Greater Trochanteric Pain Syndrome: Epidemiology and Associated Factors

Greater trochanteric pain syndrome (GTPS) is defined as tenderness to palpation over the greater trochanter with the patient in the side-lying position.1–3 In contrast to the term greater trochanteric bursitis, which implies presence of inflammation, referring to this clinical entity as GTPS is preferable for 2 reasons: (1) pain in this region frequently is not associated with signs of inflammation such as warmth, erythema, or swelling, and (2) the etiology is not fully known and may relate to myofascial pain rather than inflammation. Pain generators may be associated with the gluteus maximus, medius, or minimus bursae; muscle attachments; or overlying tissue such as the iliotibial band (ITB).2,4,5 The myofascial attachments and bursae associated with the greater trochanter may be affected by altered lower-limb biomechanics. Physical medicine and rehabilitation and orthopedics textbooks cite that osteoarthritis (OA) of the lumbar spine, hip, or knee; ITB tightness or tendonitis; or strain of the hip external rotators may contribute to trochanteric pain by adding stress to the area.4,6,7 Other experts8 have written that trochanteric bursitis is more prevalent in women, frequently associated with mechanical back strain and obesity and often with reduced hip internal rotation range of motion (ROM). However, others7 suggest that marked loss of hip internal rotation is typically not associated with trochanteric pain. One reason for the differences of opinion regarding these and other factors hypothesized to be associated with GTPS is that none have been analytically assessed.3,9 The prevalence of GTPS in adults with musculoskeletal low back pain (LBP) has been reported to be 20% to 35%.10–12 Studies differ regarding whether GTPS may11,13 or may not14 be more prevalent in women than men. However, numerous sources have recognized that there is a lack of data regarding the prevalence of GTPS.4,9 One study15 suggested that GTPS was the cause of LBP, based on findings that Oswestry Disability Index scores for female patients with LBP improved after greater trochanteric steroid injection. However, considering that the corticosteroid is systemically absorbed, this uncontrolled study may not answer whether there is an association between back pain and GTPS. Although there have been small studies of GTPS in back pain clinics,12 we are unaware of any study examining the prevalence and epidemiology of GTPS in the general population. 9 For providers of musculoskeletal care, it is important to understand factors associated with GTPS to minimize significant decline of physical function and quality of life. The long delay between presentation and diagnosis of hip external rotator muscle tears, 1 cause of GTPS, was recently found to be caused by underrecognition by physicians.16 Such underrecognition may be because of a lack of education or attention. Frequently, GTPS is associated with pain at night, pain when standing greater than 15 minutes, or radiating pains and paresthesias.11 These complaints may lead to ordering tests such as magnetic resonance imaging or electromyography to assess for radiculopathy instead of conducting a well-informed physical examination. Understanding whether GTPS is associated with sex, body mass index (BMI), or other lower-limb musculoskeletal diagnoses would enable future study of risk factors for incident and progressive GTPS. Additionally, the characterization of activity level or hip flexibility that could affect pathomechanics at other joints in the kinetic chain, such as the knee or spine, would also guide rehabilitation considerations. To address these needs, this study assessed the prevalence of GTPS in a community-based population complaining of lower-limb pain and whether GTPS was associated with 4 purported risk factors: (1) ipsilateral ITB pain, (2) knee OA, (3) obesity, and (4) LBP. A secondary aim was to determine whether hip internal rotation ROM or levels of physical activity and physical performance are limited in adults with GTPS.