Greater Trochanteric Pain Syndrome (GTPS) Treatment

For many patients, GTPS often causes symptoms that fluctuate over time which can be frustrating to patients who may only experience temporary relief from previous partial treatment. This is why a structure and consistent non-surgical treatment can significantly improve symptoms in most patients over a 6 to 12 week time period. A well-structured conservative program focuses first on reducing inflammation, then restoring flexibility, and finally rebuilding strength around the hip. A solid non-surgical program includes:

Activity modification

Patients should avoid prolonged side-lying on hard surfaces and overuse. Practically, simply placing a pillow between the legs for side sleepers often significantly improves lateral hip pain.

Flexibility

Employing a daily stretching regimen throughout the day and not just at one time during the day can keep the IT band limber and promote more coordinated hip movement.

Anti-inflammatory medications

Calming the inflammation down first and then undergoing structured therapy is a crucial component of overcoming GTPs. The use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and topical anti-inflammatories is a first-line treatment for many patients who can tolerate these measures.

Injections

1. If pain and inflammation exceed that which can be controlled by oral or topical anti-inflammatories, a cortisone injection into the trochanteric bursa can provide significant acute relief
2. However, if there is actual inflammation of the gluteus tendons, an ultrasound guided injection of platelet-rich plasma (PRP) into the tendon can be considered for chronic tendinopathy or low grade partial tears.
3. Occasionally, repeated injections into the trochanteric bursa can be performed for recurrent symptoms. However, before repeating injections, there should be significant thought taken into whether appropriate therapy has been done for the hip. And if so, then suspicion should be high for a developing partial or full thickness tear in the underlying gluteus minimus or medius tendon. As a rule of thumb, more than two injections into the trochanteric bursa should trigger an MRI to truly scrutinize the tendon quality present.

Physical therapy

Regardless of how the inflammation is controlled, this should always be done in conjunction with thoughtful physical therapy. The modalities performed with physical therapy include

1. Stretching the IT band
2. Improving core stabilization to offload work the abductor muscles need to do to keep the pelvis stable
3. Strengthening of the hip abductors but only once the inflammation has calmed down sufficiently

Extracorporeal shockwave therapy (ESWT)

In chronic cases of GTPS that are refractory to the aforementioned treatments, ESWT is emerging as a useful non-invasive treatment modality. ESWT works to stimulate tissue regeneration, reduce chronic inflammation, break down tissue adhesions, and decrease pain. Recent studies in the literature show that ESWT has the ability to promote remodeling of collagen and bring healthy blood supply to the greater trochanteric area which helps in restoring tendon integrity in chronic GTPS.

Surgery is rarely needed for GTPS when patients have undergone a thoughtful and well-done conservative treatment protocol. However, there are a small minority of patients who continue to have persistent symptoms that have lasted more than 6 months of proper conservative care. In these rare situations, surgical options are targeted at alleviating the inflammation affecting each of the three main structures affected in GTPS:

1. Lengthening of the tight IT band
2. Open or minimally invasive endoscopic bursectomy with removal of the trochanteric bursa
3. If there is an associated partial or complete tendon tear, then repair of the gluteus minimus/medius tendon back down to the bone should be performed

In properly indicated patients who are motivated to undergo structured rehabilitation after surgery, most patients can expect excellent outcomes. The rehabilitation after surgery involves several weeks of protected weight-bearing, progression through a structured physical therapy program, and a gradual return to activity.

Preventing recurrence of GTPS symptoms requires a combination of various modalities to reverse the processes that caused irritation and inflammation of these lateral hip structures in the first place. The goal of prevention is long-term protection of the gluteal tendons and restoring balanced hip mechanics. Strategies to achieve this include:

1. Home exercise program: The same exercises that patients learned in therapy should be incorporated as part of their home exercise program. This includes strengthening of the hip abductors, strengthening of the core, and daily stretching of the IT band to keep it limber and prevent it from pinching the bursa
2. Working towards a healthy weight helps to limit the load placed not only on the abductor tendons but also decreases the forces on the hip, knee, and ankle joints.
3. Having the proper footwear to help offload the lateral hip structures is a simple yet effective lifestyle modification to prevent recurrence of GTPS. Patients often ask what type of shoewear should be utilized. Overall, shoes should have an adequate arch support with a good amount of cushioning in the heel. This will prevent the pelvis from dropping during gait that would excessively strain the gluteal tendons. As a rule of thumb, replacing shoes about every 300 to 500 miles or 6 to 9 months of daily use will help prevent the lateral hip structures from absorbing too much of the brunt of daily walking/running.