Greater Trochanteric Pain Syndrome (GTPS) is a common clinical condition characterized by pain and tenderness over the lateral aspect of the hip. Historically, this was almost exclusively attributed to “trochanteric bursitis.” However, contemporary imaging and histological studies have demonstrated that the primary pathology in most patients is gluteus medius and minimus tendinopathy or tearing, with bursitis often being a secondary, reactive phenomenon. For the board-certified physician, treating GTPS requires a shift from passive anti-inflammatory treatments to active, load-managed tendon rehabilitation.

1. Functional Anatomy: The “Rotator Cuff of the Hip”

The gluteus medius and minimus muscles are the primary lateral stabilizers of the hip. Because of their anatomical and functional similarities to the shoulder, they are often referred to as the “rotator cuff of the hip.”

• Gluteus Medius: Originates on the ilium and inserts onto the lateral and posterosuperior facets of the greater trochanter. It is the primary abductor and pelvic stabilizer during the stance phase of gait.
• Gluteus Minimus: Lies deep to the medius and inserts on the anterior facet. It provides joint stability and internal rotation.
• The Bursae: There are three main bursae in the lateral hip: the subgluteus maximus (trochanteric) bursa, the subgluteus medius bursa, and the subgluteus minimus bursa. These serve to reduce friction between the tendons and the bony prominence of the trochanter.

2. Pathophysiology: The Role of Compression

Unlike Achilles tendinopathy, which is often driven by tensile loading, gluteal tendinopathy is heavily influenced by compressive loading.

• The Iliotibial (IT) Band: The IT band passes directly over the greater trochanter. When the hip is adducted (as in standing on one leg or crossing legs), the IT band “squeezes” the gluteal tendons against the bone.
• Tendinopathic Changes: Chronic compression leads to a “failed healing response,” characterized by non-inflammatory collagen disorganization and increased thickness of the tendon.

3. Clinical Presentation and Physical Exam

The hallmark of GTPS is point tenderness over the greater trochanter. Patients often report pain when lying on the affected side at night or during prolonged walking.

High-Yield Provocative Tests

• Single-Leg Stance Test: The patient stands on the affected leg for 30 seconds. A positive test is the reproduction of lateral hip pain. This is highly specific for gluteal tendinopathy.
• Resisted External Derotation Test: The patient is supine with the hip flexed to 90 degrees and externally rotated. They then resist the clinician’s effort to return the hip to neutral. This loads the gluteal tendons and is often painful in GTPS.
• Fagan’s (Modified Ober’s) Test: While typically used to assess IT band tightness, it can also reproduce lateral hip pain as the IT band compresses the trochanteric structures.

4. Differential Diagnosis: The “Back-Hip” Connection

A high-yield board concept is differentiating GTPS from L4/L5 Radiculopathy.

• Radiculopathy: Pain often radiates past the knee, may be associated with weakness in foot dorsiflexion or great toe extension, and is usually accompanied by back pain.
• GTPS: Pain is localized to the lateral hip and is worsened by direct pressure (palpation).
• Double Trouble: Many patients have “Hip-Spine Syndrome,” where chronic back pain leads to an altered gait, which in turn causes secondary gluteal tendinopathy.

5. Interventional Management

• Corticosteroid Injections (CSI): Provides excellent short-term relief for the “bursitis” component. However, recent trials have shown that at one year, CSI is less effective than specialized physical therapy for long-term resolution.
• Platelet-Rich Plasma (PRP): For refractory gluteal tendinopathy or partial-thickness tears, PRP is increasingly used to stimulate a healing response in the degenerative tendon tissue.
• Trochanteric Bursectomy: Reserved for rare, recalcitrant cases that fail all conservative and interventional measures.

6. The “Load Management” Approach

The “cure” for GTPS is correct mechanical loading.

• Avoidance of Adduction: Patients are advised to avoid crossing their legs, “hanging” on one hip when standing, and sleeping in a “side-lying” position without a pillow between their knees. These positions all increase compressive stress on the tendons.
• Progressive Isometric Strengthening: Starting with isometric abductions (pushing the leg against a wall without movement) helps reduce pain and begins to load the tendon safely.
• The Trendelenburg Gait: Rehabilitation focuses on strengthening the gluteus medius to eliminate the “pelvic drop,” which reduces the repetitive “snapping” of the IT band over the trochanter.

---

High-Yield Board “Fast Facts”

• Gluteus Medius: The “Rotator Cuff of the Hip.”
• Trendelenburg Sign: Indicates weakness of the hip abductors on the stance side.
• Compressive Loading: The primary mechanism of injury in GTPS (IT band “squeezing” the tendon).
• Night Pain: Very common in GTPS; patients often cannot sleep on the affected side.
• L5 Radiculopathy: The most common neurological mimic of lateral hip pain.