed conservative management at 6-8 weeks
Significant bursitis on imaging
Severe pain limiting rehabilitation

Technique. The target is the subgluteus maximus bursa.

Patient lateral, affected side up
Identify the point of maximum tenderness over the greater trochanter
Clean the skin with antiseptic
Insert the needle perpendicular until bone is contacted
Withdraw 2-3mm and inject 1ml corticosteroid with 2-3ml local anaesthetic

What to expect. Short-term relief in 60-75%, an effect that diminishes at 3-6 months, and no evidence of long-term benefit over placebo [7]. Combine the injection with physiotherapy rehabilitation for sustained benefit.

The limit. A maximum of 3 injections is recommended, because repeated injection risks tendon weakening and atrophy.

Surgery. Surgical management is considered for:

Failed comprehensive conservative management (6-12 months)
Significant gluteal tendon tear (full thickness)
Refractory symptoms affecting quality of life

Bursectomy

Indication: Isolated refractory bursitis
Technique: Arthroscopic or open excision
Outcomes: Good if isolated bursitis (rare)

Tendon repair

Indication: Partial/full tear with good tissue
Technique: Open repair with suture anchors
Outcomes: 80-90% good/excellent outcomes

Tendon reconstruction

Indication: Chronic tear with retraction
Technique: Allograft or autograft augmentation
Outcomes: Variable - depends on tissue quality

ITB release

Indication: ITB pathology/snapping hip
Technique: Arthroscopic or open Z-plasty
Outcomes: Good for snapping, uncertain for GTPS

Surgical Options for GTPS
Procedure	Indication	Technique	Outcomes
Bursectomy	Isolated refractory bursitis	Arthroscopic or open excision	Good if isolated bursitis (rare)
Tendon repair	Partial/full tear with good tissue	Open repair with suture anchors	80-90% good/excellent outcomes
Tendon reconstruction	Chronic tear with retraction	Allograft or autograft augmentation	Variable - depends on tissue quality
ITB release	ITB pathology/snapping hip	Arthroscopic or open Z-plasty	Good for snapping, uncertain for GTPS

Open view of a full-thickness gluteus medius tear after bursectomy — With the fascia lata incised and the trochanteric bursa excised, a full-thickness gluteus medius tear lies open: the structural lesion that needs repair.Credit: Uso et al., Journal of Hip Preservation Surgery (CC BY 4.0)

Debridement and preparation of the gluteus medius footprint — Degenerative tendon and osteophytes on the anterolateral facet are cleared to recreate a bleeding footprint, while enough cortical bone is preserved for anchor fixation.Credit: Uso et al., Journal of Hip Preservation Surgery (CC BY 4.0)

Double-row crossed-limb gluteus medius reconstruction — The completed double-row, crossed-limb repair. It compresses the tendon broadly against the prepared footprint and distributes load across proximal and distal fixation points.Credit: Uso et al., Journal of Hip Preservation Surgery (CC BY 4.0)

Open hip-abductor tear before and after augmented repair — Open augmented abductor repair. A: the delaminated tear before repair, a layer lifted with forceps. B: the completed repair fixed back to the greater trochanter with transosseous sutures; the augmentation lies on the deep surface of the tendons and is not visible.Credit: Ebert et al., Knee Surgery, Sports Traumatology, Arthroscopy (CC BY 4.0)

Extracorporeal Shockwave Therapy (ESWT)

ESWT, radial or focused, is one of the few non-injection, non-surgical options with randomised-trial support in GTPS.

Rationale. Shockwaves are thought to stimulate neovascularisation and a controlled inflammatory and healing response in degenerate tendon, analogous to their established use in plantar fasciopathy and in calcific and insertional tendinopathies elsewhere. Radial ESWT is typically delivered as approximately three weekly sessions and is best combined with a home gluteal-loading programme rather than used in isolation.

