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Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, DPT, CSCS, Cert MDT Tim Lonergan , PT, DPT

GROUP ALPHA HIP PROJECT Current Best Evidence for Select Hip Disorders: Greater Trochanteric Pain Syndrome. Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, DPT, CSCS, Cert MDT Tim Lonergan , PT, DPT Lindsay Rambo, PT, DPT Mindy Riley, MPT, CSCS Pierre Roughny , PT, OCS, MTC. Objectives.

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Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, DPT, CSCS, Cert MDT Tim Lonergan , PT, DPT

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  1. GROUP ALPHA HIP PROJECTCurrent Best Evidence for Select Hip Disorders: Greater Trochanteric Pain Syndrome Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, DPT, CSCS, Cert MDT Tim Lonergan, PT, DPT Lindsay Rambo, PT, DPT Mindy Riley, MPT, CSCS Pierre Roughny, PT, OCS, MTC

  2. Objectives • Examine the epidemiology, functional anatomy, pathology, and etiologies associated with greater trochanteric pain syndrome • Discuss evidence-based diagnosis of this disorder • Present current best treatment options for this disorder

  3. Greater Trochanteric Pain Syndrome: Epidemiology • In a study of 2954 individuals taken from a sampling of a community population, 17.6% could be diagnosed with greater trochanteric pain syndrome (GTPS)1 • The mean age of the subjects was 62.4 ± 8.1 years • Females comprised 60.1% of the sample • Of those with GTPS, 344 had unilateral symptoms while 173 had bilateral symptoms • The odds ratio for GTPS in women compared with men was 3.32 (95% CI, 2.63-4.91)

  4. Greater Trochanteric Pain Syndrome: Functional Anatomy and Pathology • GTPS has commonly been referred to as “greater trochanteric bursitis”2 • However, this diagnostic label has been described as commonly being inaccurate2 Bursae of the left greater trochanter, anterior view From Williams and Cohen3

  5. Greater Trochanteric Pain Syndrome: Functional Anatomy and Pathology • GTPS is rarely associated with the findings correlated with acute inflammation such as localized warmth, erythema, or edema2 • GTPS has also been associated with numerous structures aside from bursae3

  6. Greater Trochanteric Pain Syndrome: Functional Anatomy and Pathology • Specifically, GTPS has been associated with the presence of gluteus medius muscle and tendon pathology4,5 as well as tendinopathy of the gluteus minumus5 Diagram of the muscle attachments and bursae around the greater trochanter From Kingzett-Taylor et al5

  7. Greater Trochanteric Pain Syndrome: Etiology • GTPS has been described as stemming from acute trauma such as a fall onto the lateral hip2,3 • However, repetitive microtrauma,2,3 possibly stemming from movement dysfunction throughout the lower quarter,1 has been described as having a more frequent association with GTPS

  8. Greater Trochanteric Pain Syndrome: Diagnosis – Clinical Presentation • The typical presentation is one of lateral hip pain that usually does not extend below the knee3 • Pain can also extend to the low back, buttock, groin and anterior thigh6 • Symptoms are usually chronic and insidious1,3,4,6 • “Ache” is a common description6

  9. Greater Trochanteric Pain Syndrome: Diagnosis – Clinical Presentation • Aggravating activities include the following1,3,6 • Lying the affected side • Prolonged standing • Moving into standing • High impact activities such as running

  10. Greater Trochanteric Pain Syndrome: Diagnosis – Clinical Presentation • Point tenderness is present around the area of the greater trochanter7,8 with a high level of reproduction of pain reported as well6 • One does not usually find signs of inflammation (warmth, erythema, swelling)1,3,4,7 • Symptoms are thought to be more associated with glutealmyofacial problems than those of bursas1,3,4,7

  11. Greater Trochanteric Pain Syndrome: Diagnosis – Clinical Presentation • Females are more likely to suffer from this condition by four to one4 • It is more likely to be seen in the 4th to 6th decade of life4,6 • It may be associated with back pain, with a recommendation that those with a long standing history of back and sciatica pain be screened for GTPS8 • Noted is the observation conditions such as ITB syndrome and radiculopathy, may predispose patients to GTPS, and can also simulate it3

  12. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Tenderness and a reproduction of pain over and adjacent to the greater trochanterhas been suggested as a key clinical finding in GTPS3 From Williams and Cohen3

  13. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Woodley and colleagues6 compared radiological and clinical diagnoses in order to determine the validity of a number of clinical variables in accurately predicting pathology of the gluteal tendon • 40 patients with unilateral lateral hip pain/GTPS • 37 female and 3 males • Mean age 54.4 years ± 9.5 years with age range of 33 to 78 years

