Caring Medical - Where the world comes for ProlotherapyGreater trochanteric pain syndrome – It is not sports related bursitis?

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C
| Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Greater trochanteric pain syndrome – It is not sports related bursitis?

We have seen many patients in our 26+ years of clinical practice with hip pain. One group that we see frequently are athletes who come in with a diagnosis of hip bursitis or Greater trochanteric pain syndrome.

The reason we see these patients is because traditional care has not worked for them.

A patient sitting in our examination room will usually share a story that goes like this:

  • Once I got the diagnosis of Greater trochanteric pain syndrome and inflammation/bursitis, I got a cortisone shot immediately. The cortisone helped me get  through the physical therapy I needed to return to play. I got a second injection just before the season a few months later. How did my hip feel? It felt great, it had not felt this good in a long time. I thought I was cured. During the course of the year the pain returned and it was much worse. I knew I was paying the price for short-term results. I am still doing PT but I do not want cortisone again, I need a better way other than long periods of rest which are not helpful. 

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. They help a little, they hurt sometimes.

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, and yet here you are. Looking for answers.

What we hope you find on this page is a possible explanation and solution to your hip pain problem.

The research, what may help and what not help you. How much of my problem is really bursitis?

One of the first questions we want to explore is should everything point to bursitis? You may be wondering yourself, just how much of my problem is bursitis?

In a commentary on a study in the Journal of Orthopaedic & Sports Physical Therapy (1) 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.

  • 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 present.

People with hip inflammation and no hip inflammation are having the same problems. A deeper cause of your hip problems need to be explored.

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

  • Patients do get 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.
  • Patients DID NOT get benefit from cortisone.
    • The cortisone did not work because the pain issue was not inflammation but something else.

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

You have damage, repairable damage. 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.

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.

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.”

An 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 considered “normal hip pathology,” so there were many problems causing the patients discomfort.

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

In the first study wwe 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. 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 to heal the damage.

More on Dry Needling vs Cortisone

In the study in  the Journal of Orthopaedic & Sports Physical Therapy, (3) 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.

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.

Researchers writing in the medical journal Current sports medicine reports (4) 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.

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.

Prolotherapy and Platelet Rich Plasma Injections. Are they your answer?

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 the 26+ 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.

In the hip, we use PRP with Prolotherapy

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 goes away.

Understanding Prolotherapy treatments 

In the Journal of Prolotherapy, our friend and collegue 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 the 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. At 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 of 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.

Do you have a question about hip replacement surgery or need help?
Get help and Information from our Caring Medical staff

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 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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