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Patients who have lateral hip pain historically have been diagnosed
with trochanteric bursitis and treated with nonsteroidal antiinflammatory medications, corticosteroid injections, and physical
therapy. Although this strategy is effective for most patients, a
substantial number of patients continue to have pain and functional
limitations. Over the past decade, our understanding of disorders
occurring in the peritrochanteric space has increased dramatically.
Greater trochanteric pain syndrome encompasses trochanteric
bursitis, external coxa saltans (ie, snapping hip), and abductor
tendinopathy. A thorough understanding of the anatomy, examination
findings, and imaging characteristics aids the clinician in treating these
patients. Open and endoscopic treatment options are available for use
when nonsurgical treatment is unsuccessful.
Anatomy
The anatomy of the peritrochanteric
space has been well described2,4
(Figure 1). Most patients have three
bursae peripheral to the greater
trochanter; some have four. These
fluid-filled sacs cushion and aid in
smooth motion of the gluteus tendons, iliotibial band (ITB), and tensor
fascia lata. The largest is the subgluteus maximus bursa, which is
located between the gluteus maximus
muscle and the gluteus medius tendon, lateral to the greater trochanter.
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231
Figure 1
Illustrations depicting the anatomy of the greater trochanter with tendinous insertion sites and bursae insertions. A, The three
main bursae and their positions. B, Facets of the greater trochanter. C, Footprints of the gluteus medius and gluteus minimus
tendons. (Reproduced with permission from Domb BG, Nasser RM, Botser IB: Partial-thickness tears of the gluteus medius:
Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy 2010;26[12]:1697-1705.)
232
Etiology
Accurate diagnosis of the underlying
etiology is the key to successful
management of GTPS. As noted, this
condition encompasses greater trochanteric bursitis, gluteus medius and
gluteus minimus tears, and external
coxa saltans. 1 Two or more of
these diagnoses are often seen
concomitantly.
Greater trochanteric bursitis, or
inflammation of one or more of the
peritrochanteric bursae, has historically been considered the main source
of lateral hip pain. A proposed cause
is repetitive friction between the
greater trochanter and ITB associated
with overuse, trauma, and altered
gait patterns. Imaging studies have
shown that most patients who receive
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Table 1
Comparison of the Shoulder Rotator Cuff and the Analogous Structure in the Hip
Characteristic
Functional anatomy
Internal rotator
Stabilizers and rotators; initiation
and assistance in abduction
Abduction
Clinical presentation
Imaging
Mechanism of pathology
Arthroscopic evaluation
Shoulder
Hip
Subscapularis
Supraspinatus and infraspinatus
Iliopsoas
Gluteus medius and gluteus minimus
Deltoid
Pain with motion, tenderness, weakness
in abduction
MRI and ultrasonography
Degenerative tearing
Articular tears can be visualized as
exposed footprint or delamination
Adapted with permission from Domb BG, Nasser RM, Botser IB: Partial-thickness tears of the gluteus medius: Rationale and technique for transtendinous endoscopic repair. Arthroscopy 2010;26(12):1697-1705.
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
233
Table 2
Differential Diagnosis of Hip Pain
Location of Pain
Structures
Affected
Intra-articular hip
Extra-articular hip
Muscle/tendon/
bursa
Bone
Nerve
Other
Outside the hip
Axial
Sacroiliac
Radicular
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Disorders
Femoroacetabular impingement
Dysplasia
Labral tear
Ligamentum teres tear
Synovitis
Capsulitis
Loose body
Degenerative joint disease
Osteonecrosis
Adductor strain
Iliotibial band syndrome
Iliopsoas complex disorders
Piriformis/hip external rotator
disorders
Greater trochanteric pain syndrome
Hamstring complex disorders
Stress fracture
Epiphysitis
Transient osteoporosis
Meralgia paresthetica
Genitofemoral nerve disorders
Ilioinguinal nerve disorders
Sciatic nerve disorders
Sports hernia
Pelvic visceral pain
Disk disorders
Facet disorders
Lumbar strain
Vertebral fracture
Sacroiliac disorders
Spinal stenosis
Radiculopathy
Spondylolisthesis
Differential Diagnosis
The diagnosis of GTPS can be complicated given the multiple possible
sources of pain surrounding the hip
Imaging
The most common imaging modalities used in the evaluation of GTPS
are plain radiography, ultrasonography, and MRI. A better understanding of the role of the gluteus medius
and/or gluteus minimus in GTPS has
led to an increased interest in defining
the normal and pathologic appearance of these structures via ultrasonography and MRI.
