Lateral Hip Pain | Gluteal Tendinopathy | Not Just Bursitis
- 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
- “Point tenderness over greater trochanter with normal hip ROM suggests GTPS
- “Single leg stance for 30 seconds reproduces lateral hip pain
- “MRI shows tendinopathy in 90% but bursitis alone in less than 10%
- “Female predominance due to wider pelvis increasing ITB tensile strain
Modern understanding: GTPS is primarily gluteal tendinopathy. Studies show 90% have tendon pathology while isolated bursitis occurs in less than 10%. Term "trochanteric bursitis" is outdated - use GTPS.
Point tenderness over GT with reproduced pain on single leg stance. Normal hip ROM distinguishes from OA. Lateral hip pain (not groin) distinguishes from intra-articular pathology.
Load and compression provoke: side-lying on affected hip, crossing legs, stairs (especially down), prolonged standing, single leg activities. Sleep disturbance from lying on affected side is characteristic.
4:1 female to male ratio due to wider female pelvis creating increased tensile strain on ITB and compressive load on gluteal tendons at greater trochanter insertion.
Overview and Epidemiology
Greater trochanteric pain syndrome (GTPS) is a clinical diagnosis characterized by lateral hip pain and tenderness over the greater trochanter. It is one of the most common causes of hip pain in primary care. The term "trochanteric bursitis" is now considered outdated as modern imaging studies demonstrate that the majority of patients have gluteal tendinopathy rather than primary bursitis. [1,2]
- Peak incidence in 40-60 year age group
- Marked female predominance (4:1 ratio)
- Prevalence of 10-25% in middle-aged population
- Common in runners and individuals with sedentary occupations
- Bilateral in 25-30% of cases
The concept of GTPS has evolved significantly. In the landmark ultrasound prevalence study by Long et al. (AJR 2013) of 877 patients with GTPS:
- 49.9% had gluteal tendinosis
- 20.2% had trochanteric bursitis (nearly 80% had NO bursitis)
- 28.5% had a thickened iliotibial band
- Only 0.5% had a frank gluteal tendon tear [1]
This has led to GTPS being called the "rotator cuff of the hip" as gluteal tendon pathology mirrors shoulder rotator cuff disease.
When asked about trochanteric bursitis in an exam, emphasize the modern understanding: GTPS is primarily gluteal tendinopathy. Isolated bursitis occurs in less than 10% of cases. The pathology is analogous to the shoulder rotator cuff - the gluteus medius and minimus are the abductor "cuff" of the hip.
Risk Factors:
- Female gender (wider pelvis, increased Q angle)
- Age 40-60 years
- Obesity (BMI greater than 25)
- Low back pathology (20-35% association)
- Lower limb OA (ipsilateral knee or hip)
- Leg length discrepancy
- Running (especially sudden increase in mileage)
- Sedentary occupation with prolonged sitting
Pathophysiology and Anatomy
Greater Trochanter Anatomy
The greater trochanter (GT) has three distinct facets that serve as insertion sites for the gluteal tendons:
- Location
- Most anterior aspect
- Tendon Insertion
- Gluteus minimus
- Clinical Significance
- First to tear, difficult to visualize
- Location
- Lateral prominence
- Tendon Insertion
- Gluteus medius (main)
- Clinical Significance
- Most common site of tendinopathy
- Location
- Superior-posterior
- Tendon Insertion
- Gluteus medius (secondary)
- Clinical Significance
- Extension tears may involve this
Gluteal Tendons - Hip Abductor Complex
The gluteus medius and minimus form the hip abductor mechanism and are analogous to the rotator cuff of the shoulder:
- Origin: External surface of ilium between anterior and posterior gluteal lines
- Insertion: Lateral and superoposterior facets of greater trochanter
- Innervation: Superior gluteal nerve (L4-S1)
- Function: Primary hip abductor, stabilizes pelvis during single leg stance
- Origin: External surface of ilium between anterior and inferior gluteal lines
- Insertion: Anterior facet of greater trochanter
- Innervation: Superior gluteal nerve (L4-S1)
- Function: Hip abduction, internal rotation, pelvic stabilization
The gluteus medius and minimus are called the rotator cuff of the hip. Like the supraspinatus in the shoulder, the gluteus medius is most commonly affected. Tears follow a similar pattern - starting as partial thickness undersurface tears and progressing to full thickness with retraction and fatty infiltration.
