Caring Medical - Where the world comes for ProlotherapyGreater trochanteric pain syndrome

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In a commentary on a study in the Journal of Orthopaedic & Sports Physical Therapy exploring dry needling techniques versus cortisone, Greater trochanteric pain syndrome (GTPS) is described as a chronic, intermittent pain and tenderness on the outside of the hip.

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Treatment was also described as a medical community thinking that a swollen hip bursa was the source of such pain, which led to the use of corticosteroid injections to the bursa to help decrease swelling and pain.

Researchers now believe that injuries to the muscles and tendons around the hip are the actual cause of Greater trochanteric pain syndrome, not bursitis, in fact inflammation is often not one of the patient’s symptoms

  • Chronic hip pain, such as Greater trochanteric pain syndrome, is caused by aggressive hip joint instability. As researchers are discovering. Greater trochanteric pain syndrome begins with minor damage to the hip joint tissue, primarily the ligaments, and ends with destructive abnormal joint motion (hip instability) that leads to inflammation and eventual problems of degenerative hip disease.
  • It is destructive abnormal joint motion (hip instability) that is the cause or the effect of a myriad of conditions that led to chronic hip pain, including trochanteric tendinitis or bursitis, pelvic floor dysfunction, ischiofemoral impingement, iliopsoas bursitis, myofascial pain syndrome of the tensor fascia lata, gluteal muscle tears and strain, as well as ligament sprains of the hip.

Treating hip pain means treating the hip as a whole. Not on a specific, isolated diagnosis. This may answer why some hip procedures did not work as well as they should have.

The hip is a big joint, we believe to help patients achieve their treatment goals, they need to have their entire hip treated with our comprehensive Prolotherapy program for hip pain. This is explained below.

An example of concentrating on specific hip problems instead of treating the whole hip joint can be found in medical research studies trying to find out why some hip procedures did not work as well as they should have.

An example is a paper from doctors representing Italy’s leading research hospitals.(1) The team looked to see what caused greater trochanter pain syndrome in patients with suspected femoroacetabular impingement syndrome. After magnetic resonance arthrography of the hip and an evaluation of 189 patients, in the end it was hard to say what was the true pain cause because there were so many problems with the patient’s hips that they far outnumbered femoroacetabular impingement syndrome problems.

The biggest problem the patients had was 38% had tendinopathy of the hip, 16% had bursitis. Problems considered “normal hip pathology,” so there were many problems causing the patients discomfort.

Greater trochanteric pain syndrome – treatment debates – bringing in the needles

In a study published in The Journal of orthopaedic and sports physical therapy, doctors explored dry needling (injections where nothing is injected) as an alternative to cortisone injections to reduce pain and improve function in patients.

  • They found that evidence indicates that greater trochanteric pain syndrome, chronic pain and tenderness on the outside of the hip, can be treated effectively with physical therapy and specifically with dry needling to this area.
  • Conclusion: Dry needling is as effective as cortisone injection in reducing pain and improving movement problems caused by this condition.(2)

More on Dry Needling vs Cortisone

In the studyin  the Journal of Orthopaedic & Sports Physical Therapy, doctors documented their research.

  • Forty-three participants (50 hips observed), all with greater trochanteric pain syndrome, were randomly assigned to a group receiving cortisone injection or dry needling.
  • Treatments were administered over 6 weeks, and clinical outcomes were collected at baseline and at 1, 3, and 6 weeks.
  • Results
    • Cortisone injections for greater trochanteric pain syndrome did not provide greater pain relief or reduction in functional limitations than dry needling.(3)

In other words, dry needling worked just as well.

