The evaluation and management of patients with lateral hip pain may be difficult and have a lengthy differential diagnosis (Kagan, 1999; Lachiewicz, 2011). Greater trochanteric pain syndrome is a term used to denote chronic lateral hip pain and encompasses several painful soft tissue diagnoses including coxa saltans (snapping hip), trochanteric bursitis, and gluteus minimus and gluteus medius tendon tears (Strauss, Nho, & Kelly, 2009). It is a condition that peaks in the fourth-sixth decades and is seen primarily in women by a 4:1 margin (Bird, Oakley, Shnier, & Kirkham, 2001). It is estimated to affect between 10% and 25% of the population in the industrialized world (Williams & Cohen, 2009).

The greater trochanter is part of the proximal femur and arises from the junction of the femoral neck and femoral shaft (Strauss et al., 2009). Inserted on the greater trochanter are the gluteus minimus and gluteus medius tendons that attach to the gluteus minimus and gluteus medius muscles, respectively. These muscles function as the hip abductors. Also present is the peritrochanteric space that is also known as the lateral space of the hip. In this space are several bursa that serve to cushion the gluteus tendons and lateral hip muscles (Strauss et al., 2009; Voos, Ranawat, & Kelly, 2009) (see Figures 1 and 2). Differentiating bursitis, tendon injuries, and other pathologic conditions is difficult because of the relative close proximity of these structures in the lateral hip. A thorough physical examination and history are imperative to aid in diagnosis.

Figure 1. Bony anatomy.

Figure 2. Surface anatomy. ASIS (anterior superior iliac spine).

Case 1

J.P. is a 36-year-old woman who is an avid marathoner. She presented to her physician's office with complaints of a snapping sound in her right hip when she was running. Initially asymptomatic, she now reported right hip pain with hip flexion and extension during her runs. With her knee in extension, a painful, visible, and audible snapping was present during flexion and extension of the hip. She was diagnosed with coxa saltans. Instructions were given to begin anti-inflammatory medication, rest from activities that elicit pain, apply ice to the right hip, and begin stretching exercises focusing on iliotibial band (ITB) lengthening. After a period of 8 weeks, J.P. was able to again begin running without pain.

Coxa saltans is characterized by an audible snapping of the hip during activities requiring repetitive motion of the hip. It is often seen in athletes and other vigorous exercisers. Typically pain and a snapping sound are elicited in the lateral hip during flexion, extension, or abduction of the hip as the ITB slips back and forth over the greater trochanter (LaBan, Weir, & Taylor, 2004). Diagnosis is often made with the clinical examination, but dynamic ultrasound during hip flexion and extension may demonstrate the snapping of the ITB as it glides over the greater trochanter. Treatment involves a period of rest, anti-inflammatory medication, stretching exercises, and physical therapy. Rarely is surgical intervention necessary (Strauss et al., 2009; see Figure 3).

Figure 3. Superficial dissection.

Case 2

A.G., a 55-year-old woman, presented to her nurse practitioner with complaints of an insidious onset of right lateral hip pain, which was aggravated by lying on her affected side. She otherwise characterized the pain as annoying but not prohibitive in performing her normal daily activities. She denied any precipitating trauma. A.G. was moderately active and did participate in regular daily exercise classes. Upon physical examination, she was tender over her greater trochanter but otherwise denied pain with passive or active range of motion. However, resisted hip abduction did reproduce her symptoms. Hip x-ray films showed a normal hip joint and no irregularities of the greater trochanter. A.G. was diagnosed with right greater trochanteric bursitis and was given a cortisone injection as well as a prescription for physical therapy and an anti-inflammatory medication. A.G.'s hip pain resolved within 1 month, and no further intervention was necessary.

Trochanteric bursitis is typically an overuse injury commonly seen in activities involving running, repetitive contact sports, or altered gait patterns. Its occurrence is more prominent in women older than 50 years. Pain results from inflammation of the bursa that lies superficial to the greater trochanter. The bursa is synovial tissue that forms a fluid-filled space and reduces friction of muscles and tendons over a bony prominence. Symptoms include a chronic, intermittent pain over the lateral hip. It is often exaggerated by lying on the affected side, prolonged standing, or sitting while crossing the affected leg (Strauss et al., 2009). Physical examination usually demonstrates tenderness over the greater trochanter and pain with resisted hip abduction and external rotation. Imaging studies of the hip may assist in ruling out other pathology. Treatment is focused on activity modification, ice, anti-inflammatory medication, and physical therapy. Bursal injections of steroids and local anesthetic may be utilized if other measures are unsuccessful (Strauss et al., 2009; see Figures 4a and Figures 4b).

Figure 4. (A), Bursa dissection. (B), Attempts to reproduce the bursal space by filling the bursa with air.

