Greater trochanteric pain syndrome and bursitis treatment

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Greater trochanteric pain syndrome

A patient, usually a runner or athlete, sitting in our examination room will usually share a story that goes something like this:

I guess the cortisone wore off

Once I got the diagnosis of greater trochanteric pain syndrome and inflammation/bursitis, I got a cortisone shot immediately because I needed to get back to training. The cortisone helped me get through the physical therapy and I felt like I was on the road to recovery. I got a second cortisone injection just before the season a few months later. After the second cortisone injection, my hip felt great. I thought the cortisone cured me. During the course of the year, the pain returned and it was much worse. I am still doing PT but the doctors do not want to give me any more cortisone. I guess it “wore off.”  Now I am being told the “only thing” I can do is rest for the next few months. I need a better way and another option than the long periods of rest that are not helpful. I feel like I am wasting time.

Another patient sitting in our office will tell us a little different story.

I am doing a lot of PT, I am not getting anywhere, I did one cortisone treatment. Did not help at all. I was told my muscles are tight and I need to stretch them. This helps a little, but the physical therapy is sometimes painful and sometimes I feel like I am going backward.

The older patient with an injury and numerous diagnosis

I am now retired. I was forced to retire because of numerous injuries, increased pain, and loss of function. My last diagnosis now focuses on trochanteric bursitis and a treatment plan for that. This is despite many other problems. Following a work injury and a sharp pain in my groin and stomach, I was diagnosed with pudendal nerve damage and osteitis pubis (groin pain). Continued pain saw my diagnosis increase to hip trochanteric bursitis. When I had the typical bladder symptoms, overflow incontinence, frequency, urgency, urge incontinence, and retention, the urologist diagnosed me with neurogenic bladder. But because nothing seems to “stick as far as a diagnosis or because I was not responding to treatments, one doctor I am seeing is now suggesting this is all in my head. 

If you are reading this article, you are likely someone who has explored, stretching, ice, resting, cortisone, more frequent anti-inflammatory use, and a myriad of online remedies, for a diagnosis of Greater trochanteric pain syndrome and/or hip bursitis. You may be continuing to look for answers.

We have seen many patients in our 28+ years of clinical practice with hip pain. People we see frequently with hip problems are athletes and those who do physically demanding work. The reason we see these patients is that traditional care has not worked for them. What we hope you find on this page is a possible explanation and solution to your hip pain problem.

How much of my problem is really bursitis? How much of this problem is really inflammation? Anti-inflammatories are not working for me. So how can it be a problem of inflammation?

In the illustration below and what we will explain further in this article is that anti-inflammatories may not work for you because the underlying root of the problem is not being addressed. This illustration helps us understand that bursitis or bursal sac inflammation can occur because of spasming of the gluteus medius muscle. The spasms are occurring because the muscle is being overworked in trying to help stabilize the hip. Why is the muscle in spasm? Because of a possible hip labral tear and hip ligament injury damage. Anti-inflammatories while being able to help with inflammation do not repair labrum and ligament damage.

One of the first questions we want to explore with the patient is “should everything really be pointing to bursitis?” You may be wondering yourself, after a long course of anti-inflammatory medications and your situation getting worse, just how much of your problem is bursitis?

In a commentary on a study in the Journal of Orthopaedic & Sports Physical Therapy (1), researchers wondered as well, “how much of this problem is really inflammation?” They wrote:

“The medical community once thought 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. However, researchers now believe that injuries to the muscles and tendons around the hip are the actual cause of this pain and that inflammation is often not involved.” So maybe it is not the bursa, the inflammation, and bursitis as the cause of the hip problem, maybe it is hip instability displayed as hip tendinopathy. Your problem may be one of an unstable hip.

People with hip inflammation or bursitis and people with no hip inflammation or bursitis are having the same symptoms and problems. A deeper meaning of the cause of your hip problem needs to be explored beyond bursitis

Let’s go back to the two example patient statements we started this article with.

Treating hip pain means treating the hip as a whole. Not on a specific, isolated diagnosis. This may answer your questions as to why you are not being helped.

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 soft tissue. Above in the research cited, doctors examined the muscles and tendons. In other research, including our own, we look at the muscles, tendons, and hip ligaments. In yet other research, doctors are looking at the low back. Loose, weakened, damaged hip ligaments, creates hypermobility or destructive abnormal joint motion that leads to inflammation and eventual problems of degenerative hip disease. When the hip is wobbly, the bursa becomes inflamed to help stabilize the hip. When the inflammation is removed via cortisone injection, the stabilizing factors holding the hip in place, swelling and inflammation, are removed. Your hip wobbles worse.