Rompe (2009): a crossover in time. A trial of 229 patients with refractory unilateral GTPS, reported as randomised although patients were assigned sequentially, compared home training, a single corticosteroid injection (25 mg prednisolone) and radial ESWT:

1 month - corticosteroid injection best: 75% success, against 13% for ESWT and 7% for home training
4 months - radial ESWT best: 68%, against 51% for injection and 41% for home training
15 months - ESWT (74%) and home training (80%) both significantly superior to injection (48%)

What it means. The message mirrors the LEAP trial: steroid gives fast but short-lived relief, whereas loading-based and shockwave strategies give more durable benefit. Frame ESWT as an adjunct for the patient who has failed loading and wants to avoid, or has failed, injection.

Balancing view. Barratt et al. (2016), a systematic review of eight studies (696 patients), found corticosteroid injection superior only up to three months, with radial shockwave and home training supported by only limited evidence and an overall paucity of high-quality trials. That is why guidelines describe the ESWT evidence as moderate and heterogeneous rather than definitive.

Evidence

Rompe JD, Segal NA, Cacchio A, et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med. 2009;37(10):1981-90

Level I

Key Findings:

Corticosteroid best short-term (1 month) but not durable
Radial ESWT superior at 4 months
ESWT and home training beat injection at 15 months

Finding: RCT of 229 patients with refractory unilateral GTPS randomised to home training, a single corticosteroid injection (25 mg prednisolone), or radial ESWT. Corticosteroid injection was superior at 1 month (75% vs 13% ESWT vs 7% home training). Radial ESWT was superior at 4 months (68% vs 51% injection vs 41% home training). At 15 months both ESWT (74%) and home training (80%) were significantly better than injection (48%).

Clinical implication: Radial ESWT is a reasonable adjunct for refractory GTPS, offering more durable benefit than corticosteroid injection when combined with a loading programme; the trade-off is slower onset than injection and less robust overall evidence than exercise.

Limitation: PATIENTS WERE ASSIGNED SEQUENTIALLY, WHICH IS NOT RANDOMISATION - the paper is titled and indexed as a randomised controlled trial, but its methods state that the 229 subjects were 'assigned sequentially' to the three arms. Sequential allocation is predictable, offers no allocation concealment, and lets the recruiter foresee the next arm, which is the commonest route to baseline imbalance in a nonpharmacological trial. Treat the comparison as quasi-randomised and the level of evidence as lower than the stated II. Two further limits: the population is REFRACTORY unilateral GTPS, so the very low one-month success in the home-training arm (7%) reflects patients already selected for having failed conservative measures rather than the expected response in a new presentation; and the corticosteroid arm received a single 25 mg prednisolone injection, so nothing here speaks to repeated or ultrasound-guided injection. The pattern itself is robust and is what matters clinically, because it is a crossover in time: injection wins at one month, shockwave at four months, and by fifteen months both shockwave (74%) and home training (80%) have overtaken injection (48%).

Verify on PubMed (PMID 19439758)

Prognosis and Complications

Prognosis. GTPS generally has a good prognosis with appropriate management, though recovery may be prolonged. 60-80% respond to comprehensive conservative management, with an average time to resolution of 3-6 months. Recurrence is common if load management is not maintained, and chronic cases may persist for years.

Short symptom duration (less than 3 months)

Unfavorable: Chronic symptoms (greater than 12 months)

Tendinopathy without tear

Unfavorable: Full thickness tear with retraction

Normal BMI

Unfavorable: Obesity (BMI greater than 30)

Good compliance with physiotherapy

Unfavorable: Poor engagement with rehabilitation

Modifiable risk factors addressed

Unfavorable: Ongoing provocative activities

Prognostic Factors in GTPS
Favourable	Unfavorable
Short symptom duration (less than 3 months)	Chronic symptoms (greater than 12 months)
Tendinopathy without tear	Full thickness tear with retraction
Normal BMI	Obesity (BMI greater than 30)
Good compliance with physiotherapy	Poor engagement with rehabilitation
Modifiable risk factors addressed	Ongoing provocative activities

Complications of the condition. Chronic pain affects sleep and function, gluteal weakness produces a Trendelenburg gait, the tendon may progress to a full-thickness tear, and fatty infiltration of the gluteal muscles is irreversible.