Peritrochanteric Bursae
Three bursae surround the greater trochanter:
- Subgluteus maximus bursa - largest, between gluteus maximus and GT
- Subgluteus medius bursa - between gluteus medius tendon and GT
- Subgluteus minimus bursa - between gluteus minimus tendon and anterior facet
These bursae may become inflamed secondary to tendinopathy, direct compression, or friction from the overlying iliotibial band.
Pathophysiology of Tendinopathy
GTPS develops through a combination of:
- Repetitive hip abduction loading
- Running, stair climbing, single leg activities
- Sudden increase in activity level
- ITB compression against GT during hip adduction
- Side-lying sleeping (direct compression)
- Crossing legs (hip adduction and internal rotation)
- Wider female pelvis increases ITB tension
- Increased Q angle in females
- Valgus knee alignment
- Leg length discrepancy
The combination of tensile and compressive forces leads to tendon degeneration, similar to rotator cuff tendinopathy in the shoulder.
Clinical Presentation
History
Pain Characteristics:
- Location: Lateral hip over greater trochanter
- Radiation: May radiate down lateral thigh to knee (not below knee)
- Character: Aching, burning, sometimes sharp
- Onset: Usually gradual, may follow increase in activity
- Night pain: Characteristic - unable to sleep on affected side
Difficulty sleeping on the affected side is a hallmark of GTPS. Patients often report waking at night when they roll onto the affected hip. This distinguishes GTPS from hip OA (which causes groin pain and start-up stiffness) and lumbar radiculopathy (which causes symptoms below the knee).
- Lying on affected side
- Crossing legs
- Prolonged sitting (especially on hard surfaces)
- Climbing stairs (especially descending)
- Standing from seated position
- Single leg activities (putting on shoes/socks)
- Walking - especially uphill or on uneven ground
- Feeling of hip weakness or giving way
- Difficulty with single leg activities
- Stiffness after prolonged sitting
- Limp or Trendelenburg gait
Examination
- Gait assessment - look for Trendelenburg gait
- Standing posture - note pelvic obliquity
- Muscle wasting of gluteal region (chronic cases)
- Point tenderness over greater trochanter
- Tenderness at insertion of gluteus medius (posterosuperior GT)
- Tenderness at gluteus minimus insertion (anterior GT)
- No tenderness in groin (distinguishes from hip OA)
- Hip ROM typically full and painless (distinguishes from OA)
- Pain at end-range hip adduction (compresses tendons)
- Pain at end-range hip internal rotation with flexion
- Technique
- Stand on affected leg for 30 seconds
- Positive Finding
- Reproduces lateral hip pain
- Sensitivity
- 100%
- Technique
- Stand on affected leg, observe pelvis
- Positive Finding
- Contralateral pelvis drops
- Sensitivity
- 73%
- Technique
- Flexion-abduction-external rotation
- Positive Finding
- Lateral hip pain (not groin)
- Sensitivity
- 82%
- Technique
- Side-lying, resist abduction
- Positive Finding
- Pain and/or weakness
- Sensitivity
- Variable
- Technique
- Lie on affected side
- Positive Finding
- Reproduces lateral hip pain
- Sensitivity
- High
Red Flags
The following features warrant further investigation:
- Night pain unrelated to position (may indicate tumor)
- 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)
Bedside Diagnosis: Test Performance and the Resisted External Derotation Test
The examination section lists the single-leg stance and Trendelenburg tests, but the diagnostic reasoning behind them - and the resisted external derotation test named in the Lequesne evidence - are worth developing explicitly, because in the exam you are expected to justify why a test is used to rule a diagnosis in or out, not merely to list it.
