Greater trochanteric pain syndrome and bursitis treatment

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

Greater trochanteric pain syndrome is a term used to encompass pain at the greater trochanter (lateral hip) related to the gluteal tendons or the trochanteric bursa. Often, this involves tears or tendinopathy (degeneration) of the gluteal tendons (gluteus minimus or gluteus medius) or inflammation of the bursa. As the gluteal muscles are considered active secondary stabilizers of the hip, it makes sense that these tendons can become injured because of hip instability.

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 29+ 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.

Article summary

An Introduction to Greater trochanteric pain syndrome

Let’s go to a June 2021 paper (1) from doctors at Georgetown University and the Department of Orthopaedic Surgery at Rush University Medical Center for a brief introduction to the diagnosis and treatments:

“Greater trochanteric pain syndrome encompasses a spectrum of pathologies (diagnosis), including trochanteric bursitis, external coxa saltans (snapping hip syndrome), and abductor tendinopathy and tears. Given this heterogeneity (diversity and controversy in diagnosis) as well as the high rate of comorbid conditions, diagnosis can be challenging.

Proper evaluation relies primarily on careful clinical examination. Traditional nonoperative management with activity modification, physical therapy, NSAIDs, and corticosteroid injection remains the mainstay of treatment. While limited data on ESWT (Extracorporeal shock wave therapy) and PRP (Platelet Rich Plasma injections) appear promising, large, randomized trials are required to better understand their role in managing Greater trochanteric pain syndrome. In patients with chronic symptoms (that do not respond)  to conservative therapy, both open and endoscopic operative techniques have demonstrated excellent outcomes.”

We will discuss these treatment options below.

Greater trochanteric pain syndrome and bursitis treatment

11 years later, after many treatment options, why do people still have greater trochanteric hip pain?

A December 2021 paper published in the journal BioMed Central Musculoskeletal Disorders (2) demonstrated that many people with Greater trochanteric pain syndrome continue to experience hip pain (including due to Greater trochanteric pain syndrome) and appear to have a higher chance of developing hip osteoarthritis after 11-years than a comparison group. . . Clinicians involved in treating people with Greater trochanteric pain syndrome should be aware that over time their management strategies may need to change.

The many treatment strategies that may be called in for change are:

If you are overweight your doctor will recommend weight loss. If you are unresponsive to all these problems physical therapy may be prescribed. Eventually, cortisone will be recommended as you are seen to have an inflammation that is not responding.

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.

Those suspected with greater trochanteric pain syndrome will complain of lateral hip pain with activities like walking or going up and down stairs, as well as when sitting or standing. The inability to lie on the affected side is also a common complaint. A study published in The Journal of Orthopaedic and Sports Physical Therapy (3) suggested gluteal tendinopathy is a primary source of lateral hip pain and can severely affect one’s ability to remain active or simply live without pain. Women over the age of 40 seem to be the most likely to be affected with women with this condition outnumbering men 2.4 or 4 to 1. The shape of the female pelvis is thought to be a risk factor and others have found that the gluteus medius tendon in females has a smaller insertion on the greater trochanter, thus making it less likely to distribute force, resulting in more concentrated forces on a smaller area, regardless of female body mass. This could make the tendon more susceptible to injury and overuse, especially in the presence of hip instability.

Therefore, the first question 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 (4), 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.

“Isolated trochanteric bursitis as the cause of refractory lateral hip pain appears to be rare”

A June 2022 paper (5) from university and hospital researchers in Denmark questioned whether or not patients suffered from bursitis or hip tendinopathy. In fact, they suggest that there is a much lower amount of trochanteric bursitis in patients with non-responsive lateral hip pain, the bursitis may not be the problem. Here is what the research team said:

“Bursitis at the greater trochanter has historically been identified as a major pain generator in patients with lateral hip pain. We believe that hip abductor tendon pathology plays an important and overlooked role in lateral hip pain.”

Here is how they sought to confirm their hypothesis:



The researchers wrote: “Isolated trochanteric bursitis as the cause of refractory lateral hip pain appears to be rare. We believe that the presence of hip abductor tendon pathology in lateral hip pain has been severely underestimated and a shift in focus towards treatment of these structures is necessary.”

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.

In the image below Femoroacetabular impingement and inflamed hip bursa. Problems of the hip are typically not isolated problems.

Femoroacetabular impingement of hip and hip bursitis

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. (6) 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 caused 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, and 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. (7) 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?

Greater trochanteric pain syndrome - cortisone injections

Let’s look at a March 2019 study published in the journal Clinical Rheumatology (8) 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 as cortisone

In the first study, we discussed in this article, 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.