Complications of treatment. Corticosteroid injection risks tendon weakening, skin atrophy and infection. Surgery risks infection, wound complications, recurrence and nerve injury.

Natural History

Unlike rotator cuff tears which may remain asymptomatic, gluteal tears typically cause significant symptoms due to the constant loading during walking. Fatty infiltration develops over time and is associated with poorer surgical outcomes, similar to the shoulder. Early diagnosis and appropriate management is important to prevent progression.

Guidelines, Registries & Global Practice

Global Epidemiology

Lateral hip pain affects an estimated 10-25% of adults; population-based data (Segal 2007, MOST cohort) report a point prevalence of ~15% in women and ~6.6% in men aged 50-79 years.
Incidence peaks at 1.8 per 1000 person-years in primary care for those aged 40-60 years.
Marked female predominance (roughly 3:1 to 4:1) is consistent across populations and is attributed to pelvic morphology (wider pelvis, larger trochanteric offset increasing ITB compressive load).
Strong associations with low back pain, ipsilateral knee/hip osteoarthritis, obesity, and reduced physical activity are reported worldwide.

Society Guidance Compared

NICE CKS (UK)

Diagnosis: Clinical; imaging only if uncertain or red flags
First-line: Load management, analgesia, physiotherapy
Injection / Surgery: Corticosteroid for short-term relief; refer if refractory

BOA / UK practice

Diagnosis: Clinical with US/MRI for surgical planning
First-line: Exercise-based rehabilitation (tendon load management)
Injection / Surgery: Endoscopic/open abductor repair for confirmed tears

AAOS / US sports medicine

Diagnosis: Clinical; MRI to characterise tears
First-line: Activity modification, PT, ESWT
Injection / Surgery: Image-guided injection, PRP, surgical repair

European (ESSKA/EFORT) consensus

Diagnosis: Tendinopathy spectrum framing
First-line: Progressive loading, education
Injection / Surgery: PRP and surgical repair for recalcitrant tears

GTPS / Gluteal Tendinopathy - Society Positions
Body / Source	Diagnosis	First-line	Injection / Surgery
NICE CKS (UK)	Clinical; imaging only if uncertain or red flags	Load management, analgesia, physiotherapy	Corticosteroid for short-term relief; refer if refractory
BOA / UK practice	Clinical with US/MRI for surgical planning	Exercise-based rehabilitation (tendon load management)	Endoscopic/open abductor repair for confirmed tears
AAOS / US sports medicine	Clinical; MRI to characterise tears	Activity modification, PT, ESWT	Image-guided injection, PRP, surgical repair
European (ESSKA/EFORT) consensus	Tendinopathy spectrum framing	Progressive loading, education	PRP and surgical repair for recalcitrant tears

There is broad international agreement that GTPS is a clinical diagnosis, that exercise-based rehabilitation is first-line, and that corticosteroid injection offers only short-term benefit. No major society endorses injection or surgery as primary therapy.

Registry & Outcome Notes

There is no dedicated GTPS registry. Surgical-outcome evidence comes from systematic reviews (e.g. Chandrasekaran 2015) reporting comparable results for open and endoscopic abductor repair, with retear and persistent weakness more common in chronic tears with fatty infiltration. Differentiating GTPS from referred pain after total hip arthroplasty is a recognised issue in arthroplasty-registry follow-up.

