Greater trochanteric pain syndrome

Abstract

Greater trochanteric pain syndrome (GTPS) is a common problem that is both debilitating and challenging to manage. In the past, the terms GTPS and greater trochanteric bursitis were used interchangeably, however, inflammation is not always a feature, and in fact, overuse or injury of the gluteal muscles may be the predominant feature. GTPS is now understood to involve multiple pathologies that affect the intra-articular or peri-articular spaces of the hip. Early detection and management of GTPS by GPs can improve patients’ quality of life. Currently, the use of corticosteroid injection therapy and imaging in the management of GTPS may be suboptimal. The aim of this article is to review the current management of GTPS, evidence for the efficacy and duration of action of corticosteroid injection therapy and the role of imaging techniques in the diagnosis and management of GTPS, including the ability to identify pathology and predict treatment response.

The GP curriculum and greater trochanteric pain syndrome

Clinical module 3.20: Care of people with musculoskeletal problems states that GPs should be able to:

Diagnose common, regional soft-tissue problems that can be managed in primary care

Diagnose and manage the common, regional pain syndromes such as osteoarthritis, back pain and fibromyalgia

Understand the issues and debates about use of complementary therapy and opiate analgesia for chronic pain

GTPS symptoms and clinical diagnosis

Greater trochanteric pain syndrome (GTPS) is a condition characterised clinically by pain in the lateral upper thigh, which is exacerbated by palpation of the greater trochanter and abduction of the hip joint (Strauss, Nho, & Kelly, 2010). Common associated diagnoses include:

Inflammation of nearby bursae, such as the trochanteric and subgluteal bursae (as seen in Fig. 1)

Tendinopathy

Complete or partial tears of the gluteus minimus and medius tendons

Figure 1.

Anterior view of bursae of the left greater trochanter.

GTPS is a relatively common condition; it affects approximately 10–25% of the general population (Segal et al., 2007) and confers a significant level of disability that can negatively impact on quality of life. GTPS is three to four times more common in women and more frequently occurs between the ages of 40 to 60 years. It is also seen in patients with the following co-morbidities: obesity, low back pain, osteoarthritis of the spine or ipsilateral hip or knee, and previous injury to the spine or ipsilateral hip or knee (Segal et al., 2007). The National Institute for Health and Care Excellence (NICE) guidance on diagnosis of GTPS states that the core diagnostic features include (NICE, 2010):

Lateral hip pain

Point tenderness over the greater trochanter

Positive Trendelenberg single-leg raise test in most cases

Obtaining an accurate clinical evaluation and diagnosis is important to determine the most appropriate treatment.

Conservative management with weight loss, ice packs and physiotherapy can offer symptomatic relief, and the problem can be completely resolved in most cases. However, symptoms may persist and intervention involving peri-tendinous and intra-bursal injection of corticosteroid is often undertaken (Williams & Cohen, 2009). However, the efficacy and duration of action of corticosteroid injection therapy is poorly understood (Lustenberger, Ng, Best, & Ellis, 2011).

Ultrasound imaging (USI) is often used to guide injections, identify pathology and confirm diagnosis. Magnetic resonance imaging (MRI) is sometimes used to aid diagnosis and exclude other pathologies, such as bone and articular problems that may be difficult to assess on USI. Other imaging modalities are utilised only rarely.

Heterogeneous pathologies often underlie the GTPS syndrome, which may present with varying symptoms resulting in differing and unclear responses to treatment. These factors may contribute to the fact that currently there is no robust protocol to aid diagnosis and management of GTPS. The aim of this article is to review the evidence regarding efficacy and duration of action of corticosteroid injection therapy and to examine the role of imaging in diagnosis and management of GTPS, including its ability to identify pathology and predict treatment response.

Management of GTPS

Corticosteroid injection therapy

Corticosteroid injection therapy is often the second line treatment for patients with persistent pain not improved by conservative management. The short-term efficacy of corticosteroid injection therapy for a variety of musculoskeletal disorders is well-documented (Bhagra et al., 2013; Labrosse et al., 2010; Stephen, Beutler, & O’Connor, 2008), leading to a significant improvement in quality-of-life metrics, patient satisfaction and symptomatic relief. Moreover, the procedure can be a diagnostic aid, as an absence of symptomatic improvement may suggest alternative pathology.