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, (9) 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. (10)

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

Researchers writing in the medical journal Current Sports Medicine Reports (11) gave a good summary of the challenges of identifying and treating Greater trochanteric pain syndrome. Here is what they wrote:

Is it low back pain or Greater trochanteric pain syndrome?

An April 2022 paper from Duquesne University published in the International Journal of Sports Physical Therapy (12) discussed the problems of confusing greater trochanteric pain syndrome and low back pain and how missing the diagnosis would prevent treatment interventions from working. Here is what the paper suggested: “Greater trochanteric pain syndrome presents clinicians with a similar diagnostic challenge as non-specific low back pain with special tests being unable to identify the specific pathoanatomical structure involved and do little to guide the clinician in the prescription of treatment interventions. Like the low back, the development of greater trochanteric pain syndrome has been linked to faulty mechanics during functional activities, mainly the loss of pelvic control in the frontal place secondary to hip abductor weakness or pain with hip abductor activation.” In other words, low back pain and greater trochanteric pain syndrome share the same origins.

In some cases, lateral hip pain and gluteal tendon injury are also associated with low back pain. Specifically, injury to the sacroiliac joints may increase stress on the hip in relation to lateral instability of the pelvis. Thus, any treatment at just the lateral hip will not be successful long-term unless the sacroiliac joints are also addressed. In these cases, ligaments of the sacroiliac joint, as well as the ligaments and tendons of the hip, likely require Prolotherapy (with or without PRP) to restore joint stability and eliminate pain.

Please see these related articles:

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.

In a 2019 study in The Physician and Sportsmedicine (13) from Michigan State University College of Human Medicine researchers reviewed the problem of Greater trochanteric pain syndrome and the gluteus medius tendinopathy connection.

“Greater trochanteric pain syndrome (GTPS) is a common clinical condition that can affect a wide range of patients. Historically, the condition has been associated with trochanteric bursitis. More recently, however, a growing body of literature has demonstrated gluteus medius tendinopathy and tearing is present in many cases of Greater trochanteric pain syndrome. Pathology of the gluteus medius can result in significant hip pain, loss of motion, and decreased function. Affected patients characteristically have symptoms including lateral hip pain and a Trendelenburg gait, which may be refractory to conservative management such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and injections. In these cases, both open and arthroscopic repair techniques have been described.”

This is not a new idea, in 2007 in the radiologist journal European Radiology, (14) researchers noted: “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.

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 here at Caring Medical.

Extracorporeal shock wave therapy and exercise for Greater trochanteric pain syndrome.

Extracorporeal shock wave therapy is the delivery of electric or shock waves into damaged tissue with the hopes of stimulating repair. In a December 2021 paper, (18) doctors noted: “In the treatment of greater trochanteric pain syndrome, focused extracorporeal shock wave therapy with centrifugal exercise could significantly relieve symptoms of lateral hip pain, improve functional recovery of the hip joint with good safety. This treatment strategy is worthy of application and promotion in clinical practice.”

Doctors in Italy compared the effectiveness of shock wave therapy versus therapeutic exercise, including the possibility of combining both therapies, in patients who did not respond to the first treatment. Writing in June 2023 in the Journal of personalized medicine (19), the Italian team found: “eccentric therapeutic exercise and ESWT treatments performed either alone or in combination are effective in the therapeutic management of GTPS, both in terms of pain reduction and functional recovery, in all timings analyzed (up to six months post-treatment). The combination is successful in the recovery of patients unresponsive to a single treatment and is, therefore, to be considered a valid treatment strategy.”

Are Platelet Rich Plasma Injections effective treatments for Greater trochanteric pain syndrome?

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 30-plus years of experience we have in offering patients treatments for their chronic hip and sports-related injury problems.

Surgery or PRP treatments for Greater trochanteric pain syndrome?

A December 2019 study in the medical journal Arthroscopy (20) 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 (21) 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, 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, (22) 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 (23) 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.

Prolotherapy Hip Injection Sites

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 Triamcinolone (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 anymore 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?

Knowing that most cases involve injury and degeneration to the gluteal tendons, doesn’t it make more sense to work on healing the soft tissue as opposed to undergoing cortisone injections that make it worse or unnecessary surgery? It is not uncommon for our office to see patients that have undergone multiple steroid injections for lateral hip pain or those that have previously had their bursa removed but are still seeking out pain relief after these treatments have failed. Most people want to be fully functioning without pain and are not satisfied with decreasing their pain slightly in the long term.

We hope you found this article informative and that 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

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This article was updated July 18, 2023


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