High- vs Limited-Resource Practice Variation

Well-resourced settings: ready access to ultrasound/MRI, ultrasound-guided injection, supervised physiotherapy, PRP, and endoscopic abductor repair.
Limited-resource settings: diagnosis is clinical (single-leg stance, palpation); management relies on education, home-based loading programmes, oral/topical NSAIDs, and landmark-guided corticosteroid injection. Surgery and PRP are rarely available, reinforcing the global priority of conservative, low-cost rehabilitation.

Controversies and Areas of Uncertainty

Corticosteroid injection

Useful for short-term pain relief but the LEAP RCT (Mellor 2018) showed it underperforms exercise at 1 year. Optimal timing, dose, and whether repeated injections damage tendon remain unsettled - most authors cap injections and pair them with rehabilitation.

PRP versus steroid

Fitzpatrick (2019) showed LR-PRP outperforms corticosteroid at 2 years in tendinopathy without full-thickness tear, but PRP preparation is non-standardised, costly, and not widely funded. Its place relative to a structured loading programme is undefined.

ITB stretching

Traditional ITB stretching may increase compressive load on the gluteal tendons against the trochanter and could be counterproductive. Contemporary programmes favour isometric/isotonic abductor loading over aggressive stretching.

Surgery: open vs endoscopic

Both achieve good results for abductor tears, but high-quality comparative trials are lacking. Indications, the role of tendon augmentation/reconstruction, and outcomes in chronic retracted tears with fatty infiltration remain debated.

Additional open questions include the true prevalence of asymptomatic gluteal tendinopathy, the prognostic value of MRI grading for guiding treatment, and the role of adjuncts such as extracorporeal shockwave therapy, where evidence is moderate and heterogeneous.

MCQ Practice Points

Terminology Clarification

Q: What is the current understanding of "trochanteric bursitis"?

A: Isolated bursitis is rare (less than 10%). Over 90% of GTPS cases involve gluteal tendinopathy with or without tears. The term "trochanteric bursitis" is outdated - Greater Trochanteric Pain Syndrome (GTPS) is preferred as it encompasses the spectrum of pathology.

Classic Clinical Presentation

Q: What is the pathognomonic symptom of GTPS?

A: Inability to sleep on the affected side (lateral decubitus position). This is virtually universal in GTPS and reflects direct pressure on the inflamed trochanteric region. Other features: lateral hip pain with stairs, prolonged sitting, or single-leg stance.

Examination Findings

Q: What examination finding indicates abductor weakness in GTPS?

A: Positive Trendelenburg test - pelvis drops on contralateral side during single-leg stance, indicating gluteus medius/minimus weakness or tendinopathy. Single-leg stance for 30 seconds is 100% sensitive for GTPS when positive (pain reproduction).

Key Differential

Q: How do you differentiate GTPS from hip joint pathology on examination?

A: In GTPS, hip range of motion is typically normal with pain localized to the greater trochanter on palpation. Hip joint pathology (OA, FAI, labral tears) causes groin pain, limited ROM (especially internal rotation), and positive impingement tests.

Clinical Decision Scenarios

Practise clinical reasoning and management decisions out loud

Viva scenarioStandard

Clinical prompt

“Classic GTPS presentation in typical demographic. The examiner wants you to demonstrate systematic assessment and evidence-based management.”

Viva scenarioStandard

Clinical prompt

“The examiner is testing your knowledge of modern concepts in GTPS pathology.”

Viva scenarioStandard

Clinical prompt

“Common differential diagnosis question testing clinical reasoning.”

Viva scenarioChallenging

Clinical prompt

“Testing knowledge of evidence-based management and landmark trials.”

Viva scenarioChallenging

Clinical prompt

“Testing knowledge of surgical indications and techniques.”