Rule-in versus rule-out logic
GTPS is a clinical diagnosis, and the two most useful bedside tests do different jobs. Grimaldi et al. (2017) examined 65 patients with lateral hip pain against MRI-confirmed gluteal tendinopathy:
- Single-leg stance (30 seconds) = the rule-IN test. Reproduction of lateral hip pain within 30 seconds of standing on the affected limb had a specificity of 100% and a positive likelihood ratio of approximately 12, moving a nominal 50% pretest probability to a 98% post-test probability. A positive test strongly confirms gluteal tendinopathy.
- Greater trochanter palpation = the rule-OUT test. Palpation tenderness had a sensitivity of roughly 80%, so a patient who is not tender over the greater trochanter is unlikely to have MRI-detected gluteal tendinopathy.
- Caveat: about one-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 - imaging still has a role.
The resisted external derotation test
This is the loaded provocation test validated by Lequesne et al. (2008) and frequently forgotten by candidates:
- Position: patient supine, hip and knee flexed to 90 degrees.
- Manoeuvre: the examiner passively externally rotates the hip to end range, then asks the patient to actively derotate (internally rotate) the leg back to neutral against resistance.
- Positive result: reproduction of the patient's lateral trochanteric pain.
- Performance: sensitivity 88%, specificity 97.3% against MRI in refractory GTPS. A prone variant with the hip extended is also described.
- Best Use
- Rule IN - strong confirmatory test
- Reported Performance
- Specificity 100%, LR+ approximately 12 (Grimaldi 2017)
- Best Use
- Rule OUT - if absent, tendinopathy unlikely
- Reported Performance
- Sensitivity approximately 80% (Grimaldi 2017)
- Best Use
- Loaded provocation - confirmatory
- Reported Performance
- Sensitivity 88%, specificity 97.3% (Lequesne 2008)
- 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
Examiners reward candidates who explain test logic. Use the single-leg stance as your rule-in test (specificity 100%, positive likelihood ratio approximately 12) and greater trochanter palpation as your rule-out test (sensitivity approximately 80%). Add the resisted external derotation test (specificity 97.3%) as a loaded confirmatory manoeuvre. State clearly that roughly a third of patients with MRI tendinopathy have a clinically negative examination, so imaging is still warranted if symptoms persist.
Investigations
GTPS is primarily a clinical diagnosis. Investigations are used to exclude other pathology and confirm the diagnosis in unclear or recalcitrant cases.
Imaging
- AP pelvis and lateral hip views
- Usually normal in GTPS
- May show calcification at GT insertion (calcific tendinopathy)
- Excludes hip OA, avascular necrosis, stress fracture
- First-line imaging for GTPS
- Shows tendon thickening, hypoechoic changes, tears
- Bursal fluid collection (greater than 2mm)
- Can assess for ITB pathology
- Useful for guiding injection
- Gold standard for soft tissue assessment
- Shows tendinopathy (increased T2 signal)
- Demonstrates partial and full-thickness tears
- Assesses muscle quality (fatty infiltration)
- 91% accuracy in diagnosing abductor tears (Cvitanic 2004) [4]
- MRI Findings
- Bursitis with minimal tendon changes
- Management Implication
- Conservative - physio, activity modification
- MRI Findings
- Tendinopathy - increased T1 signal
- Management Implication
- Conservative - physio, may consider injection
- MRI Findings
- Partial thickness tear
- Management Implication
- Prolonged conservative trial, PRP consideration
- MRI Findings
- Full thickness tear without retraction
- Management Implication
- Consider surgical repair if conservative fails
- MRI Findings
- Complete tear with retraction, fatty atrophy
- Management Implication
- Surgical repair vs reconstruction
MRI is 91% accurate for diagnosing gluteal tendon tears (Cvitanic 2004). The single most useful sign 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 gluteal muscles - directly analogous to rotator cuff assessment.
