Peri Trochanteric Syndrome: Symptoms, Causes, Diagnosis, and Treatments

What is Peri Trochanteric Syndrome?

Peri Trochanteric Syndrome (PTS) is an umbrella term encompassing various conditions that cause pain around the greater trochanter of the femur, the prominent bony point on the outside of the hip, primarily involving the gluteal tendons and surrounding bursae.

Understanding the Anatomy: The Greater Trochanter

To fully grasp Peri Trochanteric Syndrome, it's essential to understand the anatomy of the lateral hip. The greater trochanter is a large, irregular, quadrilateral eminence located at the junction of the neck and shaft of the femur. It serves as a crucial attachment point for several powerful muscles that move the hip, including the gluteus medius, gluteus minimus, and vastus lateralis.

• Gluteus Medius and Minimus: These muscles are vital for hip abduction (moving the leg away from the body) and stabilizing the pelvis during walking and running. Their tendons attach directly to the greater trochanter.
• Trochanteric Bursae: Several small, fluid-filled sacs called bursae are located around the greater trochanter. Their primary function is to reduce friction between tendons, muscles, and bone during movement. The most commonly implicated is the greater trochanteric bursa, situated between the greater trochanter and the iliotibial (IT) band.
• Iliotibial (IT) Band: A thick band of fascia that runs down the outside of the thigh, passing over the greater trochanter and inserting into the tibia.

What is Peri Trochanteric Syndrome (PTS)?

Peri Trochanteric Syndrome is not a single diagnosis but rather a collection of conditions characterized by pain and tenderness over the greater trochanter. While historically often diagnosed as "trochanteric bursitis," current understanding and evidence suggest that gluteal tendinopathy (degeneration or injury to the gluteus medius and/or minimus tendons) is the primary pathology in the majority of cases, with bursal inflammation often being secondary or absent.

Key conditions under the PTS umbrella include:

• Gluteal Tendinopathy: This is the most common cause of PTS, involving pain and degeneration of the gluteus medius and/or minimus tendons where they attach to the greater trochanter. It's often an overuse injury but can also result from acute trauma.
• Greater Trochanteric Bursitis: Inflammation of one of the bursae surrounding the greater trochanter. While less common as a primary issue than tendinopathy, it can occur, often secondary to tendon pathology or direct trauma.
• External Snapping Hip Syndrome: Caused by the IT band or gluteus maximus tendon snapping over the greater trochanter during hip movement.
• Referred Pain: Pain from the lumbar spine (lower back), sacroiliac joint, or hip joint itself can sometimes mimic PTS.

The term Greater Trochanteric Pain Syndrome (GTPS) is increasingly used interchangeably with PTS, reflecting the broader understanding beyond just bursitis.

Causes and Risk Factors

PTS typically develops due to a combination of factors, including:

• Repetitive Overuse: Activities involving repetitive hip abduction or external rotation, such as running, cycling, hiking, or prolonged standing, can stress the gluteal tendons and bursae.
• Direct Trauma: A fall directly onto the side of the hip can cause acute inflammation or injury.
• Muscle Imbalances:
  • Weak Gluteal Muscles: Insufficient strength in the gluteus medius and minimus can lead to abnormal biomechanics and increased stress on the tendons.
  • Tight Iliotibial (IT) Band: A tight IT band can increase compressive forces on the greater trochanter and underlying structures.
• Biomechanical Issues:
  • Leg Length Discrepancy: A difference in leg length can alter gait mechanics, placing uneven stress on the hips.
  • Gait Abnormalities: Abnormal walking or running patterns.
  • Pelvic Instability: Weak core muscles can contribute to poor pelvic control.
• Poor Posture: Prolonged standing or sitting in positions that compress the lateral hip.
• Hip Osteoarthritis: Degenerative changes in the hip joint can alter mechanics and contribute to PTS.
• Lumbar Spine Pathology: Conditions like sciatica or spinal stenosis can refer pain to the hip area.
• Obesity: Increased weight can place additional stress on hip joints and surrounding structures.
• Age and Gender: More common in middle-aged and older adults, particularly women, possibly due to wider pelvic anatomy and hormonal factors.

Common Symptoms

The symptoms of Peri Trochanteric Syndrome typically include:

• Lateral Hip Pain: The hallmark symptom is pain on the outside of the hip, directly over the greater trochanter.
• Tenderness to Touch: The area over the greater trochanter is often very tender when pressed.
• Pain Worsened by Activity: Activities such as walking, running, climbing stairs, or prolonged standing can exacerbate the pain.
• Pain with Lying on Affected Side: Sleeping on the painful side can be very uncomfortable, often waking individuals at night.
• Pain with Getting Up from a Chair: Particularly after prolonged sitting.
• Pain Radiating Down the Thigh: The pain may radiate down the outside of the thigh towards the knee, but typically not past it.
• Stiffness: A feeling of stiffness in the hip, especially after periods of inactivity.
• Clicking or Snapping Sensation: In cases of external snapping hip syndrome.