NICE guidelines on GTPS management indicate that currently there are no clinical trials that provide strong evidence for treatment strategies. Recommendations are largely based on expert opinion, with only low-quality evidence from case-series (NICE, 2010). After conservative measures, including ice compression, pain medication and weight loss, have been tried, the guidance states that an injection of methyl prednisolone (40–80 mg) or triamcinolone (40 mg) mixed with 5–10 ml lidocaine 1% can be injected into the tender area up to three times at 3-monthly intervals (NICE, 2010). The evidence for duration of action is limited by the retrospective nature of many of the studies, small sample sizes and short follow-up (mostly up to 4 weeks). These issues can result in errors, due to recall bias, poor statistical power and a lack of evidence for long-term duration of action. Additionally, studies differ extensively in methodology, and lack a standardised process to assess effectiveness of the treatment (Del Buono, Papalia, Khanduja, Denaro, & Maffulli, 2012).

Evidence from some studies suggests that the benefits of corticosteroid injection therapy may have limited duration. A randomised controlled trial (Brinks et al., 2011) compared the effectiveness of corticosteroid injection therapy with expectant management at 3-month and 12-month follow-up visits. The study’s primary outcome measure was pain severity measured numerically on a rating scale of 0 to 10, and results showed a statistically significant difference at 3 months for corticosteroid injection therapy versus usual care, but at 12 months this difference was no longer present. This finding is further supported by another randomised controlled trial (Rompe et al., 2009) that compared the efficacy of home training, local corticosteroid injection therapy, or radial shock wave therapy. Primary outcome measures were degree of recovery measured on a six-point Likert scale and pain severity measured numerically from 0 to10. The results showed that at 1-month post intervention, local corticosteroid injection therapy was significantly more effective than the other treatment modalities. This advantage diminished at 4 and 15 months.

This evidence would suggest that the duration of action for corticosteroid injection therapy is limited. The treatment has a greater impact on symptoms in the short-term when compared with other non-operative measures. The advantages of immediate symptomatic relief may not outweigh the disadvantages of further treatment, which may increase the overall cost of management, both in economic terms and patient-related factors, due to undertaking multiple sequential interventions.

GTPS may present with slightly differing pathologies, and their heterogeneous nature makes direct comparison between study populations challenging. There are several factors that may influence treatment outcomes, such as: previous treatment; sedentary lifestyle; and specific co-morbidities such as pre-existing injury, arthritic disease, and obesity (Walker, Kannangara, Bruce, Michael, & van der Wall, 2007; Williams & Cohen, 2009). These factors are frequently not included in patient data and may affect treatment outcomes. Future research needs to incorporate prospective study designs, collection of patient baseline characteristics, large sample sizes, as well as longer follow-up times (greater than 12 months) to help improve the quality of available evidence and patient care. A summary of the evidence available for treatment options in GTPS is presented in Table 1.

Table 1.

Summary of evidence for treatment options in GTPS management.

