Changes

September 2023 — minor update. A typographical error has been corrected. 

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of greater trochanteric pain syndrome.
• Initiate appropriate primary care management.
• Refer to secondary care when appropriate. 

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic. 

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Greater trochanteric pain syndrome is a regional pain syndrome in which chronic intermittent pain is felt around the greater trochanter (the bony prominence on the lateral aspect of the hip) [Reid, 2016].
• Trochanteric bursitis is inflammation of a bursa adjacent to the greater trochanter [Reid, 2016].
  • Bursae are sacs lined with synovial membrane that lie over bony prominences and allow muscles, tendons, and fascia to move freely. Although most people have three bursae around the greater trochanter, up to twenty bursae have been identified.
• The term 'trochanteric bursitis' was previously used for what is now known as 'greater trochanteric pain syndrome'. The inclusive term 'greater trochanteric pain syndrome' is preferred as the trochanteric bursae play a smaller role than was previously thought and inflammation is not always present [Mallow, 2014; Reid, 2016].

What causes it?

• Greater trochanteric pain syndrome is caused by inflammation or physical trauma in muscles (gluteus maximus, medius, minimus, or piriformis), tendons, fascia, or bursae. The most common causes are [Reid, 2016]:
  • Tendinopathy/muscular tear of the gluteus medius.
  • Tendinopathy/muscular tear of the gluteal minimus.
  • Trochanteric bursitis. 
• There is often co-existence of both bursitis and tendinopathy.
• Other causes include:
  • Iliotibial band thickening [Wilson, 2014]. 
  • Infection of the trochanteric bursa (septic bursitis) is a rare cause of greater trochanteric pain syndrome [Makkie, 2010; Novatnack, 2015].

What conditions are associated with greater trochanteric pain syndrome?

• Greater trochanteric pain syndrome frequently occurs together with other conditions [Mallow, 2014; Reid, 2016]:
  • Lumbar spine conditions, such as osteoarthritis, degenerative disc disease, and radiculopathy.
  • Osteoarthritis (OA) of the knee, especially on the affected side.
  • Hip osteoarthritis (on the affected or unaffected side) — approximately two-thirds of people with greater trochanteric pain syndrome have co-existing hip joint osteoarthritis or low back pain.
  • Rheumatoid arthritis.
  • Fibromyalgia.
  • Iliotibial band (ITB) tenderness.
• Leg length discrepancy and obesity may be associated with greater trochanteric pain syndrome [Chowdhury, 2014; Reid, 2016; Plinsinga, 2019].

How common is it?

• Greater trochanteric pain syndrome affects approximately 1.8–5.6 people per 1000 per year [Reid, 2016].
• It is more prevalent in women aged 40–60 years, but it can occur in younger people, especially runners, footballers, and dancers [Chowdhury, 2014; Reid, 2016].

What is the prognosis?

• Greater trochanteric pain syndrome is usually a self-limiting condition and resolves in over 90% of people with conservative treatment such as rest, analgesia, physiotherapy, and corticosteroid injection [Reid, 2016]. 
  • A few cases persist despite treatment and time — these refractory cases may require surgical intervention (for example bursectomy, iliotibial band [ITB] lengthening techniques or gluteal tendon repair).
• A systematic review that summarized the evidence for generic prognostic factors across a range of musculoskeletal conditions, regardless of pain site, identified the following factors associated with poorer outcomes [Artus, 2017]: 
  • High pain intensity.
  • Long pain duration.
  • Widespread pain.
  • High functional disability.
  • Presence of previous pain episodes.
  • Somatization.
  • Movement restriction.
  • Depression/anxiety.
  • Poor coping strategy.

What are the signs and symptoms of greater trochanteric pain syndrome?

• Greater trochanteric pain syndrome typically presents as chronic lateral hip/thigh/buttock pain which can be intermittent or persistent.
  
  • The onset is usually gradual and may progressively worsen over time.
  • Pain may radiate down the lateral aspect of the thigh, but rarely below the knee.
• The pain is typically aggravated by physical activity (for example walking), with pressure on that side of the body (for example when lying down). 
• There is pain on palpation of the greater trochanter. 

How should I assess suspected greater trochanteric pain syndrome?

