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.
- Patients do receive a short-term benefit from cortisone injections that get rid of inflammation. Often the pain returns.
- The cortisone addressed the inflammation and did not address the true problem of what caused the inflammation. This could be an underlying problem of hip instability. Your hip is weak.
- Patients DID NOT get benefit from cortisone.
- The cortisone did not work because the pain issue was not inflammation but something else. This could be an underlying problem of hip instability.
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.
- It is destructive abnormal joint motion (your hip wobbling worse) that is the cause or the effect of a myriad of conditions that led to chronic hip pain, including trochanteric tendonitis 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.
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.
- The objective of this study was to perform the first randomized double-blind placebo-controlled trial to investigate the efficacy of local glucocorticoid injection in the management of greater trochanteric pain syndrome.
An average study patient profile:
- Lateral hip pain that has lasted for more than one month
- Pain score greater than 4 out of 10.
- Pain on palpation of the greater trochanter.
The study participants were divided into two groups:
- Half received local anesthetic and glucocorticoid (intervention) or injection with normal saline solution (placebo).
- The primary outcome of interest was the difference in pain intensity at 4 weeks post-injection between the 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.
- 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.
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.
- 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.
- Cortisone injections for greater trochanteric pain syndrome did not provide greater pain relief or reduction in functional limitations than dry needling.
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)
- Ultrasound assists in the determination of the pathology underlying greater trochanteric pain syndrome; however, there exists no consensus regarding the Ultrasound criteria used to define these pathologies. (In other words, different doctors may refer to the same suspected cause of the same hip pain by different names).
- To prove this point they referred to medical research. Here is what they found:
- “Trochanteric bursitis” was defined in 10 studies as the pain source.
- “Tendinopathy” was defined in 4 studies as the pain source
- “Tendinosis” was defined in 7 studies as the pain source
- “Tendon tears” were defined in 8 studies, 6 of which distinguished between “partial- and full-thickness tears.”
- “Tendon pathology” was most frequent in 5 studies
- and “bursitis in 2 studies”
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:
- 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 that 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.
- It is important to address hip rotator cuff tendinopathy and pelvic core instability.
- 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.
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:
- “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. (8)
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.”(9)
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. (10)
Researchers from the 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.”(11)
Continuing your research on treatments on our site:
The following pages offer treatment options as offered her at Caring Medical.
- Gluteus Medius Tendinopathy Injections.
- Greater trochanter pain syndrome in patients with suspected femoroacetabular impingement syndrome.
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.
- Platelet Rich Plasma Therapy draws out your own blood into a vial. Your blood is then “spun,” in a centrifuge to isolate out the components that heal injuries. These would be the anti-inflammatory and growth factors found in the blood platelets. This “Platelet Rich,” solution is then reintroduced, via injection, into the areas causing pain and weakness.
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:
- A total of 5 PRP and 5 surgery studies were examined. There were 94 patients in the PRP studies and 185 patients in the surgical studies.
- The average follow-up time was shorter for the PRP studies (range, 2-26 months) than with surgery (range, 12-70 months). (Our note: typical of the longer surgical recovery times).
- The Methodological Index for Non-randomized Studies scores (this is a scoring system developed because surgery cannot easily be measured vs. controls,) for the PRP and surgery groups were 11.25 and 11.4, respectively. (About the same outcomes)
- The conclusion of this research: “Both PRP and surgical intervention for the treatment of recalcitrant greater trochanteric pain syndrome showed statistically and clinically significant improvements. . . . Although not covered by most medical insurance companies, PRP injections for recalcitrant greater trochanteric pain syndrome provides an effective and safe alternative after failed physical therapy.”
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?
- For pain scores at one to three months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both one to three months and six to twelve months.
- Conclusion: “Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.”
In January 2020, a study from Greece published in the medical journal Cureus, (14) compared PRP injections to cortisone injections.
- In this paper, 24 patients with greater trochanteric pain syndrome were divided into two groups – Group A and Group B.
- In Group A, patients received an ultrasound-guided PRP injection treatment
- In Group B patients received ultrasound-guided cortisone injections
- Both the PRP and cortisone groups showed improved pain and function scores, however, the PRP group had a statistically significant decrease in pain and increase in functionality at the last follow-up (24 weeks post-injection). No complications were reported. The researchers summarized their findings as: “patients with greater trochanteric pain syndrome present better and longer-lasting clinical results when treated with ultrasound-guided PRP injections compared to those with cortisone.”
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
- This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
- This patient has a suspected labral tear and ligament injury.
- The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
- The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
- From the front of the hip (1:05), we can treat the pubofemoral ligament and the iliofemoral ligaments
- From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles you’re obviously going to get you to know some of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
- Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
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
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated October 5, 2021