Standard radiography may be useful when evaluating patients with
lateral hip pain. Many patients with
intra-articular pathology have pain
referred to the lateral hip. Routine
radiography can assist in ruling out
hip degenerative joint disease, femoroacetabular impingement, and dysplasia. These conditions should be
ruled out before treatment of GTPS is
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Figure 2
Figure 3
hip because snapping of the trochanter against the ITB can be visualized and correlated with patient
symptoms. In the evaluation of gluteus medius pathology, the probe can
be used to palpate different areas of
the tendon for a pain response, and a
diagnostic injection can be performed
to test for pain resolution. In a recent
study, Long et al9 retrospectively
evaluated 877 trochanteric sonograms in patients with greater trochanteric pain and found that most
patients did not have trochanteric
bursitis. The ultrasonographic characteristics identified included gluteal
tendinosis in 50% of patients, a
thickened ITB in 28.5% of patients, a
gluteal tendon tear in 0.5% of
patients, and trochanteric bursitis in
20% of patients.
The primary means of evaluating a
patient for GTPS is MRI (Figure 2).
MRI or magnetic resonance arthrography allows visualization of
the hip joint and extra-articular
structures, which can help rule out
other hip disorders. Trochanteric
bursitis can result in inflammation
visible within the area surrounding
Figure 4
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235
Figure 5
Management
Nonsurgical
As noted, GTPS has typically been
classified as trochanteric bursitis
and treated with anti-inflammatory
medications, physical therapy, and
corticosteroid
injections.
Nonsurgical management of GTPS has
been successful in most patients.19
Furia et al20 analyzed a group of
patients treated nonsurgically with
rest, physical therapy, ultrasonography, injections, ice, and heat. The
authors noted that 10 of 15 patients
(66%) were able to return to sports
and 5 of 6 patients (83%) were able
to return to labor occupations 3
months after initiation of nonsurgical management.
The use of corticosteroid injection
in the treatment of GTPS has been
236
Surgical
Surgical management of GTPS should
be reserved for patients with symptoms
that have been present for a minimum
of 6 to 12 months and in whom nonsurgical treatment has been unsuccessful. Multiple techniques have been
used to treat GTPS depending on the
etiology of the pain. Open or endoscopic approaches can be used.
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Figure 6
Trochanteric Bursitis
Open treatment of refractory trochanteric bursitis has been performed
for decades. Brooker24 described
bursectomy with release of the ITB in
1979. In most case series, whether
the approach was open or endoscopic, the treatment of trochanteric
bursitis has involved both release of
the ITB and dbridement of the trochanteric bursa.
In several small case series, open
ITB release and bursectomy have
been performed with satisfactory
results. In one study, 12 patients
underwent trochanteric reduction
osteotomy for refractory bursitis and
had good results at 23.5 months. In
that study, 11 of 12 patients reported
their improvement as great or very
great. Five of these patients had previously undergone a failed open ITB
release with bursectomy.25
Isolated trochanteric bursectomy
can be performed arthroscopically
(Figure 5). Published results consist
primarily of small case series. Fox26
reported the results of isolated
arthroscopic trochanteric bursectomy without ITB release for
refractory trochanteric bursitis in
2002. In that study, 23 of 27 patients
Figure 7
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237
Figure 8
Illustrations depicting surgical repair of a gluteus medius tendon tear in a right hip.
Proximal is left, and distal is right. A, Superficial view of an intact gluteus tendon.
B, Cross-sectional view of an intact gluteus tendon. C, Superficial view of the
undersurface of a gluteus tendon tear (gray shaded area). D, Cross-sectional view of
the undersurface of a gluteus tendon tear (arrow). E, Superficial view of a longitudinal
incision along the gluteus tendon fibers. F, Cross-sectional view of a longitudinal
incision along the gluteus tendon fibers (arrow). G, Superficial view demonstrating
anchor placement and suture passage through tendon edges, after dbridement of
the tear and decortication of the bony bed. H, Cross-sectional view demonstrating
anchor placement and suture passage. I, Superficial view of the final repair of the
gluteus tendon. J, Cross-sectional view of the final repair of the gluteus tendon.
238
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Summary
The anatomy and characteristic
pathology of the peritrochanteric
space has recently begun to be better
understood. The diagnosis of GTPS,
which encompasses greater trochanteric bursitis, gluteus medius and
gluteus minimus tears, and external
coxa saltans (ie, snapping hip), can be
complicated. Nonsurgical methods
are the mainstay of treatment of
GTPS. In patients who do not
respond well to nonsurgical treatment, open or endoscopic surgical
treatment has shown promise.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
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239
240
34.
McCormick F, Alpaugh K,
Nwachukwu BU, Yanke AB, Martin SD:
Endoscopic repair of full-thickness
abductor tendon tears: Surgical technique
and outcome at minimum of 1-year followup. Arthroscopy 2013;29(12):1941-1947.
35.
40.
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.