Lesser Trochanter Pain: Causes, Symptoms, Diagnosis, and Treatment

What is the pain over the lesser trochanter?

Pain localized over the lesser trochanter of the femur typically indicates an issue with the iliopsoas muscle or its tendon, the primary structure attaching at this bony landmark. Common causes include tendinopathy, bursitis, or, less frequently, an avulsion fracture.

Understanding the Lesser Trochanter and Surrounding Anatomy

The lesser trochanter is a small, conical projection located on the posteromedial aspect of the proximal femur, just inferior to the femoral neck. While often overshadowed by the larger greater trochanter, it serves a crucial anatomical role as the primary insertion point for the iliopsoas muscle.

The iliopsoas is a powerful hip flexor, formed by the convergence of the iliacus and psoas major muscles in the abdomen and pelvis. It plays a vital role in:

• Hip flexion: Lifting the knee towards the chest, as in walking, running, or stair climbing.
• Trunk flexion: Assisting in bending the trunk forward (when the legs are fixed).
• Pelvic stabilization: Contributing to postural control.

Given its deep location and the significant forces it can generate, conditions affecting the iliopsoas tendon at its lesser trochanter insertion can lead to substantial pain and functional limitation.

Common Causes of Pain Over the Lesser Trochanter

Pain in this specific area is almost invariably related to the iliopsoas complex. The most common conditions include:

• Iliopsoas Tendinopathy/Tendinitis: This is the most frequent cause. It refers to inflammation (tendinitis) or degenerative changes (tendinopathy) within the iliopsoas tendon.
  • Mechanism: Often an overuse injury resulting from repetitive hip flexion activities (e.g., running, cycling, dancing, martial arts, rowing). It can also occur acutely from a sudden, forceful contraction or stretch.
  • Risk Factors: Inadequate warm-up, rapid increase in training intensity, poor core stability, muscle imbalances (e.g., tight hip flexors, weak glutes).
• Iliopsoas Bursitis: The iliopsoas bursa is a fluid-filled sac located deep to the iliopsoas muscle and tendon, anterior to the hip joint capsule. It helps reduce friction.
  • Mechanism: Inflammation of this bursa can occur due to repetitive friction from the overlying tendon, often in conjunction with iliopsoas tendinopathy or underlying hip joint pathology (e.g., osteoarthritis, labral tears).
• Avulsion Fracture of the Lesser Trochanter: While less common, this is a significant injury.
  • Mechanism: A sudden, forceful contraction of the iliopsoas muscle can pull a fragment of bone away from the lesser trochanter. This is more prevalent in skeletally immature individuals (adolescents) where the growth plate is weaker than the tendon. It can also occur in adults with weakened bone (e.g., osteoporosis, metastatic disease).
• Iliopsoas Muscle Strain/Tear: An acute injury to the muscle belly or its musculotendinous junction.
  • Mechanism: Occurs from overstretching or a sudden, powerful contraction, similar to other muscle strains.
• Referred Pain: Less commonly, pain in this area can be referred from other sources, although direct lesser trochanter pain is highly suggestive of local pathology.
  • Lumbar Spine: Issues with the lower lumbar spine (L1-L3 nerve roots) can sometimes refer pain to the groin and hip flexor region.
  • Hip Joint Pathology: Conditions like femoroacetabular impingement (FAI), labral tears, or hip osteoarthritis can sometimes cause anterior hip or groin pain that may be perceived near the lesser trochanter.

Accompanying Symptoms

Pain over the lesser trochanter often presents with specific characteristics:

• Aggravated by Activity: Pain typically worsens with activities involving hip flexion, such as:
  • Running (especially uphill or sprinting)
  • Kicking
  • Stair climbing
  • Performing sit-ups or leg raises
  • Bringing the knee towards the chest
• Pain with Hip Extension: Stretching the iliopsoas (e.g., extending the leg backward) can also elicit pain.
• Tenderness: Deep palpation in the groin region, medial to the femoral artery, may elicit tenderness over the iliopsoas tendon.
• Stiffness: Especially noticeable after periods of rest or in the morning.
• Clicking or Snapping Sensation: In some cases, particularly with iliopsoas tendinopathy or bursitis, a snapping sensation (internal snapping hip syndrome) may be felt or heard as the tendon moves over the femoral head or iliopectineal eminence.
• Weakness: Difficulty or perceived weakness in hip flexion.
• Limping: May occur in more severe cases or with acute injuries like an avulsion fracture.

