Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001 Sep;44(9):2138-45. Bird PA1, Oakley SP, Shnier R, Kirkham BW.
From the Study
“All subjects were women (median age 58 years, range 36-75 years). The median duration of symptoms was 12 months (range 12-60 months). MRI findings were as follows: 11 patients (45.8%) had a gluteus medius tear, 15 patients (62.5%) had gluteus medius tendinitis (pure tendinitis in 9 patients and tendinitis with a tear in 6 patients), 2 patients had trochanteric bursal distension, and 1 patient had avascular necrosis of the femoral head. Trendelenburg’s sign was the most accurate of the 3 physical signs in predicting a tendon tear, with a sensitivity of 72.7% and a specificity of 76.9%. Moreover, Trendelenburg’s sign was the most reliable measure, with a calculated intraobserver kappa of 0.676 (95% confidence interval 0.270-1.08).”
“The results support the hypothesis that gluteus medius tendon pathology is important in defining GTPS. In this series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology. The physical findings suggest that Trendelenburg’s sign is the most sensitive and specific physical sign for the detection of gluteus medius tears, with an acceptable intraobserver reliability. Further delineation with MRI, especially in patients with a positive Trendelenburg’s sign, is recommended prior to any consideration of surgery in this group of patients. Finally, with the pathology of this condition defined, the challenge will be to devise and assess, by randomized controlled trial, an appropriate treatment strategy for this group of patients.”
“Bursal distension in isolation was not identified in any of the cases reviewed.”
“Physical therapy may also provide symptom relief, but it is likely that physiotherapy would need to be tailored to strengthen the abductors of the hip and would be preferable to the current techniques of treatment , which includes stretching of the iliotibial band.”[emphasis mine]
This is a study that I wish I had read in 2001! Trochanteric bursitis was one of those diagnoses that was easy to make, hip abductor weakness, opposite hip dropping when walking, sharp tenderness with palpation over the side of the hip/greater trochanter, which was and is still frequently referred to physical therapy. The problem was and still is that there were no studies guiding physical therapists with regards to how to treat trochanteric bursitis, or bursitis of any kind, rather just few descriptions of what therapists did. With this a few other similar studies showing that the condition is primarily tendinopathy, I started applying tendinopathy treatment programs which included an emphasis on hip abductor strengthening, just as authors of this study suggested, with remarkably better results than I got from iliotibial band stretches, again, just as the authors suggested.
Unfortunately I still get regular referrals to treat “trochanteric bursitis” and none for “greater trochanteric pain syndrome” so it takes a while to get the word out. The problem for patients is that improper diagnosis leads to improper treatment and as this study found 45% of patients progressed to the point of having tears of the hip abductor muscles, which are not so easy to treat and can lead to long term disability. The take home message for patients is that if you have been diagnosed with trochanteric bursitis you have probably been diagnosed incorrectly which then becomes a problem if you are treated incorrectly. There is fairly extensive amount of research for tendinopathy/tendinitis on other body parts and that research suggests that RICE (rest, ice, compression, and elevation) various stretches and painful massage does not help much to heal the tendon and restore muscle strength, rather strengthening exercises heals tendons and restores muscle strength.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.
Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.