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.

“It was hard to say what was the true pain cause because there were so many problems with the patient’s hips.”

One example is a paper from doctors representing Italy’s leading research hospitals. (2) 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 were considered “normal hip pathology,” so there were many problems causing the patient discomfort.

The great complexity of the problem can be seen in a February 2020 study in the Journal of Physical Therapy Science. (3) Here a Japanese research team made these observations:

Gluteus medius syndrome (pain on the outer side of the hip)  is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis.  . . Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome.”

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


Does cortisone really wear off?

Let’s look at a March 2019 study published in the journal Clinical Rheumatology (4) and what researchers looking at the benefits of cortisone for greater trochanteric pain syndrome observed in their patient outcomes.

An average study patient profile:

The study participants were divided into two groups:

There were no significant differences between the two groups in terms of pain reduction at 1 month. Patients who received the cortisone injection tended to show smaller improvement in pain scores

“Given the lack of long-term improvement and the potential for cortisone-related side effects, this intervention is of limited benefit.”

There were no significant differences in pain scores between groups at 3 and 6 months. In the management of greater trochanteric pain syndrome, local glucocorticoid injections are of no greater efficacy than the injection of normal saline solution. Given the lack of long-term improvement and the potential for cortisone-related side effects, this intervention is of limited benefit.

Saline and dry needling are just as effective

In the first study, we discussed in this article, published in The Journal of Orthopaedic and Sports Physical Therapy(1) doctors explored dry needling (injections where nothing is injected) as an alternative to cortisone injections to reduce pain and improve function in patients.

This again supports the idea that your problems may not be one of inflammation but rather a lack of inflammation. Dry needling is a puncture that causes a small injury. The idea behind dry needling is that this small injury will reboot the immune system (new inflammation) to heal the damage.

Dry Needling vs Cortisone

In a study in the Journal of Orthopaedic & Sports Physical Therapy, (5) doctors documented in their research that dry needling works just as well as cortisone.

In other words, dry needling worked just as well.

Greater trochanteric pain syndrome diagnosis and evaluation can be tricky – this may be why you are not getting the help you need.

In July 2020, researchers at Aalborg University in Denmark commented on the confusion some patients may feel when their doctor talks about greater trochanteric pain syndrome. Their observations on this confusion appeared in the journal Ultrasound in Medicine & Biology. (6)

The challenges of identifying Greater trochanteric pain syndrome or another diagnosis to get to a proper treatment

Researchers writing in the medical journal Current Sports Medicine Reports (7) gave a good summary of the challenges of identifying and treating Greater trochanteric pain syndrome. Here is what they wrote:

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

Supportive of this statement are 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 comes from the European Journal of Radiology:

Researchers from Argentina came to the same conclusion:

Researchers from Australia came to the same conclusion:

Researchers from the United States came to the same conclusion:

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

Are Platelet Rich Plasma Injections effective treatments?

Many people reading this article may have been told about Platelet Rich Plasma therapy (PRP). They may have heard very good things, they may have heard some not good things. The not-good things usually are confined to the “it will not work for you,” suggestion they are given.

We are going to challenge that statement with some independent research and the 27+ years of experience we have in offering patients treatments for their chronic hip and sports-related injury problems.

Surgery or PRP treatments?

A December 2019 study in the medical journal Arthroscopy (12) compared PRP injections versus surgical treatment for recalcitrant greater trochanteric pain syndrome. In this research, investigators examined previously conducted studies to offer accumulated evidence for the benefit of one, the other, both, or neither in the patient base.

Here is the summary of this research:

Corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs

A March 2021 study in the Clinical Journal of Sports Medicine (13) examined a number of proposed nonoperative management strategies for greater trochanteric pain syndrome. Among them are PRP injections.

The comparison of treatments included injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs, and extracorporeal shockwave therapy. The results of this review study comparing these treatments?

In January 2020, a study from Greece published in the medical journal Cureus, (14) compared PRP injections to cortisone injections.

Is the problem of Greater trochanteric pain syndrome a problem of the ball of the hip falling out of the socket?

