Buttock pain, Hip pain, Iliotibial Band pain, Outer hip pain, Hip bursitis, Gluteal tendinopathy, Bursitis, Lateral hip pain, Nighttime buttock pain, Pain during movement, Degeneration, Overuse
Greater trocantheric pain refers to pain localized on the outer side of the hip. Sometimes the pain can also radiate down the outer thigh towards the knee. It is often associated with inflammation or tendinopathy of the tendinous attachment area of the deep gluteal muscles. Irritation or inflammation of the bursae in the area can also be a contributing factor. The outer side of the hip is usually sensitive to touch, and it can be uncomfortable to sleep on the affected side.
The condition is often linked to excessive physical exertion, direct injuries to the area, repetitive microtrauma, degeneration or tears. It typically starts with an irritation of the gluteal tendons which may also cause an inflammatory response. If left untreated, the symptoms and inflammation can spread to the surrounding tissues, causing the pain to radiate. Consequently, long-lasting gluteal tendon issues often involve simultaneous irritation of the bursae or the iliotibial band.
Previously, pain on the outer side of the hip was thought to be primarily due to bursitis. However, current research indicates that the pain on the outer side of the hip is primarily caused by non-inflammatory tendon issues in the gluteus medius or minimus muscles. This however, does not rule out the possibility of inflammation, even though it appears to be relatively rare.
Epidemiology
Greater trochanteric pain is much more common in women than in men. This can be partially explained by women having wider hips, which increases the tightness of the iliotibial band, causing structures such as tendons and bursae in the greater trochanteric area to become compressed against bony structures. Additionally, overweight or obesity appears to increase the prevalence of this condition.
Pain in the greater trochanteric region is most commonly experienced in the age range of 40-60 years, but it can also affect individuals younger or older than this. In such cases, there are often predisposing factors contributing to the condition. For example, runners tend to experience this type of pain slightly more frequently than the general population.
The duration of the pain is influenced by various factors, but on average, it persists for over 6 months, affecting as much as 10-15% of the population at some point in their lives.
Etiology
The development of greater trochanteric pain can be influenced by several different factors that, alone or in combination, result in pain on the outer side of the hip. Often, there is a history of overuse or underuse, repeated microtraumas, or a single macroinjury such as a tear, rupture, or contusion.
Biomechanical factors, such as poor lower limb control and alignment difficulties, weakened core stability or weakness in the pelvic area, can also contribute to pain in the greater trochanteric area. Repetitive movements that increase friction in the iliotibial band and the greater trochanteric area can add pressure and irritation to tendon and bursa structures.
Sleeping on one's side or excessive exercise can also increase pressure in the greater trochanteric area and may be a contributing factor in discomfort. Postural habits where the knee is constantly closer to the midline than the hip can also increase pressure and friction on the outer side of the hip. Examples of this include sitting with crossed legs or adopting the so-called "hip rest" posture, where one leans one leg against the hip dropped on the other side.
Causes leading to greater trochanteric pain is highly varied, and the mentioned reasons are by no means the only ones. Often, the background is individual, involving both internal and external loading factors that, when combined, cause and perpetuate pain. From a rehabilitation perspective, it's essential to identify these background factors as meticulous as possible in order to create a comprehensive rehabilitation plan to manage the condition effectively.
