What is gluteal tendinopathy, trochanteric bursitis & GTPS?
Pain over the side of the hip is commonly related to changes in the health of the tendons that join the gluteal (buttock) muscles to the hip, and sometimes of the nearby bursae (fluid filled sacks that help reduce friction between tendons and bones). The condition may be diagnosed as gluteal tendinopathy or tendinitis, trochanteric bursitis or Greater Trochanteric Pain Syndrome (GTPS) which encompasses both. The good news is, that regardless of the diagnostic term and whether in your case the tendons or bursae seem to be most affected, the underlying cause appears to be the same and strategies to improve health of one, will help the other as well.
What are the usual symptoms?
The main symptom is pain and tenderness over the bony prominence (bump) at the side of the hip, called the greater trochanter (As shown in the figure to the left). Pain may also spread down the outer surface of the thigh towards the knee and sometimes just below the knee (As shown in the figure to the left). Pain that extends all the way to the foot is more likely to be related to a problem in the lower back. The pain of gluteal tendinopathy (+/- bursitis) is often worst at night, particularly when lying on either side and may result in substantial sleep disturbance. The pain may also have a significant impact on activity levels due to pain experienced when walking & standing on one leg, particularly walking uphills/slopes.
Usual symptoms of gluteal tendinopathy/ trochanteric bursitis /GTPS
Pain over the side of the hip experienced when:
- Lying on the side at night
- Walking uphills and stairs
- Standing on one leg, for example when dressing
- Sitting in low chairs especially with crossed legs
- Getting up from chairs and during the first steps
What causes gluteal tendinopathy and bursitis and who is most likely to develop the problem?
Many factors influence the health of the tendons and bursae at the side of the hip, but either too much or too little stimulus may result in tissue changes. Poor postures or movement patterns may over time contribute to reduced tendon health. Recent Australian research has shown that the gluteal (buttock) muscles (gluteus medius and minimus) of those with painful gluteal tendinopathy are weaker¹ and activate in different ways to those with painfree hips². Those with lateral hip pain also tend to move in ways that result in higher than normal loads passing across their gluteal tendons³. Those with painful gluteal tendinopathy tend to walk with greater pelvic tilt (as demonstrated by the dotted line) or side-shift or lean their body a little more to the side (as shown in the figure to the left).
Changes in tendons and bursae are not necessarily painful, but if weakened tendons are unable to cope with their workload, pain may develop. Pain is often triggered by sudden increases in activity levels, where the tendons have not been given adequate time to adapt to the new loads, such as taking up a new sport or activity or returning to activity after illness, injury or pregnancy. For example, going on holidays and walking lots of hills or stairs or for long distances along the beach may cause a painful reaction. Sudden loads on the tendon during a slip or fall can also result in pain and injury or a gain in weight may add more load to these tendons that support your bodyweight when standing on one leg.
Eighteen percent of the population aged over 50 suffers with lateral hip pain and women are 3 times more likely to develop greater trochanteric pain syndrome4. Change in hormones are thought to contribute to the development of tendon changes, but there are usually a number of casual factors. The onset of pain associated with a combination of hormonal change during menopause, weight gain during this time and a sudden increase in activity levels to deal with this, is a common story related to health professionals.
Common Triggers for the Development of Lateral Hip Pain:
- Fitness Kick
- Unaccustomed activity on holiday
- Returning to activity too quickly after injury, illness or pregnancy
- Slip or Fall
- Hormonal change during menopause
- Weight gain
Getting Help. What is the treatment for gluteal tendinopathy, trochanteric bursitis & GTPS?
A high-quality research study recently published in the British Medical Journal5 compared three common treatment approaches: Education and Exercise provided by physiotherapists, Cortisone Injection and adopting a Wait-and-See approach with simple advice. They found:
- Education and exercise was superior to wait-and-see in both the short (8 weeks) and long term (12 months)
- Education and exercise was superior to injection in both the short (8 weeks) and long term (12 months)
- Injection is no more successful than wait and see in the long term (12 months)
Figure 3: Rates of success of different treatments for painful gluteal tendinopathy, in both the short and long term. Green people represent a successful outcome.
The education and exercise approach provided information to participants regarding minimising provocative tendon loads in everyday life and an exercise programme that focusses on improving movement patterns and load tolerance of the tendons (the ability of the tendons to accept load without pain). Comparison with other research outcomes suggests that all programs are not equally effective, so finding a Hip Pain Professional who is up to date with the latest research will help ensure you get the best possible outcome.
References:
- Allison, K., Vicenzino, B., Wrigley, T., Grimaldi, A., Hodges, P. and Bennell, K. (2016). Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Medicine & Science in Sports & Exercise, 48(3), pp.346-352.
- Allison, K., Salomoni, S., Bennell, K., Wrigley, T., Hug, F., Vicenzino, B., Grimaldi, A. and Hodges, P. (2017). Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 28(2), pp.686-695.
- Allison, K., Wrigley, T., Vicenzino, B., Bennell, K., Grimaldi, A. and Hodges, P. (2016). Kinematics and kinetics during walking in individuals with gluteal tendinopathy. Clinical Biomechanics, 32, pp.56-63.
- Segal, N., Felson, D., Torner, J., Zhu, Y., Curtis, J., Niu, J. and Nevitt, M. (2007). Greater Trochanteric Pain Syndrome: Epidemiology and Associated Factors. Archives of Physical Medicine and Rehabilitation, 88(8), pp.988-992.
- Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H. and Vicenzino, B. (2018). 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, May 2;361:k1662.
