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.
11 years later you still have greater trochanteric hip pain.
How much of my problem is really bursitis? How much of this problem is really inflammation?
People with hip inflammation or bursitis and people with no hip inflammation or bursitis are having the same symptoms and problems.
Isolated trochanteric bursitis as the cause of refractory lateral hip pain appears to be rare.
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.
“It was hard to say what was the true pain cause because there were so many problems with the patient’s hips.”
Greater trochanteric pain syndrome – treatment debates – Does cortisone really wear off?
Saline and dry needling are just as effective as cortisone.
Greater trochanteric pain syndrome diagnosis and evaluation can be tricky – this may be why you are not getting the help you need.
The challenges of identifying Greater trochanteric pain syndrome or another diagnosis to get to proper treatment.
Is it low back pain or Greater trochanteric pain syndrome?
Why do clinicians keep looking for bursitis when bursitis is not the problem?
Extracorporeal shock wave therapy and exercise for Greater trochanteric pain syndrome.
Are Platelet Rich Plasma Injections effective treatments for Greater trochanteric pain syndrome?
Surgery or PRP treatments for Greater trochanteric pain syndrome?
Corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs.
Is the problem of Greater trochanteric pain syndrome a problem of the ball of the hip falling out of the socket?

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.

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:

Rest and immobilization. Staying off your feet
Ice to reduce swelling and act as pain relief.
Over-the-counter pain relief medications.
Anti-inflammatory treatments, oral and injectables.

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.

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.

“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 MRIs of 120 patients with lateral hip pain (94% women, average age 54 years) were evaluated by two raters for trochanter-related pathologies, including hip abductor tendon pathology and bursitis.

Results:

Two (2%) patients were diagnosed with greater trochanteric bursitis with no relevant hip abductor tendon pathology
Thirty (25%) patients had elements of inflammation (high-intensity MRI signals) in the greater trochanteric bursa with relevant hip abductor tendon pathology.
Five (4%) patients had relevant hip abductor tendon pathology with bursitis in the sub-gluteus minimus bursa with no bursitis in the greater trochanteric bursa.
The remaining 83 (69%) patients had no sign of trochanter-related bursitis.

Conclusion:

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.

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, 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. (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?

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.

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 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.

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, (9) 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 injections 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.

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)

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 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:

Disorders causing lateral hip pain are encountered frequently by physicians.
Evaluating these problems can be challenging because of the myriad of potential causes, and 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.
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.

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:

“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.”(15)

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. (16)

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.”(17)

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

Greater trochanter pain syndrome in patients with suspected femoroacetabular impingement syndrome.

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.

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 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:

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 (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?

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, (22) 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 (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.

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

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 to know some of the smaller muscles too including the Obturator, and 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?

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

References
1 Pianka MA, Serino J, DeFroda SF, Bodendorfer BM. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE Open Medicine. 2021 Jun;9:20503121211022582. [Google Scholar]
2 Bicket L, Cooke J, Knott I, Fearon A. The natural history of greater trochanteric pain syndrome: an 11-year follow-up study. BMC musculoskeletal disorders. 2021 Dec;22(1):1-0. [Google Scholar]
3 Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):910-22. [Google Scholar]
4 Hip Pain: Dry Needling Versus Cortisone Injections. J Orthop Sports Phys Ther 2017;47(4):240. [Google Scholar]
5 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]
6 Lange J, Tvedesøe C, Lund B, Bohn MB. Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain. Danish medical journal. 2022 Jun 15;69(7). [Google Scholar]
7 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]
8 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]
9 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]
10 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]
11 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]
12 Disantis AE, Martin RL. Classification Based Treatment of Greater Trochanteric Pain Syndrome (GTPS) with Integration of the Movement System. International Journal of Sports Physical Therapy. 2022;17(3):508. [Google Scholar]
13 LaPorte C, Vasaris M, Gossett L, Boykin R, Menge T. Gluteus medius tears of the hip: a comprehensive approach. The Physician and Sportsmedicine. 2019 Jan 2;47(1):15-20. [Google Scholar]
14.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]
15. 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]
16. 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]
17. 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]
18 Shi LJ, Li TQ, Xu X, Wang PX, Li ZZ, Gao FQ, Sun W. Focused extracorporeal shock wave therapy with centrifugal exercise for the treatment of greater trochanteric pain syndrome. Zhongguo gu Shang= China Journal of Orthopaedics and Traumatology. 2021 Dec 1;34(12):1158-64. [Google Scholar]
19 Notarnicola A, Ladisa I, Lanzilotta P, Bizzoca D, Covelli I, Bianchi FP, Maccagnano G, Farì G, Moretti B. Shock Waves and Therapeutic Exercise in Greater Trochanteric Pain Syndrome: A Prospective Randomized Clinical Trial with Cross-Over. Journal of Personalized Medicine. 2023 Jun 10;13(6):976.
20 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]
21 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). [Google Scholar]
22 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]
23 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 July 18, 2023

6538