Exam day cheat sheet

GREATER TROCHANTERIC PAIN SYNDROME

KEY CONCEPT

NOT JUST BURSITIS - 90% have gluteal tendinopathy
Isolated bursitis occurs in less than 10% of cases
Rotator cuff of the hip - gluteus medius/minimus
Female predominance 4:1 due to wider pelvis biomechanics

CLINICAL FEATURES

Lateral hip pain over greater trochanter
Unable to sleep on affected side - pathognomonic
Pain with stairs (especially down), crossing legs, single leg stance
Point tenderness over GT with NORMAL hip ROM
Positive Trendelenburg indicates abductor weakness

EXAMINATION - STEPS

S = Single leg stance 30 seconds (rule-IN: specificity 100%, LR+ ~12)
T = Trendelenburg test (72.7% sensitive for a tear, Bird 2001)
E = External rotation strength in prone
P = Palpation tenderness over GT
S = Side-lying reproduces symptoms

DIFFERENTIAL FROM HIP OA

GTPS = lateral hip pain, OA = groin pain (C-sign)
GTPS = normal hip ROM, OA = reduced ROM
GTPS = point tenderness GT, OA = no focal tenderness
GTPS = worse side-lying, OA = start-up stiffness

IMAGING

Clinical diagnosis - imaging if refractory or diagnostic uncertainty
Ultrasound: first-line, shows tendinopathy, bursitis, tears
MRI: gold standard - 91% accurate for gluteal tears
MRI grading: tendinopathy to partial to full tear with fatty infiltration

MANAGEMENT

Education and load modification FIRST (avoid side-lying, crossing legs)
Physiotherapy - gluteal strengthening, avoid provocative positions
Exercise SUPERIOR to injection at 1 year (Mellor 2018 RCT)
Injection only if failing at 6-8 weeks - max 3 injections
Surgery for failed 6-12 months conservative + significant tear

SURGERY OPTIONS

Tendon repair with suture anchors - 80-90% good outcomes
Reconstruction for chronic tears with retraction
Bursectomy only if isolated bursitis (rare)
Fatty infiltration predicts poorer surgical outcome

Evidence Base

Evidence

Long SS, Surrey DE, Nazarian LN. Sonography of GTPS and the rarity of primary bursitis. AJR Am J Roentgenol. 2013;201(5):1083-6

Level III

Key Findings:

Gluteal tendinosis in 49.9% - bursitis in only 20.2%
Nearly 80% had no bursitis on ultrasound
ITB thickening present in 28.5%

Finding: Retrospective review of 877 unique patients (602 women, 275 men; mean age 54 years) imaged with ultrasound for GTPS. 700 (79.8%) had NO bursitis; only 177 (20.2%) had trochanteric bursitis. 438 (49.9%) had gluteal tendinosis, 4 (0.5%) had gluteal tendon tears, and 250 (28.5%) had a thickened iliotibial band.

Clinical implication: The landmark prevalence study establishing that GTPS is primarily a tendinopathy of the gluteus medius/minimus, not a bursitis. The term trochanteric bursitis is misleading.

Limitation: A RETROSPECTIVE READ OF SONOGRAMS WITH NO REFERENCE STANDARD, AND ITS TEAR RATE GIVES THE GAME AWAY - 877 patients is a large series and the headline conclusion is almost certainly right, but nothing here was verified against MRI, surgery or histology, so every prevalence depends on one department's sonographic thresholds for calling a bursa distended or a tendon abnormal. The internal check is the tear rate: only 4 of 877 patients (0.5%) were reported to have a gluteal tendon tear, far below what MRI and surgical series find in this population, so ultrasound in this dataset was clearly insensitive to tears. That does not undermine the paper's actual claim - bursitis in 20.2% against gluteal tendinosis in 49.9%, and that ratio is the teaching worth keeping - but it does mean the study cannot be cited for how often tears occur, and a negative ultrasound must not be used to exclude one. Patients were referred for sonography because of lateral hip pain, so this is a prevalence among the imaged rather than among all sufferers.