Risk factors
Risk factors for greater trochanteric pain are similar to those associated with other tendon issues and pain conditions. Below are some reasons and risk factors for pain in the greater trochanteric region:
I. Common Risk Factors:
Overuse and mechanical overload
Insufficient exercise, leading to degeneration and circulatory challenges
Muscle fatty infiltration
Microtrauma and inadequate healing
Compression and friction of tendons and bursa structures
II. Work and Hobby-Related Risk Factors:
Static and ergonomically unfavorable work postures
Physically demanding work
Repeated pelvic girdle loading
Poor or insufficient recovery
Sports and activities with increased strain to the hip and pelvic area
III. Psychological Factors:
Stress
Anxiety
Depression
Sleep-related challenges
IV. The role of Hip Abductors and Iliotibial Band:
Weak hip abductors, especially weakness in the Gluteus medius muscle, can lead to increased hip adduction during functional loading. This in it self, can lead to compression of the Gluteus medius and minimus tendons against the greater trochanter
Increased tension in the Iliotibial band increases pressure on the gluteal tendon
Increased hip flexion angles can also increase compression in the greater trochanteric area, which is why prolonged sitting can contribute to the condition
Factors related to weak pelvic and core stability can also increase the load on the outer side of the hip
Degenerative changes in gluteal tendon structures are usually observed in people suffering from greater trochanteric pain
V. Gender:
Women are more susceptible to greater trochanteric pain due to factors such as pelvic width, biomechanical challenges, different activity levels, and varying hormonal function
Women also have a smaller attachment of the Gluteus medius muscle, resulting in greater mechanical stress on a smaller area
VI. Increased Bursal Fluid and Inflammation:
Increased fluid in the bursa is thought to result from tendon pathology rather than bursitis
Previously, the condition was believed to be due to bursitis, leading to the frequent use of corticosteroid injections, which are now performed much less frequently
VII. Gluteal Tendon Tears:
Often an unnoticed cause of greater trochanteric pain
Tears in the Gluteus medius muscle are observed in up to 25% of middle-aged women and about 10% of men
Degenerative tears are more common than tears following acute injury
Tears in the Gluteus medius and minimus muscles are associated with tendon and tendon attachment degeneration
Degenerative fraying and tears at the attachment site of the Gluteus medius and minimus muscles, along with other tendon degenerative changes, disturbed blood circulation, and impaired metabolism, can cause pain in the tendon structures attached to the greater trochanter
Tears can be complete or partial, with partial tears occurring more frequently
VIII. Associated Conditions:
Greater trochanteric pain is common in patients with lumbar degeneration and low back pain. Up to 51% of patients with lumbar disc degeneration, spinal stenosis, or facet joint arthritis also experience lateral hip pain
Hip osteoarthritis is often associated with greater trochanteric pain
The most common cause of pain, limping and instability following hip replacement surgery is typically degeneration, damage and fatty infiltration of the Gluteus medisu muscle
The most common cause of pain following hip replacement surgery is muscle damage, which can be attributed to poor preoperative condition of the gluteal muscles and their attachment sites as well as the surgical approach
Iliotibial band syndrome and knee osteoarthritis also predispose individuals to greater trochanteric pain
IX. Leg Length Discrepancy:
Leg length discrepancy does not appear to have an effect on the development of greater trochanteric pain, despite common beliefs of it doing so
Symptoms
Greater trochanteric pain typically manifests as pain on the outer side of the hip. This pain can in some cases radiate down along the outer edge of the thigh towards the knee. Pain radiating below the knee is rarely caused by greater trochanteric pain, but is quite common in either lumbar disc prolapse or lumbar stenosis. The painful area on the outer side of the hip is often sensitive to touch, making it difficult to lie on the affected side. Pain worsens in situations where there is increased pressure or friction in the area, such as when climbing stairs or hills, lying on your side, or sitting in a chair.
The pain may not be extremely severe, but it is often described as aching and quite disruptive. Some people have compared the pain to a toothache that constantly reminds them of its presence and hinders their daily activities. It is a characteristic feature of greater trochanteric pain that it makes sleeping difficult, which is a significant inconvenience for many.
Other symptoms may include:
Sensitivity on the outer side of the hip that worsens when touched
Pain that intensifies when lying on one's side
Pain during weight-bearing activities such as walking, climbing stairs, standing or running
Pain that can radiate down the outer edge of the thigh towards the knee
Increased pain with prolonged sitting
Increased pain when tensing the hip abductors
Increased pain when sitting with crossed legs or in the "hip rest" posture
Treatment
The primary treatment strategy for greater trochanteric pain is conservative in nature. It combines both pharmacological and non-pharmacological pain management methods along with physiotherapy. Exercise is aimed at improving the biomechanical characteristics of the core, pelvis and hip and reducing increased load or pressure on the affected tissues.
The goal of treatment is to alleviate pain and improve function and work capacity. This is achieved through a precise, progressive and individualized exercise program, often including mobility-enhancing exercises and manual therapy.
Pharmacological treatment typically involves a combination of pain relievers and anti-inflammatory medications and potential inflammation can also be managed with cold therapy, which is often repeated several times a day.
Surgical interventions should be considered only if conservative treatment does not achieve the desired results or when there is a significant tendon tear. The choice of surgical procedure is based on the individual's situation and findings, but surgery often involves one of the following:
Removal of the bursa
Iliotibial band procedures: release of the iliotibial fascia or resection of the lateral synovial corner
Greater trochanteric reduction
Abductor tendon reconstruction
Surgical interventions for greater trochanteric pain are rare and are not considered until conservative treatment has been attempted.