Laboratory Tests
Not routinely required. Consider in atypical presentations:
- ESR, CRP - if infection or inflammatory arthritis suspected
- Rheumatoid factor - if inflammatory arthritis suspected
- HbA1c - screen for diabetes in recurrent cases
Differential Diagnosis
- Pain Location
- Lateral hip over GT
- Key Distinguishing Features
- Point tenderness GT, normal ROM, side-lying pain
- Pain Location
- Groin (C-sign)
- Key Distinguishing Features
- Reduced ROM, crepitus, start-up stiffness, X-ray changes
- Pain Location
- Lateral thigh to below knee
- Key Distinguishing Features
- Back pain, dermatomal distribution, neurological signs
- Pain Location
- Lateral hip, audible snap
- Key Distinguishing Features
- Palpable/visible snap with hip flexion, usually painless
- Pain Location
- Anterolateral thigh
- Key Distinguishing Features
- Sensory symptoms, no motor weakness, LFCN territory
- Pain Location
- Groin, lateral hip
- Key Distinguishing Features
- Activity-related, worse with weight bearing, high index of suspicion
Hip OA typically presents with groin pain. Patients demonstrate the "C-sign" - cupping the hand around the hip with thumb posteriorly and fingers anteriorly in the groin. GTPS patients point directly to the lateral hip. This is a key distinguishing feature in the exam setting.
Management
Management follows a stepwise approach with conservative measures as first-line. Surgical intervention is reserved for recalcitrant cases or significant tears. [5,6]
Conservative Management
- Patient education about pathology and prognosis
- Avoid sleeping on affected side (pillow between knees)
- Avoid crossing legs
- Limit stair climbing (use handrail, lead with unaffected leg)
- Activity modification - reduce running, single leg loading
- Weight loss if BMI greater than 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 if failing conservative at 6-8 weeks
- Shockwave therapy (ESWT) - moderate evidence
- PRP injection - emerging evidence for tendinopathy
Physiotherapy Focus:
The exercise programme should avoid provocative positions (hip adduction, compression) initially:
- Exercises
- Isometric hip abduction in neutral
- Key Points
- Pain-free range, avoid compression
- Exercises
- Bridging, clamshells, side-lying abduction
- Key Points
- Progress load gradually, monitor symptoms
- Exercises
- Standing hip abduction, step-ups
- Key Points
- Single leg loading with good control
- Exercises
- Running, stairs, sport-specific
- Key Points
- Full return to activity
Injection Therapy
- Failed conservative management at 6-8 weeks
- Significant bursitis on imaging
- Severe pain limiting rehabilitation
- Patient lateral with affected side up
- Identify point of maximum tenderness over GT
- Clean skin with antiseptic
- Insert needle perpendicular until bone contacted
- Withdraw 2-3mm and inject 1ml corticosteroid + 2-3ml local anaesthetic
- Target subgluteus maximus bursa
- Short-term relief in 60-75%
- Effect diminishes at 3-6 months
- No evidence of long-term benefit vs placebo [7]
- Risk of tendon weakening with repeated injections
Corticosteroid injection provides short-term relief but should be combined with physiotherapy rehabilitation for sustained benefit. Maximum of 3 injections recommended due to risk of tendon atrophy.
Surgical Management
Indications:
- Failed comprehensive conservative management (6-12 months)
- Significant gluteal tendon tear (full thickness)
- Refractory symptoms affecting quality of life
Options:
- Indication
- Isolated refractory bursitis
- Technique
- Arthroscopic or open excision
- Outcomes
- Good if isolated bursitis (rare)
- Indication
- Partial/full tear with good tissue
- Technique
- Open repair with suture anchors
- Outcomes
- 80-90% good/excellent outcomes
- Indication
- Chronic tear with retraction
- Technique
- Allograft or autograft augmentation
- Outcomes
- Variable - depends on tissue quality
- Indication
- ITB pathology/snapping hip
- Technique
- Arthroscopic or open Z-plasty
- Outcomes
- Good for snapping, uncertain for GTPS
Extracorporeal Shockwave Therapy (ESWT)
ESWT (radial or focused shockwave) appears repeatedly in this topic as an adjunct - in the treatment timeline, the management algorithm, the controversies section and the cheat sheet - yet its evidence deserves a dedicated framing, because it is one of the few non-injection, non-surgical options with randomised-trial support in GTPS.