A November 2020 study in the Orthopaedic Journal of Sports Medicine (15) examined whether or not Greater trochanteric pain syndrome was primarily a problem of tendinosis/tendinopathy of the hip abductors or was this a problem of intrinsic acetabular (the natural socket) bony stability of the hip? Simply, is the ball of the hip falling out of the socket? Here is what the researchers suggested:

“The most important finding of this study was that, within our study population, an increased Tönnis angle predicted the presence of Greater trochanteric pain syndrome. The Tönnis angle is a measure of the weight-bearing surface of the acetabulum (socket), and higher angles indicate decreased coverage of the femoral head (ball). This finding supported our hypothesis that decreased acetabular constraint of the femoral head (the ball is falling out of the socket) within the femoroacetabular articulation may result in increased load on the hip abductors, resulting in the greater trochanteric pain syndrome.”

In the hip, we use PRP with Prolotherapy to treat hip instability

Comprehensive Prolotherapy is an injection technique that uses a simple sugar, dextrose. It is combined with Platelet Rich Plasma Therapy (blood platelets) to address damage and micro-tearing of the ligaments, tendons, and soft tissue in the hip. A series of injections are placed at the tender and weakened areas of the affected structures of the hip. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction.

The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, creating stronger ligaments and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the hip structures function normally rather than subluxing and moving out of place. When the hip functions normally, the pain and swelling go away.

Understanding Prolotherapy treatments 

In the Journal of Prolotherapy, our friend, and colleague Jörn Funck, MD explained why he left orthopedic surgery to become a Prolotherapist. It has a lot to do with poor traditional treatment results for patients with chronic hip pain and “bursitis.”

“…many patients show more pain on the outer side of the hip going down to the knee. The large bone called the greater trochanter, where the gluteal muscles and a bursa (fluid-filled sac) attach is often the origin of the pain and typically such a person is diagnosed with trochanteric bursitis (inflammation of the bursa). Until the year 2000, I typically injected this bursa, like all my teachers before me, with 40 mg Triamcinolon (cortisone) with mostly good, but only temporary relief. So people came back for more injections. In the end, I recall five patients who did not respond any more to this therapy. So I sent them to an orthopedic clinic, where the bursa was surgically removed.

The end result was always negative in my experience. I thought the reason for the pain must be the gluteus medius tendon, one of the big hip muscles, and not the famous bursa. I started treating the tendon of the gluteus medius, which runs to the outer hip point called the greater trochanter, and got good results with Prolotherapy. From 2002 to 2006, I treated 162 patients with these symptoms and was successful in 140 cases. Finally, I was convinced when I cured five patients with gluteus medius problems after hip replacement surgeries. The surgeons could not determine the reason for their remaining pain. But Prolotherapy was able to rid them of their remaining pain.”

What Dr. Funck revealed is what we have seen in our own experiences dating back to when we first opened Caring Medical back in 1993.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your hip pain challenges.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Hip Pain: Dry Needling Versus Cortisone Injections. J Orthop Sports Phys Ther 2017;47(4):240. [Google Scholar]
2 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]
3 Kameda M, Tanimae H, Kihara A, Matsumoto F. Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review. Journal of Physical Therapy Science. 2020;32(2):173-91. [Google Scholar]
4 Nissen MJ, Brulhart L, Faundez A, Finckh A, Courvoisier DS, Genevay S. Glucocorticoid injections for greater trochanteric pain syndrome: a randomized double-blind placebo-controlled (GLUTEAL) trial. Clinical rheumatology. 2019 Mar 14;38(3):647-55. [Google Scholar]
5 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]
6 Hilligsøe M, Rathleff MS, Olesen JL. Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome: A Systematic Review. Ultrasound Med Biol. 2020;46(7):1584-1598. [Google Scholar]
7. 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]
8.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]
9.  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]
10. 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]
11. 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. [Google Scholar]
12. Walker-Santiago R, Wojnowski NM, Lall AC, Maldonado DR, Rabe SM, Domb BG. Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Dec 25. [Google Scholar]
13 Begkas D, Chatzopoulos ST, Touzopoulos P, Balanika A, Pastroudis A. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study. Cureus. 2020 Jan;12(1).
14 Gazendam A, Ekhtiari S, Axelrod D, Gouveia K, Gyemi L, Ayeni O, Bhandari M. Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine. 2021 Mar 12. [Google Scholar]
15 Goldman LA, Land EV, Adsit MH, Balazs CG. Hip Stability May Influence the Development of Greater Trochanteric Pain Syndrome: A Case-Control Study of Consecutive Patients. Orthopaedic Journal of Sports Medicine. 2020 Nov 3;8(11):2325967120958699. [Google Scholar]

This article was updated October 5, 2021

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