  14. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Patients underwent physical examination by one of eleven physical therapists and an MRI read by one of three radiologists • Nine clinical variables were found to be useful predictors of gluteal tendon pathology in symptomatic hips

  15. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests From Woodley et al6

  16. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • As a corollary to these findings, the results of a study by Bird et al4 also suggest that a positive Trendelenburg sign was the single most sensitive clinical sign to implicate a tear of the gluteus medius in GTPS

  17. Greater Trochanteric Pain Syndrome: Diagnosis – Imaging Studies • Plain film radiographs inconclusive • Bird et al.4 • 45% of subjects with GTPS had gluteus medius/hip abductor muscle tear diagnosed via MRI. • Cvitanic et al9 • Diagnostic accuracy of MRI versus arthroscopy for hip abductor tear is 91% with overall sensitivity of 93%.

  18. Greater Trochanteric Pain Syndrome: Intervention – Non-surgical • Shock Wave Therapy (SWT) • “shock waves are produced after a projectile in a hand piece is accelerated by a pressurized air source and strikes a 15-mm-diameter metal applicator. The energy generated is transmitted to the skin as a shock wave through a standard, commercially available ultrasound gel. The waves are then dispersed radially from the application site into the surrounding tissues.”10

  19. Greater Trochanteric Pain Syndrome: Intervention – Non-surgical • Corticosteroid injection with local anesthetic (CS Inj) • Shbeeb et al studied effect of single CS injusing multiple dosages. Results revealed 77% success with relief of symptoms at week 1, 68% at week 6, and 61% at week 262 • Palpation vs. under fluoroscope – no significant findings indicated providing cortisone injection based on palpation of trochanteric bursa and area of pain vs. using fluoroscope to identify bursa 3 • Cohen et al also found no difference in injection using fleuroscope and found minimal relief after 3 months with all CS injections despite promising results at one month follow ups and also determined using fleuroscope could be counterproductive in patients without actual bursal inflammation 11

  20. Greater Trochanteric Pain Syndrome: Intervention – Non-surgical • Exercise Program • Many studies cited giving patients a home exercise program as part of “typical” or “usual” conservative care in comparison to SWT, CS injections, and oral analgesics 12, 3, 13 • Typical programs consisted of stretching of the IT Band and tensor fascia lata, and strengthening of all glutealmusculature13 • Rompe et al compared SWT, HEP and CS Inj among 228 patients, showing that CS inj had a great initail effect but over time, HEP and SWT were superior to CS Inj.13

  21. Greater Trochanteric Pain Syndrome: Intervention – Non-surgical • Physical Therapy • Very little research has been done in this area specifically and no documentation was found supporting specific treatment protocols for GTPS regarding manual treatment or exercise/stretching/etc • Common misdiagnosis and co morbidities do include low back pain, osteoarthritis, ITB tenderness and obesity3 • Based on our knowledge of pain patterns, objective deficits and co morbidities related to GTPS, we can deduce that mobilization of the hip would help to improve hip mobility. This would in turn allow us to address other deficits such as strength and muscle length issues • more research needs to be done on this patient population

  22. Greater Trochanteric Pain Syndrome: Intervention – Surgical • Surgical interventions are not very common for GTPS, though in severe cases after conservative measures fail, surgery may be considered.5 • Common Complications12 • Hematoma • Impaired abductor function • Hardware removal • Swelling

  23. Greater Trochanteric Pain Syndrome: Intervention – Surgical • Lengthening/Release of the Iliotibial Band (ITB) • Proximal Z-plasty (commonly done with debridement and bursectomy) - average VAS change of 5.6, average Hip Harris Score change of 3612 • Proximal Longitudinal Release (commonly done with debridement and bursectomy) - average VAS change of 4.1, average Hip Harris Score change of 3212 • Distal Z-plasty - average VAS change of 7.0, average Hip Harris Score change of 3012 • All results report significant improvements and high satisfaction rates12

  24. Greater Trochanteric Pain Syndrome: Intervention – Surgical • TrochantericReduction Osteotomy • Very minimal research currently, initially tried following failed lengthening procedures – early study reveals good results based on reducing friction of ITB and trochanter14, increasing strength15and improving blood flow • Govaert et al – 10 patients (12 hips with 5 previous,failed surgeries) showing 92% progressed to great or very great improvement, 9 patients had returned to normal activity at mean follow up of 2 years. The other 3 had >50% satisfaction.16