shockwaves are thought to stimulate neovascularisation and a controlled inflammatory/healing response in degenerate tendon, analogous to their established use in plantar fasciopathy and calcific/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.
a randomised trial of 229 patients with refractory unilateral GTPS compared home training, a single corticosteroid injection (25 mg prednisolone), and radial ESWT. The result is a classic exam "time-crossover":
- At 1 month: corticosteroid injection was best (75% success versus 13% ESWT and 7% home training).
- At 4 months: radial ESWT was best (68% success versus 51% injection and 41% home training).
- At 15 months: ESWT (74%) and home training (80%) were both significantly superior to injection (48%).
The message mirrors the LEAP trial: steroid gives fast but short-lived relief, whereas loading-based and shockwave strategies give more durable benefit. 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 - which is why guidelines describe the ESWT evidence as moderate and heterogeneous rather than definitive.
- Corticosteroid best short-term (1 month) but not durable
- Radial ESWT superior at 4 months
- ESWT and home training beat injection at 15 months
Remember Rompe (2009) as a time-crossover: corticosteroid injection wins at 1 month, but radial ESWT and home training overtake it by 4 months and remain superior at 15 months. This reinforces the core GTPS principle that durable improvement comes from loading and tendon-directed strategies, not from steroid. Frame ESWT as a moderate-evidence adjunct for the patient who has failed loading and wants to avoid or has failed injection.
Prognosis and Complications
Prognosis
GTPS generally has a good prognosis with appropriate management, though recovery may be prolonged.
Conservative Treatment Outcomes:
- 60-80% respond to comprehensive conservative management
- Average time to resolution: 3-6 months
- Recurrence common if load management not maintained
- Chronic cases may persist for years
Factors Affecting Prognosis:
- Unfavorable
- Chronic symptoms (greater than 12 months)
- Unfavorable
- Full thickness tear with retraction
- Unfavorable
- Obesity (BMI greater than 30)
- Unfavorable
- Poor engagement with rehabilitation
- Unfavorable
- Ongoing provocative activities
Complications
- Chronic pain affecting sleep and function
- Gluteal weakness and Trendelenburg gait
- Progression to full thickness tear
- Fatty infiltration of gluteal muscles (irreversible)
- Corticosteroid injection: tendon weakening, skin atrophy, infection
- Surgery: infection, wound complications, recurrence, nerve injury
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
- 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
- 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
- Diagnosis
- Clinical; MRI to characterise tears
- First-line
- Activity modification, PT, ESWT
- Injection / Surgery
- Image-guided injection, PRP, surgical repair
- Diagnosis
- Tendinopathy spectrum framing
- First-line
- Progressive loading, education
- Injection / Surgery
- 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
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.
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.
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.
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
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.
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.
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).
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.
At a Glance
Greater trochanteric pain syndrome (GTPS) is primarily caused by gluteal tendinopathy—not bursitis as historically believed. Studies show 90% have tendon pathology while isolated bursitis occurs in less than 10%. GTPS is the "rotator cuff of the hip" with gluteus medius/minimus tears analogous to shoulder pathology. Patients present with lateral hip pain (distinct from groin pain of hip OA) worse when side-lying and during single-leg activities (stairs, standing). There is a 4:1 female predominance due to wider pelvis creating increased ITB tensile strain and compressive load on gluteal tendon insertions. Point tenderness over the greater trochanter with normal hip ROM is key. Trendelenburg test assesses abductor function. Load modification is essential—avoid crossing legs, prolonged standing, and sleeping on the affected side.