Verify on PubMed (PMID 24147479)

Evidence

Cvitanic O, Henzie G, Skezas N, et al. MRI diagnosis of tears of the hip abductor tendons. AJR Am J Roentgenol. 2004;182(1):137-43

Level III

Key Findings:

MRI 91% accurate for abductor tendon tears
T2 hyperintensity superior to GT is the key sign
Tendon elongation and discontinuity are secondary signs

Finding: 74 hips (45 patients), 15 with surgically proven abductor tears. Overall MRI accuracy for diagnosing abductor tendon tears was 91%. A focus of T2 hyperintensity superior to the greater trochanter was the single best sign (sensitivity 73%, specificity 95%).

Clinical implication: MRI is the reference standard for assessing gluteal tendon integrity and is useful for surgical planning. Note the best single sign reaches only 73% sensitivity, so correlate with clinical findings.

Limitation: A CASE-CONTROL DESIGN WITH A PARTLY UNVERIFIED CONTROL GROUP, WHICH SYSTEMATICALLY INFLATES ACCURACY - 15 hips had surgically proven tears and the other 59 were 'either asymptomatic or had surgically confirmed intact tendons', so a substantial part of the comparison group was never operated on and its true status is assumed rather than known. Selecting clear-cut cases and clear-cut controls is the classic spectrum bias: the difficult intermediate hips that generate real diagnostic error were never in the study, and 91% accuracy will not survive contact with an unselected clinic population. Interobserver agreement was only 'good to fair', which matters because these signs are subjective. The study is also from 2004 using 35-42 cm fields of view, large by modern standards, so image quality is not that of a current dedicated hip protocol. What transfers is the sign and its honest ceiling, which the page already states correctly: T2 hyperintensity superior to the greater trochanter reaches only 73% sensitivity, so a normal MRI does not exclude a tear either.

Verify on PubMed (PMID 14684527)

Evidence

Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise vs corticosteroid injection vs wait-and-see for gluteal tendinopathy (LEAP). BMJ. 2018;361:k1662

Level I

Key Findings:

Education plus exercise superior to injection at 8 and 52 weeks
Corticosteroid benefit not maintained at 1 year
Load-management education is a core component

Finding: Three-arm RCT of 204 participants (MRI-confirmed gluteal tendinopathy). At 8 weeks, success on global rating of change was 77% (education+exercise), 58% (corticosteroid injection) and 29% (wait-and-see). At 52 weeks, education+exercise (78%) remained superior to injection (57%) and wait-and-see (52%) for global improvement.

Clinical implication: Physiotherapy-led education and exercise is first-line. A single corticosteroid injection gives only short-term benefit; reserve it for adjunctive use, not as primary therapy.

Limitation: THE COMPARATOR IS WAIT-AND-SEE, NOT PLACEBO, AND ONLY THE ASSESSOR WAS BLINDED - patients knew whether they were exercising, being injected or being asked to wait, and the primary outcome is a patient-reported global rating of change, so expectation effects are unmeasured and unavoidable in a trial of this design. That is not a fault of the investigators, since exercise cannot be blinded, but it caps how much of the 49.1% risk difference over wait-and-see belongs to the exercise itself. Read the two endpoints separately at 52 weeks, because they diverge and the page should say which one it is quoting: education plus exercise remained better than injection on GLOBAL improvement (risk difference 20.4%), but there was NO significant difference in PAIN intensity between them (mean difference -0.26, 95% CI -1.06 to 0.55). The long-term advantage of exercise is therefore in how patients rate their overall condition rather than in how much it hurts. Participants were 35-70 with at least three months of symptoms and MRI-confirmed tendinopathy, mostly women, and anyone injected within the previous 12 months was excluded - so this is not evidence about the refractory or repeatedly injected patient.