  25. Greater Trochanteric Pain Syndrome: Intervention – Surgical • Bursectomy • Wiese et al – bursectomy of 45 hips without addressing ITB showing visual analog scale improvements from 7.2 to 3.8 (3.4 change) at 25 month follow up17 • Craig et al – bursectomy with abductor muscle repairs of 17 hips showing Hip Harris Score Improvements from 46 to 82 (36 point change) with 16/17 reporting good or complete resolution at 45 months18 • Baker et al – arthroscopic bursectomy for 30 patients with VAS improvement from 7.2 to 3.1 over 26 months19

  26. Greater Trochanteric Pain Syndrome: Intervention – Post-surgical • Dependent on the procedure • Trochanteric reduction osteotomy5 • PWB for 6 weeks then FWB • Can resume normal activity 12-14 weeks post op • Bursectomy or Iliotibial band release20 • PWB x20lbs for 2 weeks, then WBAT • Avoid irritation to lateral hip structures • Gluteus medius/minimusrepairs20 • PWB x20lbs for 6 weeks, FWB by 8 weeks • Isometric hip abduction started at 6 weeks post op

  27. Greater Trochanteric Pain Syndrome: Intervention – Post-surgical • Endoscopic repair of gluteus medius21 • Level 5 evidence, physician protocol • Precautions • No active abduction or IR, passive ER or adduction (for 6 weeks) • 20lb weight bearing x 6 weeks • 0-4 weeks • PROM (within guidelines), isometrics at 2 weeks, core stability, bike, modalities • 4-8 weeks • May add hip flexion/extension strengthening, FWB by 8 weeks with crutches, core stability • 8-12 weeks • Off crutches, hip strengthening, balance, neuro re-ed, sport specific exercise, passive stretching • 3-6 months (evaluate for discharge) • Hip outcome score (Harris), Biodex 15% of uninvolved, step down test

  28. References • Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, Nevitt MC; Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988-992. • Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc. 1996;71(6):565-569. • Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. AnesthAnalg. 2009;108(5):1662-1670. • Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44(9):2138-2145. • Kingzett-Taylor A, Tirman PF, Feller J, McGann W, Prieto V, Wischer T, Cameron JA, Cvitanic O, Genant HK. Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. AJR Am J Roentgenol. 1999;173(4):1123-1126. • Woodley SJ, et al. Lateral hip pain: findings from magnetic resonance imaging and clinical examination. JOSPT. 2008; 38: 313-328. • Karpinski MRK, Piggott H. Greater trochanteric pain syndrome. A report of 15 cases. The Journal of Bone and Joint Surgery.1985; 67(5): 762-63. • Sayegh F, Potoupnis M, Kapetanos G. Greater trochanteric bursitis pain syndrome in females with chronic low back pain and sciatica. ActaOrthopaedicsBelgica. 2004; 70(5): 423-28.

  29. References • Cvitanic et al. MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). ARJ. 2004;182(1): 137-143. • Furia JP, Rompe JD, Maffuli N. Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome. Am J Sports Med. 2009;27(9):1806-1813. • Cohen SP, Narvaez JC, Lebovits AH, Stojanovic MP. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth. 2005;94:100-106. • Lustenberger D, Ng V, Best T, and Ellis T. Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sport Med. 2011;21:447-453. • Rompe J, Segal N, Cacchio A, et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanteric pain syndrome. Am J Sports Med. 2009;37:1981-1990. • Macnicol MF, Makris D. Distal transfer of the greater trochanter. J Bone Joint Surg Br. 1991;73-B:838-41. • Free SA, Delp SL. Trochanteric transfer in total hip replacement: effects on the moment arms and force-generating capacities of the hip abductors. J Orthop Res. 1996;14:245-50.

  30. References • Govaert L, van der Vis H, Marti R, et al. Trochanteric reduction osteotomy as a treatment for refractory trochanteric bursitis. J Bone Joint Surg Br. 2003;85:199-203. • Wiese M, Rubenthaler F, Willburger R, et al. Early results of endoscopic trochanter bursectomy. IntOrthop. 2004;28:218-221. • CraigR, Gwynne Jones D, Oakley A, et al. Iliotiial band Z-lengthening for regractorytrochanteric bursitis (greater trochanteric pain syndrome). ANZ J Surg. 2007;77:996-998. • Baker CL Jr, Massie RV, Hurt WG, Savory CG. Arthroscopic bursectomy for recalcitrant trochanteric bursitis (greater trochanteric pain syndrome). ANZ J Surg. 2007;23:827-32. • Sekiya J, Safran M, Ranawat A, Leunig M. Techniques in Hip Arthroscopy and Joint Preservation.Saunders; 2010. • Kelly, Dr. Bryan. “Hip Arthroscopy Rehabilitation: Gluteus Medius Repair With or Without Labral Debridement..” Web. 20 Jan 2012. http://www.bryankellymd.com/pdf/gluteus-medius-repair-labral-debridement.pdf

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