Diagnosis and Assessment

A healthcare professional will typically perform a thorough assessment, including:

• Clinical History: Detailed questions about the onset of pain, aggravating and alleviating factors, activity levels, and any previous injuries.
• Physical Examination:
  • Palpation: Assessing for tenderness over the iliopsoas tendon.
  • Range of Motion: Assessing hip flexion, extension, and rotation.
  • Strength Testing: Resisted hip flexion (e.g., asking the patient to lift their knee against resistance) will often reproduce the pain.
  • Special Tests: Tests like the Thomas Test or Modified Thomas Test can assess hip flexor tightness.
• Imaging Studies:
  • X-rays: Primarily used to rule out bony pathologies like avulsion fractures, stress fractures, or hip joint osteoarthritis.
  • Ultrasound: Can visualize the iliopsoas tendon and bursa, detecting inflammation, thickening, or fluid accumulation. It can also guide injections.
  • MRI (Magnetic Resonance Imaging): Provides detailed images of soft tissues (tendons, muscles, bursae) and can identify tendinopathy, bursitis, muscle tears, or subtle hip joint pathologies.

General Management and Treatment Approaches

Treatment for pain over the lesser trochanter typically begins with conservative measures, focusing on reducing inflammation, restoring function, and addressing underlying biomechanical factors.

• Rest and Activity Modification: Temporarily avoiding or modifying activities that aggravate the pain is crucial. This doesn't necessarily mean complete immobilization but rather reducing load on the iliopsoas.
• Ice and Heat: Applying ice packs to the affected area can help reduce acute inflammation and pain. Heat may be beneficial for muscle relaxation and chronic stiffness.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter or prescription NSAIDs can help manage pain and inflammation.
• Physical Therapy: This is a cornerstone of treatment. A physical therapist will design a program that may include:
  • Stretching: Gentle stretching of the iliopsoas, quadriceps, and other hip flexors to improve flexibility.
  • Strengthening: Progressive strengthening exercises for the hip extensors (glutes), core muscles, and other hip stabilizing muscles to improve muscle balance and support.
  • Manual Therapy: Techniques like soft tissue massage or joint mobilizations to address muscle tightness or joint restrictions.
  • Biomechanical Analysis: Identifying and correcting gait abnormalities, training errors, or postural imbalances.
  • Gradual Return to Activity: A structured program to safely reintroduce activities and prevent recurrence.
• Injections: For persistent pain, a corticosteroid injection into the iliopsoas bursa or around the tendon (often guided by ultrasound) can provide temporary pain relief. Platelet-rich plasma (PRP) injections are also being explored for chronic tendinopathies.
• Surgical Intervention: Surgery is rarely needed for iliopsoas tendinopathy or bursitis and is typically reserved for severe, chronic cases unresponsive to extensive conservative management. Avulsion fractures may require surgical fixation, especially in displaced cases or in athletes.

Prevention Strategies

Preventing pain over the lesser trochanter involves a holistic approach to hip health and training:

• Proper Warm-up and Cool-down: Always include dynamic warm-ups before activity and static stretches afterward.
• Gradual Progression: Increase training intensity, duration, or volume gradually to allow the body to adapt.
• Flexibility and Mobility: Regularly stretch the hip flexors, quadriceps, and hamstrings to maintain optimal hip mobility.
• Strength Balance: Ensure balanced strength between hip flexors, extensors, abductors, and adductors. Focus on strengthening the glutes and core muscles.
• Core Stability: A strong core provides a stable base for hip movement, reducing excessive strain on the hip flexors.
• Appropriate Footwear and Equipment: Use supportive footwear and ensure exercise equipment is properly adjusted.

When to Seek Professional Medical Advice

While many cases of iliopsoas-related pain can improve with rest and self-care, it's important to consult a healthcare professional if you experience:

• Severe or sudden pain: Especially if it occurred after a specific incident or trauma.
• Inability to bear weight: Or significant difficulty walking.
• Pain that worsens or does not improve: After a few days of rest and conservative measures.
• Associated symptoms: Such as fever, significant swelling, numbness, or tingling.
• Concerns about an avulsion fracture: Particularly in adolescents or if a sudden "pop" was heard or felt.

A timely and accurate diagnosis is essential for effective management and to prevent chronic issues or more serious complications.