Case 3

T.K. is an active 58-year-old woman with a 7-year history of right-sided lateral hip pain. In the last year, her pain required the cessation of her daily running, an activity that she had participated in for 30 years. She was initially diagnosed with greater trochanteric bursitis and failed conservative treatment of physical therapy, nonsteroidal anti-inflammatory drugs, and steroid injection. She presented to her orthopaedic physician with continued right hip pain, exacerbated by prolonged sitting and climbing stairs. She was unable to sleep on her affected side. Physical examination elicited pain with palpation over the greater trochanter, radiating into the proximal lateral thigh. There was no groin pain or pain with active or passive range of motion of the hip. She had pain with 30-second single leg stance and walked with a Trendelenburg gait. She denied back pain or radicular symptoms. Muscle testing of the hip was normal with the exception of 4/5 abductor strength. Radiologic workup demonstrated normal hip x-rays, but magnetic resonance imaging identified partial tears of the gluteus medius and gluteus minimus tendons.

With better knowledge of anatomy and pathology, and advances in magnetic resonance imaging technology, practitioners have also improved their ability to identify tears of the gluteus medius and gluteus minimus tendons. In the past, these injuries were often under-recognized (El-Husseiny, Patel, Rayan, & Haddad, 2011). As these tendon injuries have become better understood, their function has been compared to the supraspinatus and infraspinatus tendons of the shoulder rotator cuff (RTC). Thus, the term hip RTC has been used when discussing the gluteus minimus and gluteus medius tendons. As the shoulder tendons aid in stabilizing the shoulder and initiating and assisting with abduction and rotation, similarly the gluteus minimus and medius tendons aid in hip stability and assistance with hip abduction and pelvic rotation (Domb, Nasser, & Botser, 2010). Likewise, the progression of gluteal medius and minimus tears is often analogous to the progression of RTC tears, that is, tendinitis, tendinosis, and eventual tendon tearing (Strauss et al., 2009; see Figures 5-8).

Figure 5. Deep dissection medius and minimus.

Figure 6. Physical examination (flexion and external rotation).

Figure 7. Physical examination (single leg stance).

Figure 8. Physical examination (resisted hip abduction).

As with T.K., usual presentation of patients with hip abductor tears involves lateral hip pain with palpation over the greater trochanter. Pain and weakness with resisted hip abduction, pain with hip flexion with external rotation, and pain with single-leg stance for 30 seconds or less are usually present (Lequesne, Mathieu, Vuillemin-Bodaghi, Bard, & Djian, 2008). The patient may ambulate with a limp and an antalgic gait. Pain is often exaggerated by prolonged sitting, lying on the affected side, stair climbing, rising from a seated position, or other strenuous activity (Bewyer & Chen, 2005; Bird et al., 2001). Typically the patient denies trauma and relates to the examiner an insidious onset of symptoms. Often failed treatment has previously been initiated for the presumptive diagnosis of trochanteric bursitis (Domb et al., 2010). Diagnostic testing with AP pelvis x-rays is initiated to rule out other pathology and may occasionally demonstrate bone spurring off the greater trochanter (Steinert et al., 2010). Ultrasound may be helpful in detecting inflammation consistent with tendinitis/tendinosis and can detect the presence of partial or full-thickness tendon tears (El-Husseiny et al., 2011). Magnetic resonance imaging is also utilized for diagnosis of gluteal tendon tears and is currently the more favored imaging modality (LaBan et al., 2004). Gluteus minimus and gluteus medius tendon tears frequently fail conservative treatment, and until recently surgical options rarely have been recommended (Bird et al., 2001; Domb et al., 2010).

Until recently, operative repair of tendon tears was done only by an open approach. This surgical approach involves opening the lateral trochanteric region and exposing the tendons through the excised bursa. Partial tendon tears can be repaired with suture. Full-thickness tears can be reattached to the greater trochanter through interosseous drill holes or with suture anchors. Sclerotic bone is excised down to a bleeding bed to promote healing prior to reattachment (El-Husseiny et al., 2011). In recent years, an increased understanding of hip pathology through better magnetic resonance imaging and advances in hip arthroscopy techniques has enabled the utilization of this procedure for treatment of painful lateral hip conditions. All pathologies included in greater trochanteric pain syndrome have been successfully treated using an endoscopic approach (Voos, Rudzki, Shindle, Martin, & Kelly, 2007).

Postoperative rehabilitation for gluteus minimus and medius tears consists of an initial 6-week period of physical therapy, utilizing protected weight bearing of 20 lb or less with crutches or a walker. Active hip abduction must be minimized, but hip flexion and extension are not limited. At 6 weeks, isometric hip abductor strengthening should begin. More aggressive strengthening and increased activity may begin at the 12-week postoperative period. Return to running should be delayed until hip abductor strength is equal (Voos et al., 2009).

References