Lateral hip pain – An update on diagnosis and treatment techniques
Paul Michael – Moving with Ease Physio, Robina, Gold Coast.
Today’s article will be about lateral hip pain since today my mother asked me if I could treat the pain that has been troubling her now for many months. Since it is my mum, I thought I’d do a little extra research before we visited her in Brisbane!
More often than not, lateral hip pain is best diagnosed as greater trochanteric pain syndrome (GTPS). This common complaint is often mistaken as “trochanteric bursitis”, however, we know now with many studies and advancing radiology techniques, that primary trochanteric bursitis is actually quite uncommon. Gluteal tendinopathy in conjunction with bursitis is more frequently found, however, the exact cause of the pain syndrome is still unknown.
GTPS is very much female dominant and occurs most frequently between the ages of 50-70 years of age. Apart from age and gender there are some other factors that make it more likely that a person will have this issue, and those are (1 & 2):
- High body mass index
- Hip and knee osteoarthritis
- Lumbar facet or sacroiliac joint pain
- Foot biomechanics issues (eg bunion, prolonged pronation)
- Gait dysfunction due to pelvic muscle weakness
The actual mechanism of “WHY” there is pain is thought to be repetitive friction between the greater trochanter and the fascia lata / iliotibial band.
Studies have reviewed the management of GTPS and have nominated several approaches that may be taken to treat the pain. These include:
- Local Corticosteroid injection (CSI)
- Shockwave therapy (SWT)
- Platelet-rich plasma (PRP)
- Activity modification
- Pain and anti-inflammatory medication
- Weight reduction
GTPS is generally self-limiting, in that it will eventually come good, but if persistent pain does occur surgical options may be sought after, including bursectomy, iliotibial band lengthening, and gluteal tendon repair.
So why is this cruel problem so hard to treat? My answer to this is that there is always a difficulty with resting the area. Don’t forget your body will heal if given the opportunity and right environment to do so. In the case of the gluteal muscles, they are active with every step…so to rest them means not to take steps. Which is quite hard.
I think that activity modification is best done with some moderation in mind. That is, don’t walk unnecessarily. Change your exercise to one of swimming, cycling or some other non-stepping activity…just until the hip settles. Until there is a reduction in pain from activity modification, tape, SWT, CSI, dry needling, foot/shoe modification, there is no point in administering the strengthening/rehab component.
My approach is that conservative measures should be first, then less conservative measures later. For this reason, laser (LLLT) is my next choice due to lack of long-term side-effects, then injection therapy, in conjunction with ongoing activity modification and physiotherapy.
As to whether corticosteroid or PRP? Well, I usually think if there are no visible tears on USS then corticosteroid injection (CSI) is appropriate. One study of 173 clients with steroid injections showed that there was a diminishing rate of improvement after 1, 3 and 6 months post injection with still 56% of people at 6 months reported improvements.
This statistic is quite re-assuring yet other studies have shown that there is also a high rate of reoccurrence in the long term, post CSI. If there are visible gluteal tears I like to err on the side of caution and ideally I think a strict plan of rest, PRP then restrengthening is appropriate, but reality is that many of the people presenting to me with this issue are retirees and not willing the pay the cost of one, two or even three PRP injections that are often required.
What I did find interesting in my research was that there is growing evidence for SWT as a treatment of GTPS. This is of particular interest to me since I have an SWT machine in the clinic. Two studies showed that treatment with low energy SWT was effective with positive results maintained at 12 months (3 & 4). Another study showing that repetitive low energy SWT was actually better than CSI at 4 months (4).
Could it be a faster route to just succumb to the need for a non-weight bearing set-up whereby the client walks with crutches for 3-6 weeks and then, once the healing process has taken hold, re-strengthening begins? If I could actually guarantee my client the inconvenience was worth it, I’d recommend it more rigidly, but to be honest, at this stage I wouldn’t be sure. Happy to trial willing subjects in my study though (mum?).
- Diane Reid The management of greater trochanteric pain syndrome: A systematic literature review J Orthop. Mar 2016
- Lustenberger DP1, Ng VY, Best TM, Ellis TJ.Efficacy of treatment of trochanteric bursitis: a systematic review. Clinical Journal of Sports Medicine Sep 2011
- Furia J.P., Rompe J.D., Maffulli N. Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome. Am J Sports Med. 2009;37:1806–1813. [PubMed]
- Rompe J.D., Segal N.A., Cacchio A., Furia J.P., Morral A., Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med. 2009;37:1981–1990. [PubMed]