Verify on PubMed (PMID 29720374)

Evidence

Fitzpatrick J, Bulsara MK, O'Donnell J, et al. Leucocyte-rich PRP vs corticosteroid for gluteal tendinopathy: RCT with 2-year follow-up. Am J Sports Med. 2019;47(5):1130-7

Level I

Key Findings:

LR-PRP superior to corticosteroid at 12 and 24 weeks
PRP benefit sustained at 2 years; steroid benefit transient
Effective in tendinopathy without full-thickness tear

Finding: Double-blind RCT, 80 patients (no full-thickness tears) randomised to ultrasound-guided intratendinous LR-PRP or corticosteroid injection. Modified Harris Hip Score favoured LR-PRP at 12 weeks (74.0 vs 67.1) and 24 weeks (77.6 vs 65.7). LR-PRP improvement was sustained to 2 years (baseline 53.8 to 82.6); corticosteroid benefit peaked at 6 weeks and was lost by 24 weeks.

Clinical implication: LR-PRP is a reasonable option for recalcitrant gluteal tendinopathy without full-thickness tearing, offering more durable benefit than corticosteroid - though it is not yet a universally funded or available therapy.

Limitation: AN OPEN-LABEL CROSSOVER AFTER 3 MONTHS DISMANTLES THE RANDOMISED COMPARISON LONG BEFORE 2 YEARS - 27 corticosteroid patients were deemed to have failed at 16 to 24 weeks and were then given PRP. By 104 weeks there is no intact injection arm left to compare against, so the two-year result is effectively an uncontrolled PRP cohort and must not be quoted as randomised two-year superiority. The genuinely randomised comparison runs to 12 and 24 weeks, and at 12 weeks the difference is modest and marginal - modified Harris Hip Score 74.05 versus 67.13, p = 0.048 - on an instrument whose minimal clinically important difference is around 8 points, so the randomised phase shows a statistically significant difference of about the size a patient might not notice. More persuasive than that p value is the crossover group's own trajectory, improving from 59.22 at exit to 77.53 at 104 weeks. Population: 80 patients, mean age 60, nine women to every man, symptoms over 15 months, and critically NO full-thickness tears - so none of this extends to the torn tendon.

Verify on PubMed (PMID 30840831)

Evidence

Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Diagnostic value of two clinical tests in refractory GTPS. Arthritis Rheum. 2008;59(2):241-6

Level II

Key Findings:

Single-leg stance (30s): sensitivity 100% in 17 patients - an upper bound, not a reliable estimate
Resisted external derotation: sensitivity 88%
Specificity measured against pain-free controls, not against other causes of lateral hip pain

Finding: Prospective validation study in 17 patients with refractory GTPS (MRI as gold standard). The 30-second single-leg stance test had sensitivity 100% and specificity 97.3%; the resisted external derotation test (supine) had sensitivity 88% and specificity 97.3%. Every patient had MRI-confirmed disease, so specificity was derived from a separate pain-free control group rather than from other causes of lateral hip pain.

Clinical implication: The 30-second single-leg stance is the most useful bedside test for GTPS and reproduces the patient's lateral hip pain - a high-yield examination point.

Limitation: SEVENTEEN PATIENTS, AND THE SPECIFICITY COMES FROM HEALTHY CONTROLS RATHER THAN FROM OTHER CAUSES OF LATERAL HIP PAIN - MRI showed tendinopathy or bursitis in ALL 17 patients, so within the patient group there were no true negatives at all, and the 97.3% specificity was generated by examining a matched population WITHOUT hip pain. That is the wrong comparison for the clinical question. The test's real job is to separate gluteal tendinopathy from the other causes of lateral hip pain - referred lumbar pain, hip osteoarthritis, meralgia paraesthetica - and this design never asked it to. The tests were also performed by a single unblinded physician who knew every patient had been referred with refractory GTPS. THE 100% SENSITIVITY SHOULD NOT BE TAUGHT AS A NUMBER: Grimaldi's larger study on this same page, with a blinded radiologist, found 31% of MRI-positive patients had a negative clinical examination. Seventeen patients cannot exclude a false-negative rate of that size - at n = 17 the confidence interval around 100% sensitivity still reaches down to roughly 80%. Use the manoeuvre as a good rule-in test and drop the 100%.