Physical therapy
Physical therapy begins with a comprehensive assessment of background factors, which is used to create the most individualized rehabilitation program possible for managing the condition. No two rehabilitation programs are exactly the same, although they often share similar components and goals.
The primary goal of physical therapy is to reduce greater trochanteric pain and improve the functional capacity. In the initial phase of rehabilitation, the focus is on pain relief, which is often achieved through various passive treatments such as soft tissue manipulation, joint mobilization, acupuncture or other pain management methods. If you want to learn more about manual therapy and its effects on pain, you can read about it here.
In addition, it's important to understand the factors that typically exacerbate pain, so these can be either avoided or at least minimized. Modifying one's own load is also an integral part of treatment. Information and understanding of the nature of the condition, its background factors, and the potential duration of pain seem to improve the prognosis.
As the pain subsides, the rehabilitation program often shifts towards strengthening the tissues and enhancing core, pelvic, and lower limb control and kinematics. Progressive training is aimed at improving the load tolerance of the affected structures so that they don't become as sensitive in the future. Possible limitations in range of motion are addressed using a combination of manual therapy and mobility exercises.
When designing a rehabilitation plan, it's essential to consider the specific needs and desires of the individual. The rehabilitation plan is always shaped individually and can be quite different depending on whether the person is, for example, an office worker whose hip primarily troubles them during sedentary work or an athlete who cannot continue their profession due to pain.
Below are a few physical therapy treatment methods and their primary goals in the rehabilitation of greater trochanteric pain:
Progressive training and load modification
Managing overall load
Reducing compression and stretching load on irritated tissues
Strengthening muscles and improving the load tolerance of tendon structures
Pain relief
Manual therapy
Modulation of descending pain pathways and pain relief
Reducing muscle tension
Increasing muscle performance
Reduced cortisol secretion
Improved blood circulation
Increase mobility
Decreased pain interference
Information and education
Providing sufficient information about the nature of the condition, its background factors, and rehabilitation can reduce patient concerns and increase self-efficacy and motivation for rehabilitation. This also helps address factors that positively or negatively affect treatment prognosis and timing. This reduces patient uncertainty and potential anxiety, often making it easier to live with pain.
Self care
Rest and Load Modification: Allow your hip and surrounding tissues sufficient time to heal by avoiding activities that worsen the pain, such as lying on the painful hip, excessive exercise, or intense stretching.
Try Cold Therapy: Cold therapy can help alleviate pain and possible inflammation. You can use ice, cold packs, or cold gel.
Pain Medication: Ibuprofen and paracetamol can relieve pain and potential inflammation. Always follow the recommended dosage and seek advice from a healthcare professional if you are unsure.
Heat Therapy: Heat can help relax muscles and reduce pain.
Stretching: Try gentle, dynamic stretches to improve fluid circulation in the tissues around the hip. However, avoid intense or prolonged stretching, as these may worsen the pain.
Strengthen Muscles: Strengthening exercises develop muscles and enhance hip stability. Start your training gently and increase the load gradually. Rapid progression in an exercise program often only worsens the pain.
Modify Posture and Movement Habits: Avoid movements and postures that exacerbate the pain. This includes prolonged sitting, standing with the hip tilted, climbing stairs, or extended standing.
Weight Management: If you are overweight, weight loss can reduce stress on the hip joint and help decrease pain.
Aids: In some cases, a cane or crutches can help reduce the load on the hip while decreasing pain.
Sleep Position: Avoid sleeping positions where the painful hip is pressed against the mattress or under prolonged stretch during the night. Try placing a thick pillow between your knees when sleeping on your pain-free side.
Consult a physiotherapist if your pain persists despite self-care measures or if it hinders your daily activities. A physiotherapist can create a tailored rehabilitation plan and provide necessary treatments to speed up pain relief and improve your functional abilities.
Furthermore, if your pain continues to worsen or doesn't improve, it's highly advisable to seek a doctor's evaluation. A doctor may recommend further tests, such as imaging studies, and consider other treatment options, including potential surgical intervention. In any case, collaboration with healthcare professionals is crucial for effective pain management and recovery.
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