The diagnosis of greater trochanteric pain syndrome is made on clinical grounds: 

• Ask about:
  • The signs and symptoms, including the location (anterior groin, buttock, lateral hip, lower back, or anterior thigh), radiation, nature and onset of pain, and what aggravates or relieves it (for example standing or sitting for extended periods).
  • Occupational, daily, and sporting activities, and whether this activity has been increased or decreased recently. 
  • History of trauma or previous hip-related conditions. 
  • Medication use, including corticosteroids.
• Conduct a complete neuromusculoskeletal examination.
  • Palpate the greater trochanter — tenderness is typically elicited at a point over the gluteus medius tendon or its insertion into the greater trochanter.
    • Pain on greater trochanter palpation is a key indicator. 
  • Observe for an abnormal gait.
    • Antalgic gait — there is a shortened stance on the affected leg, and when walking, less time is spent bearing weight on the affected side than on the other. 
    • Trendelenburg gait — there is a lateral trunk lean towards the supported limb during the stance phase. 
  • Conduct a physical examination of the hip — there is often pain on resisted active abduction, resisted internal rotation, and/or resisted external rotation of the hip joint on the affected side.
• Check for associated conditions such as lumbar spine conditions and arthritis of the hip or knee. 
• Exclude other conditions with presentations similar to that of greater trochanteric pain syndrome.
  • Arrange a plain radiograph of the hip if there is any suspicion of acute fracture, dislocation, or stress fracture.
• Exclude any underlying infection of the bursae.
  • A tender palpable mass, redness, oedema, or warmth around the lateral hip would suggest possible infection.

Differential diagnosis

Conditions that can present similarly to greater trochanteric pain syndrome include:

• Soft-tissue conditions
  • Iliotibial band/snapping hip syndrome
    • History: lateral hip pain on walking, running, or cycling, with or without snapping; lateral knee pain aggravated by repetitive activity.
    • Examination: symptoms can be reproduced by adducting the hip joint while it is held in extension and external rotation (Ober's test).
  • Iliopsoas bursitis 
    • History: reproducible painful snapping sensations in the anterior hip.
    • Examination: tenderness on deep palpation over the femoral triangle (upper inner thigh).
  • Sports hernia/athletic pubalgia/Gilmore's groin 
    • History: dull, diffuse pain radiating to the inner thigh. Pain with direct pressure, sneezing, sit-ups, kicking, or Valsalva manoeuvre.
    • Examination: no hernia, tenderness of the inguinal canal or pubic tubercle, adductor origin, pain with resisted sit-up or hip flexion.
• Joint and bone conditions
  • Arthritis  
    • History: gradual onset of pain in the hip or groin that is made worse by weight bearing and relieved by prolonged rest. Pain may be referred to the anterior or lateral hip, groin, and around the knee.
    • Examination: the range of motion of the hip joint is limited by pain, especially on internal rotation with the hip and knee flexed; there is usually an antalgic gait (limp in which less time is spent bearing weight on the affected side).
    • For more information, see the CKS topics on Ankylosing spondylitis, Osteoarthritis, and Rheumatoid arthritis.
  • Avascular necrosis of the femoral head
    • History: gradual onset of dull ache in the groin, thigh, and buttock; history of use of corticosteroids or alcohol misuse (although these risk factors are often not present).
    • Examination: the range of movement of the hip joint is restricted only in advanced stages of avascular necrosis.
    • Tests: the diagnosis is confirmed radiologically — in its early stages, avascular necrosis of the femoral head will be shown on magnetic resonance imaging, but not on X-ray. 
  • Fracture of the femoral neck 
    • History: associated with acute trauma or repetitive weight-bearing exercise, deep, referred pain with weight bearing, worse with activity. 
    • Examination: pain may be present with extremes of motion, active straight leg raise, leg roll test, or hopping, and palpation of the greater trochanter. 
  • Sacroiliac joint dysfunction  
    • History: pain over the posterior buttock, radiating to the buttock, groin, and posterior proximal thigh.
    • Examination: pain when the sacroiliac joint is stressed, for example with the sacroiliac (posterior) shear test.
  • Hip impingement syndrome  
    • History: pain in the groin and hip area related to sporting activity.
    • Examination: pain or restriction of movement when the hip joint is flexed or rotated internally.
• Neurological conditions
  • Meralgia paraesthetica (entrapment of the lateral femoral cutaneous nerve)
    • History: numbness, tingling (paraesthesia), and burning pain in the distribution of the nerve (anterolateral hip and thigh to just above the knee), which is aggravated by walking and by extension of the hip joint; recent gain in weight.
    • Examination: symptoms may be reproduced by pressure over the lateral femoral cutaneous nerve. A more accurate test, especially in people who are overweight, may be pinprick sensation over the lateral aspect of the thigh.
  • Lumbar radiculopathy  
    • History: leg numbness, paraesthesia, and pain radiating to below the knee; often accompanied by low back pain.
    • Examination: symptoms can be reproduced by the straight leg raising test or by the femoral nerve stretch test.
    • For more information, see the CKS topic on Sciatica (lumbar radiculopathy).

Scenario: Management

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of greater trochanteric pain syndrome.

Search dates

July 2016 - April 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• *Bursitis/
• exp hip joint/
• lateral hip pain.kw
• greater trochanteric pain.kw
• trochanteric bursitis.kw
• (tronchanteric adj bursitits).ti,ab.
• (“greater trochanteric bursitis” or GTBS) adj (pain or syndrome$).ti,ab.
• (corticosteroid adj injection$).ti,ab.
• *adrenal cortex hormones/ (synonym corticosteroids)

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.