Verify on PubMed (PMID 18240186)

Evidence

Kjeldsen T, Hvidt KJ, Bohn MB, et al. Exercise compared to a control condition or other conservative treatment options in GTPS: systematic review and meta-analysis of randomised controlled trials. Physiotherapy. 2024;123:69-80

Level I (systematic review and meta-analysis of RCTs)

Key Findings:

Six RCTs, 733 patients; ROB2 risk-of-bias assessment and GRADE certainty rating; prospectively registered (CRD42021261380)
In the long term exercise SLIGHTLY reduces hip pain and disease severity and slightly improves physical function and global rating of change versus control
Versus corticosteroid injection, exercise improves long-term global rating of change
No serious adverse events reported in any trial

Clinical implication: This is the highest level of evidence in the field and it supports a strong recommendation for exercise as first-line treatment in clinically diagnosed GTPS - generalising the single-trial LEAP result above.

Limitation: THE AUTHORS CALL IT A STRONG RECOMMENDATION WHILE DESCRIBING THE EFFECT AS SLIGHT, AND BOTH STATEMENTS ARE THEIRS - the meta-analysis repeatedly uses the word 'slightly' for the pain, severity and function benefits over a control condition, then concludes that the evidence supports a strong recommendation. That is not a contradiction once you see what is driving it: the effect sizes are small, but exercise has no serious adverse events in any of the six trials, so the benefit-to-harm ratio is what makes the recommendation strong rather than the size of the benefit. Tell patients the effect is real and modest, not transformative. The base is thin for a level I citation - six trials and 733 patients, with only TWO trials contributing to the comparison against corticosteroid injection and two against shockwave, so several of the headline comparisons rest on a pair of studies apiece. One of those two injection trials is LEAP, cited above, so this review and that trial are not independent evidence. GRADE certainty is not quoted in the abstract for individual comparisons, and 'control condition' pools sham exercise with wait-and-see, which are different comparators.

Verify on PubMed (PMID 38295551)

Evidence

Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of MRI and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44(9):2138-45

Level II (prospective diagnostic cohort)

Key Findings:

24 women with clinical GTPS, all imaged by MRI: gluteus medius TEAR in 45.8% and gluteus medius tendinitis in 62.5%
Trochanteric bursal distension in only 2 of 24, and never in the absence of gluteus medius pathology
Trendelenburg's sign was the most accurate of three signs for predicting a tear: sensitivity 72.7%, specificity 76.9%
Trendelenburg's sign was also the most reproducible: intraobserver kappa 0.676 (95% CI 0.270-1.08)

Clinical implication: The source of the 73% Trendelenburg sensitivity quoted on this page, and the study that first established gluteus medius tendon pathology rather than bursitis as the substrate of GTPS - bursal distension never occurred alone.

Limitation: TWENTY-FOUR PATIENTS, ALL WOMEN, AND THE RELIABILITY ESTIMATE IS INTRAOBSERVER ONLY - the kappa of 0.676 was calculated by having the SAME observer repeat the examination in 12 patients at two months, so it measures whether one clinician agrees with himself, not whether two clinicians agree; interobserver reliability, which is what matters when a sign is taught, was never assessed. The confidence interval on that kappa runs from 0.270 to 1.08, which both crosses into poor agreement and exceeds the maximum possible value of 1, so the estimate is extremely imprecise. The diagnostic figures rest on 11 tears in 24 patients, and being an all-female cohort with a median symptom duration of 12 months it is neither a general GTPS population nor an early one. Note also what the reference standard was: a single radiologist reading 1.5-T MRI, with no surgical confirmation of any tear. The finding that has held up across two decades and larger series is the qualitative one - bursal distension is uncommon and does not occur without tendon pathology, so treating the bursa alone treats the wrong structure.

Verify on PubMed (PMID 11592379)