Diagnosis of PTS

Diagnosing PTS involves a thorough clinical evaluation by a healthcare professional, often including:

• Medical History: Discussing symptoms, activity levels, and any previous injuries or medical conditions.
• Physical Examination:
  • Palpation: The clinician will press on the greater trochanter to assess for tenderness.
  • Range of Motion Tests: Assessing hip movement, including abduction, adduction, flexion, and rotation.
  • Provocative Tests: Specific movements that reproduce pain, such as resisted hip abduction, FADER (flexion, adduction, external rotation) test, or single-leg stance.
  • Gait Analysis: Observing walking patterns to identify biomechanical issues.
• Imaging Studies:
  • X-rays: Primarily used to rule out bony pathologies like fractures, arthritis, or calcification.
  • Ultrasound: Can visualize soft tissue structures, identify tendon pathology (tears, thickening), and bursal inflammation. It's also useful for guiding injections.
  • MRI (Magnetic Resonance Imaging): Provides detailed images of soft tissues, including tendons, muscles, and bursae, and is considered the gold standard for confirming gluteal tendinopathy or significant bursitis.

Treatment and Management Strategies

The treatment for Peri Trochanteric Syndrome is primarily conservative, focusing on reducing pain, improving function, and addressing underlying causes.

Conservative Management

• Rest and Activity Modification: Avoiding activities that aggravate the pain is crucial. This doesn't necessarily mean complete rest but rather modifying movements to reduce stress on the hip.
• Ice Application: Applying ice packs to the lateral hip for 15-20 minutes several times a day can help reduce pain and inflammation.
• 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 and typically includes:
  • Stretching: Focusing on the IT band, hip flexors, and hamstrings to improve flexibility.
  • Strengthening Exercises: Crucially, strengthening the gluteus medius and minimus, hip abductors, and core muscles to improve stability and correct muscle imbalances. Eccentric strengthening (where the muscle lengthens under tension) is particularly beneficial for tendinopathy.
  • Manual Therapy: Techniques such as massage, joint mobilizations, or dry needling to address muscle tightness and improve tissue mobility.
  • Biomechanical Correction: Addressing gait abnormalities, leg length discrepancies, and posture.
  • Education: Guidance on activity modification, proper body mechanics, and sleeping positions.
• Assistive Devices: Crutches or a cane may be used temporarily to reduce weight-bearing stress on the affected hip.
• Footwear Assessment: Ensuring appropriate and supportive footwear.

Injections

If conservative measures are insufficient, injections may be considered:

• Corticosteroid Injections: Injections of a corticosteroid (a powerful anti-inflammatory medication) directly into the affected bursa or around the gluteal tendons can provide temporary pain relief. However, repeat injections are generally discouraged due to potential side effects like tendon weakening.
• Platelet-Rich Plasma (PRP) Injections: For chronic gluteal tendinopathy, PRP, derived from the patient's own blood, may be injected to promote tissue healing and regeneration. This is a newer treatment with growing evidence.

Surgical Intervention

Surgery for PTS is rare and typically reserved for severe, chronic cases that have not responded to extensive conservative treatment (usually after 6-12 months). Surgical options may include:

• Bursectomy: Removal of the inflamed bursa.
• Tendon Repair: Repair of significant tears in the gluteus medius or minimus tendons.
• IT Band Release: In cases where a tight IT band is a major contributing factor to snapping hip or compression.

Prevention Strategies

Preventing PTS often involves addressing risk factors and maintaining good biomechanics:

• Gradual Increase in Activity: Avoid sudden increases in the intensity, duration, or frequency of exercise.
• Strengthen Gluteal and Core Muscles: Regular exercises targeting hip abductors, rotators, and core stabilizers can prevent imbalances.
• Regular Stretching: Maintain flexibility in the IT band, hip flexors, and hamstrings.
• Proper Footwear: Wear supportive shoes appropriate for your activities.
• Address Biomechanical Issues: Work with a physical therapist to correct leg length discrepancies, gait abnormalities, or pelvic instability.
• Maintain a Healthy Weight: Reduce stress on the hip joints.
• Avoid Prolonged Compression: If possible, avoid sleeping on your side without a pillow between your knees, and avoid prolonged sitting in positions that compress the lateral hip.

When to See a Doctor

It's advisable to consult a healthcare professional if you experience:

• Persistent hip pain that doesn't improve with rest and basic self-care.
• Pain that worsens or significantly interferes with daily activities.
• Inability to bear weight on the affected leg.
• Signs of infection, such as fever, redness, or warmth around the hip.
• Sudden, severe pain following an injury.

Conclusion

Peri Trochanteric Syndrome is a common cause of lateral hip pain, with gluteal tendinopathy being the most frequent underlying issue. While often debilitating, it is highly treatable with a comprehensive approach focusing on activity modification, physical therapy, and addressing biomechanical factors. Understanding the condition and proactively managing its risk factors can lead to effective pain relief and a return to full activity.