GTPSGTPS Risk Factors - FLAME
Hook:FLAME - lateral hip pain that burns like a FLAME!
GTPSGTPS Examination - STEPS
Hook:Take STEPS to examine GTPS - systematic approach to lateral hip pain
MSALGluteal Tendon Insertions - MSAL
Hook:MSAL - Medius Superoposterior And Lateral, minimus Anterior - Like the shoulder cuff insertions
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“Classic GTPS presentation in typical demographic. The examiner wants you to demonstrate systematic assessment and evidence-based management.”
“The examiner is testing your knowledge of modern concepts in GTPS pathology.”
“Common differential diagnosis question testing clinical reasoning.”
“Testing knowledge of evidence-based management and landmark trials.”
“Testing knowledge of surgical indications and techniques.”
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 (100% sensitive)
- T = Trendelenburg test (73% sensitive)
- 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
- Gluteal tendinosis in 49.9% - bursitis in only 20.2%
- Nearly 80% had no bursitis on ultrasound
- ITB thickening present in 28.5%
- MRI 91% accurate for abductor tendon tears
- T2 hyperintensity superior to GT is the key sign
- Tendon elongation and discontinuity are secondary signs
- 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
- 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
- Single-leg stance (30s): sensitivity 100%, specificity 97.3%
- Resisted external derotation: sensitivity 88%
- Both tests validated against MRI
Suggested Reading
- Long SS, Surrey DE, Nazarian LN. Sonographic pathoanatomy of greater trochanteric pain syndrome. J Ultrasound Med. 2023;42(9):2001-2010. doi:10.1002/jum.16174
- Speers CJ, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. Br J Gen Pract. 2017;67(663):479-480. doi:10.3399/bjgp17X693041
- Barratt PA, Brookes N, Newson A. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE Open Med. 2021;9:20503121211022582. doi:10.1177/20503121211022582
- Cvitanic O, Henzie G, Skezas N, et al. MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). AJR Am J Roentgenol. 2004;182(1):137-143. doi:10.2214/ajr.182.1.1820137
- Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662. doi:10.1136/bmj.k1662
- Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015;45(11):910-922. doi:10.2519/jospt.2015.5829
- Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care. Ann Fam Med. 2011;9(3):226-234. doi:10.1370/afm.1232
- Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Rheum. 2008;59(2):241-246. doi:10.1002/art.23354
- Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control study. J Arthroplasty. 2014;29(2):383-386. doi:10.1016/j.arth.2012.10.016
- Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-1670. doi:10.1213/ane.0b013e31819d6562
- Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988-992. doi:10.1016/j.apmr.2007.04.014
- Fitzpatrick J, Bulsara MK, O'Donnell J, et al. Leucocyte-rich platelet-rich plasma treatment of gluteus medius and minimus tendinopathy: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2019;47(5):1130-1137. doi:10.1177/0363546519826969
- Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: a systematic review. Arthroscopy. 2015;31(10):2057-2067. doi:10.1016/j.arthro.2015.03.042
- Mallow M, Nazarian LN. Greater trochanteric pain syndrome diagnosis and treatment. Phys Med Rehabil Clin N Am. 2014;25(2):279-289. doi:10.1016/j.pmr.2014.01.009
- Redmond JM, Chen AW, Domb BG. Greater trochanteric pain syndrome. J Am Acad Orthop Surg. 2016;24(4):231-240. doi:10.5435/JAAOS-D-14-00406
Key Guidelines
- NICE Clinical Knowledge Summary: Greater trochanteric pain syndrome
- AAOS resources on management of hip pain
Additional Reading
- Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Med. 2015;45(8):1107-1119.
- Albers IS, Zwerver J, Diercks RL, et al. Incidence and prevalence of lower extremity tendinopathy in a general population. Ann Rheum Dis. 2016;75(10):1778-1782.