Author and year	Study type	Sample size	Treatment	Outcomes measured	Follow-up	Results	Conclusion
Stephens et al. (2008)	Review article	NA	CI	• Symptom relief • Frequency of injections • Injection technique • Type and dose of injections.	NA	• Systematic evidence is lacking • Corticosteroid injection can provide symptomatic relief, provides guidance on dose and type of steroid and injection technique	Systematic evidence needed to clarify use in healthcare problems
Rompe et al. (2009)	Randomised controlled trial	n = 229	Home training programme, intra-bursal corticosteroid injection or repetitive low-energy shock-wave treatment (SWT)	• Degree of recovery (six-point Likert scale) • Pain severity (10-point rating scale)	1, 4 and 15 months	• 1 month: Success (i.e. complete recovery or much improved) in 7%, 75% and 13% in home training, corticosteroid injection and SWT groups, respectively • 4 months: Success in 41%, 51% and 68% in home training, corticosteroid injection and SWT groups, respectively • 15 months: Success in 80%, 48% and 74% in home training, corticosteroid injection and SWT groups, respectively	Home training, corticosteroid injection and SWT can provide benefit. Specifically, corticosteroid injection provides only short-lived benefit, with home training and SWT offering sustained improvement
Labrosse et al. (2010)	Prospective cohort	n = 54	USI-guided injections	• Pain (10 cm visual analogue scale (VAS)) • Patient satisfaction (four-point rating scale)	1 month	• 1 month: At least 30% reduction in VAS pain score in 72% of patients. 70% patient satisfaction	At 1 month, corticosteroid injection provides a reduction in VAS pain score
Brinks et al. (2011)	Randomised controlled trial	n = 120	Expectant management or corticosteroid injection	• Pain severity (10-point rating scale) • Recovery at 3- and 12-month follow-up visits)	3 and 12 months	• 3 months: 55% recovered in corticosteroid injection group compared with 34% in expectant management group (odds ratio (OR) = 2.38; 95% confidence interval (CI), 1.14–5.00) • 12 months: 61% recovered in corticosteroid injection group compared with 60% in expectant management group (OR = 1.05; 95% corticosteroid injection, 0.50–2.27).	Greater short-term improvement with corticosteroid injection compared with expectant management; benefit diminished at 12 months.
Bhagra et al. (2013)	Retrospective cohort	n = 1188 (Trochanteric bursa injections n = 279)	Intra-bursa CI	• Pain (six- point Likert scale) • Quality of life.	1 month	• Pain score pre-corticosteroid injection = 3.29, post-corticosteroid injection = 2.58 (p < 0.0001).	Reduction in pain score at 1 month post corticosteroid injection. Clinical significance unclear

Role of imaging in GTPS

Recent research has questioned the role and use of imaging modalities in the management of GTPS, both for diagnosis and corticosteroid injection therapy guidance (Cohen et al., 2009; Cohen, Narvaez, Lebovits, & Stojanovic, 2005; Wilson, Shanahan, & Smith, 2013).

Diagnosis

Diagnosis of GTPS is usually made clinically, with imaging investigations occasionally used to identify contributory pathology and to rule out other underlying pathology.

Investigation with USI in the management GTPS possesses several advantages over other modalities, including low cost and wide availability (Chowdhury, Naaseri, Lee, & Rajeswaran, 2014). For these reasons USI has played a dominant role in the diagnosis and guidance of treatment for GTPS. USI is often used to identify tendinopathy and partial- or full-thickness gluteal tendon tears. Fearon, Scarvell, Cook, and Smith (2010) concluded that USI had a sensitivity of 0.79 and positive predictive value of 1.0 when comparing USI with intra-operative assessment to diagnose a gluteus medius or minimus tear, but a lower capability (sensitivity = 0.61) of diagnosing bursal pathology.

In clinical practice, USI does have significant drawbacks. It has a relatively poor diagnostic sensitivity and specificity and is largely operator-dependent when compared with superior imaging modalities such as MRI. This limits diagnostic effectiveness, leading to uncertainty in its role in the management of GTPS and its capacity to predict treatment outcomes (Del Buono et al., 2012). Other modalities such as MRI, fluoroscopy and computerised tomography are not considered first line investigations, unless surgical review is required, predominantly due to resource constraints (Chowdhury et al., 2014).

MRI is occasionally used to aid diagnosis and in pre-operative planning, for example, prior to tendon repair. It is documented in the literature that MRI has a high specificity (approaching 100%) for demonstrating tendon tears, oedema associated with tendinopathy, and muscle atrophy that may all be seen in GTPS (Del Buono et al., 2012). These pathological changes correlate with patient symptoms, including pain (Wilson et al., 2013). MRI also has the ability to exclude interosseous pathology that would not be visualized on USI.

The pathology identified on MRI in GTPS can differ between study populations (Bird, Oakley, Shnier, & Kirkham, 2001; Wilson et al., 2013). This may be due to the heterogeneous nature of GTPS, but may also reflect differing study methodologies and study sample sizes. However, a recent systematic review suggested that MRI might be the current investigation of choice for GTPS as all (n = 7) studies reviewed showed little discrepancy between MRI pathological findings and intra-operative findings or clinical findings (McMahon, Smith, & Hing, 2012). The literature remains divided as to whether the benefits of using MRI outweigh the disadvantages (cost, availability and patient convenience). This is especially relevant when the diagnosis can often easily be made clinically in a GP setting.

