What is the commonest cause of pain on the side of the hip ?
Greeter trochanteric pain syndrome (GTPS) or trochanteric bursitis is a common reason for pain at the side of hip especially in females between the age of 40-60 years. It affects approximately 1.8 per 1000 patients annually and is a result of degenerative changes affecting the tendons of the buttock muscles and bursa.
The side of the hip has a large bony bump called the greater trochanter. A thick band of tissue (called iliotibial band or ITB) and number of tendon pass over this bony bump. Also present in this region are numerous bursae which are fluid filled sacs to prevent friction between these structures as we move our leg. There could be as many as 20 bursae in this region of which 3 are consistently present in most individuals. GTPS diagnosis includes a range of conditions with similar symptoms such as tears or degenerative change of the of gluteal muscles and inflammation of the bursae in this region.
What causes this condition and who all are at risk?
The likely cause of GTPS is repetitive friction and microtrauma between the bony bump on the outer side of hip (greater trochanter) and the band of tissue (ITB), muscles passing over it. Abnormal hip biomechanics are believed to contribute to this condition.
There are several factors that increase one’s chances ofdeveloping this condition. These include
- Age between the age of 40–60 years. It may also occur in extremely active younger patients who do regular exercises
- Gender – 4 times more common in women
- Being overweight
- Leg length discrepancies
- Fall/ injury
- Repetitive activity, mechanical overload, training errors or high-intensity training
- Sedentary lifestyle
- Gait changes& incorrect posture
- Post hip replacement surgery
- Other conditions such as rheumatoid arthritis&gout
- Hip arthritis or low back pain is seen in approximately two thirds of individuals with GTPS
What are the symptoms of trochanteric bursitis/ GTPS?
Common symptoms include
- Aching or burning pain on the side of the hip with increased pain on pressing the area. Pain can radiate towards the outer thigh up to the knee or buttock
- Pain is worse when lying on the affected site
- Pain worse with high impact physical activities, cycling, walking, climbing stairs, getting up from a low chair or getting out of a car
- As the problem progresses, it can produce a limp when walking
- Eventually, the pain may become constant and may also be present at rest
The condition can be differentiated from hip arthritis as the ability to put shoes and socks is not affectedcontrary to hip arthritis where such tasks become difficult to perform.
How is this condition diagnosed?
GTPS can be diagnosedclinically on the basis of symptoms and examination findings. Local tenderness is a common finding. Difficulty in standing on one leg (on the affected side) is commonly observed. Pain on trying to rotate the hip outwards against resistance is also a common finding.
Other tests such asultrasound scan or MRImay also be requested forfurther evaluation.
- Ultrasound scans – these may demonstrate thickening ,calcification or tears of the tendons, fluid-filled and thickened bursa
- MRI is very effective to recognize partial and full thickness tears, calcification and muscle atrophy . It may demonstrate oedema which is one of the earliest signs of tendon problems.
What are the pain relief options in GTPS?
Over 90% of cases of GTPS resolve with conservative measures. Main goals of treatment include managing load, reducing compressive forces across greater trochanter and strengthening gluteal muscles. Non-surgical treatment options for this condition include
- Relative rest& activity modification – This is especially useful in younger patients as in this age group GTPS is mostly because of overuse. Activities that worsen symptoms such as sleeping on the affected side should be avoided. Using a pillow between legs when sleeping in helpful
- During initial stages ice compression(wrapped in a towel) for 10-15 minutes several times a day can help
- Supportive devices such as crutches or a cane in opposite hand can help
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Physical therapy including stretching and strengthening exercises, shock wave therapy (SWT) is sometimes used in the treatment
- Losing weight can help in those who are overweight
INJECTIONS
- Ultrasound guided local corticosteroid injection is commonly used in the management of this condition. This can be easily performed as an OPD procedure and can provide permeant or lasting relief. These injections should be viewed as an opportunity to engage with an effective rehabilitation/ physical therapy programme. Some individuals may require a repeat injection.
- Regenerative therapy such as PRP may be considered in specific circumstances especially prior to consideration of surgical intervention, although studies supporting their use are limited.
- Surgery in considered in specific situations where the above measures fail to provide relief. Options include simple longitudinal release or lengthening of the overlying band of tissue(ITB), excision of bursa, open or arthroscopic gluteus medius tendon repair and reattachment.