Greater trochanteric pain syndrome diagnosis and evaluation can be tricky

Researchers writing in the medical journal Current sports medicine reports gave a good summary of the challenges of identifying and treating Greater trochanteric pain syndrome. Here is what they wrote:

  • Disorders causing lateral hip pain are encountered frequently by physicians.
  • Evaluating these problems can be challenging because of the myriad of potential causes, the complex anatomy of the peritrochanteric structures. (Peritrochanteric Pain Syndrome describes conditions which cause pain in the lateral hip between the greater trochanter and the Iliotibial Band. An example is Snapping Hip Syndrome.)
    • Further compounding the problem of physical and radiological evaluation is the inconsistently described etiologic factors. Misconceptions about the causes of lateral hip pain and tenderness are common and frequently lead to approaches that only provide temporary solutions rather than address the underlying cause of the disease.
  • Trochanteric bursitis is implicated frequently but is seldom the primary cause of pain in chronic cases.
    • It is important to address hip rotator cuff tendinopathy and pelvic core instability.
      • Treatment options include therapeutic exercise, physical modalities, corticosteroid injections, extracorporeal shock wave therapy, and regenerative injection therapies.
    • For difficult cases, surgery may be appropriate.
  • By understanding the anatomy of the peritrochanteric structures, and the pathologic processes most likely responsible for symptomatology and dysfunction, the physician will be prepared to provide effective long-term solutions for this common problem.(4)

Why do clinicians keep looking for bursitis when bursitis is not the problem?

Supportive of this statement is multiple studies showing that degeneration of the gluteal tendons, which attach near the bursa often fool providers into thinking the patients have bursitis.

The first study come from the European journal of radiology:

  • Gluteus minimus or gluteus medius tendinopathy rather than trochanteric bursitis, is the cause of greater trochanteric pain syndrome. Trochanteric bursitis is no longer the preferred terminology, because this condition is rarely present.”
    • In this study, only 5 of 124 patients with trochanteric pain had bursitis, and most of those with bursitis also had associated tendinopathy.(5)

Researchers from Argentina came to the same conclusion:

  • “Inflammation of the trochanteric bursa has been postulated for a long time as the main cause of pain at the trochanteric level. However, some studies have questioned the real involvement of the trochanteric bursa in greater trochanteric pain syndrome, and tendinopathy of the gluteus medius and/or minimus has been proposed as an important cause of this syndrome.”(6)

Researchers from Australia came to the same conclusion:

  • In a heavily cited paper by their fellow researchers, radiologists in Australia found of seventy-five patients with pain and point tenderness over the greater trochanter, only 8 had fluid pooling in the trochanteric bursae per sonography.(7)

Researchers from United States came to the same conclusion:

  • Radiologists from Thomas Jefferson University Hospital also found that of “877 patients with greater trochanteric pain,700 (79.8%) did not have bursitis on ultrasound, revealing that the cause of greater trochanteric pain syndrome is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band.”(8)

Continuing your research on treatments on our site:
The following pages offer treatment options as offered her at Caring Medical.

1. Pozzi G, Lanza E, Parra CG, Merli I, Sconfienza LM, Zerbi A. Incidence of greater trochanteric pain syndrome in patients suspected for femoroacetabular impingement evaluated using magnetic resonance arthrography of the hip. La radiologia medica. 2017 Mar 1;122(3):208-14. [Google Scholar]

2 Hip Pain: Dry Needling Versus Cortisone Injections. J Orthop Sports Phys Ther 2017;47(4):240. [Google Scholar]

3 Brennan KL, Allen BC, Maldonado YM. Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial. J Orthop Sports Phys Ther. 2017 Apr;47(4):232-239. [Google Scholar]

4. Ho GW1, Howard TM. Greater trochanteric pain syndrome: more than bursitis and iliotibial tract friction. Curr Sports Med Rep. 2012 Sep-Oct;11(5):232-8. [Google Scholar]

5.Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. European Radiology. 2007;17(7): 1772-1783. [Google Scholar]

6.  Quiroz C, Ruta S, Rosa J, Navarta DA, Garcia-Monaco R, Soriano ER. Ultrasound evaluation of the Greater Trochanter Pain Syndrome: Bursitis or tendinopathy? [Google Scholar]

7. Connell DA, Bass C, Sykes CJ, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. European Radiology. 2003; 13(6): 1339-1347. [Google Scholar]

8. Long SS, Surrey DE, Nazarian LV. Sonography of Greater Trochanteric Pain Syndrome and the rarity of primary bursitis. American Journal of Roentgenology. 2013; 201(5): 1083-1086. [Pubmed] [Google Scholar]


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