Corticosteroid injection guidance

Fluoroscopy has been used to replace previously unguided injections, under the premise that blind injections led to suboptimal treatment responses. In the hip region, 21 bursae have been identified with three surrounding the greater trochanter, the area usually targeted in the delivery of corticosteroid injection therapy (Shbeeb & Matteson, 1996). Cohen et al. (2005) concluded in a pilot study that fluoroscopic imaging was necessary to aid delivery of the corticosteroid injection in the targeted region. Bursagrams were not obtained in 55% of cases upon first needle placement, resulting in inadequate corticosteroid delivery to the bursal tissues. Subsequently, that research group also concluded that fluoroscopically guided injections (in addition to increased cost, complexity of treatment, and exposure of patients to additional and unnecessary ionizing radiation) demonstrated no difference in clinical outcomes or symptomatic relief compared with blind injections in 65 patients in a multicenter double-blind randomised controlled study (Cohen et al., 2009).

A recent study of USI corticosteroid injection guidance and symptomatic response found a better response when injections were performed blind rather than with USI guidance (Wilson et al., 2013).

Imaging findings and correlation with treatment response

Although there is evidence to support the role of MRI as a diagnostic aid, the significance of its role in predicting treatment response remains unclear. One study of 97 patients with clinically diagnosed GTPS using MRI and bone cintigraphy identified lumbar degenerative disease, gluteus medius tendinopathy, and trochanteric bursitis as common pathological features linked with the diagnosis of GTPS (Walker et al., 2007). Of note, the study identified that only 63% of patients responded to CI treatment. The authors consider the varying response to treatment and the complex interrelationships between varying pathologies may be due to a mechanistic model of GTPS, and that imaging investigation may not provide a robust result to allow prognostic prediction.

Another study retrospectively included 45 cases in its final comparison examining the effectiveness of USI-guided CI into the greater trochanteric bursa versus the subgluteus medius bursa (McEvoy, Lee, Blankenbaker, del Rio, & Keene, 2013). Injections into the trochanteric bursa provided more effective symptomatic relief, but follow-up was very short; patients were only assessed once, at 14 days post injection. Significantly, the study also identified that there was no association between symptomatic relief and the USI findings of tendinopathy, bursitis or enthesopathy. This finding questions the modality’s ability to predict treatment response. A summary of the evidence available for the role of imaging in GTPS can be seen in supplementary table 1.

Discussion

The evidence for the role of imaging techniques in the management of GTPS remains controversial.

Many studies have demonstrated that USI may not be clinically indicated in GTPS management, due to the modality’s relatively poor diagnostic sensitivity and specificity. In addition, studies on USI use in the guidance of CI have shown no real difference in terms of outcomes compared with blind CI carried out in primary care. Furthermore, imaging-diagnosed pathology does not appear to correlate well with symptom severity or symptom relief post treatment. These studies are disadvantaged by retrospective design and small sample sizes.

MRI has increased sensitivity and specificity compared with USI, however, the identified pathology may not necessarily indicate symptom severity, treatment response or prognosis, and is significantly more expensive than USI.

Imaging is likely to be useful if there is diagnostic uncertainty, a suspicion of different pathologies requiring interventional treatment or when treatments options have been exhausted.

In clinically diagnosed GTPS, USI and MRI do not seem to help predict treatment response. Therefore, imaging as a primary investigation in the early stages of GTPS is unhelpful and unlikely to help alter management or prognosis. Therapeutic response to CI may help confirm the diagnosis. Management regimes need to be investigated to determine each treatment’s efficacy in the long term, and to assess the role of imaging in treatment.

Conclusions

GTPS is a common condition that can be treated conservatively in the majority of cases. GTPS poses a significant burden on medical resources and patient quality of life, as well as having uncertain management strategies beyond conservative measures. GTPS has a wide range of associated pathologies in patients studied. CI appears to provide effective short-term symptomatic relief. The efficacy and duration of action of CI may be limited, and the role and clinical use of certain imaging techniques in management protocols is unclear. Further research is needed to inform an effective management protocol for GTPS in primary and secondary care.

Key points

The majority of patients with GTPS can be treated conservatively

CIs for GTPS have a short duration of action

The role of imaging in a secondary care setting in the management of GTPS is unclear and may not be required in delivering injections or to predict treatment response

Further research with long-term follow-up data is needed to clarify the optimum management of GTPS

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