Hip - Repetetive Microtrauma Injuries: GTPS and Iliopsoas Bursitis

What are other terms for Greater Trochanteric Pain Syndrome?

Trochanteric Bursitis

What conditions should be considered in the differential diagnosis of iliopsoas bursitis?

Iliopectineal Bursitis, Iliopsoas Impingement, and Subspine impingement

What is subspine impingement?

Contact of AIIS and distal femoral neck

What is Greater Trochanteric Pain Syndrome (GTPS)?

A group of diagnoses causing lateral/peritrochanteric hip pain

What is trochanteric bursitis?

Repetitive friction/compression between the greater trochanter and IT band (ITB)

When does friction/compression occur in trochanteric bursitis?

During hip flexion and extension

What tendon problems can contribute to GTPS?

Gluteus medius and minimus tendinopathy or tears

Why are the gluteus medius/minimus sometimes called the "RTC of the hip"?

They help stabilize the hip, similar to how the rotator cuff stabilizes the shoulder

Where do the gluteus medius and minimus insert?

On the posterior aspect of the greater trochanter

In adults ≥60 years old, how common are degenerative gluteus medius/minimus tears?

Approximately 10%.

What does histology suggest about GTPS?

Degenerative tendinopathy may be more likely than primary bursa inflammation

What is external snapping hip?

Repetitive gliding of the ITB/anterior gluteus maximus over the greater trochanter

During what movements does external snapping hip occur?

Hip flexion, extension, and abduction

What is the incidence of GTPS in females?

15.0%

How much more likely are females to develop GTPS compared to males?

Up to 4× more likely

What is the incidence of GTPS in males?

6.6%

What is the typical age range for GTPS?

4th-6th decades of life

What is the main clinical presentation of GTPS?

Pain and tenderness over the greater trochanteric area

How does GTPS typically begin?

Insidious onset

How is GTPS pain typically described?

Deep, dull, aching pain

What activities or positions can aggravate GTPS?

Prolonged standing, sitting with the affected leg crossed, lying on the affected side, and stair climbing

What typically decreases GTPS pain?

Rest

What type of problem may selective tissue tension testing identify in GTPS?

A musculotendinous (MT) problem

Why can bursitis present as a musculotendinous problem during selective tissue tension testing?

The bursa acts functionally as a musculotendinous structure during testing

Which muscles are tested when assessing lateral hip bursitis/GTPS?

TFL, gluteus maximus, gluteus medius, and gluteus minimus

How would you differentiate between a L/S and a hip pain generator?

LQ Screen

When performing STTT on someone with GTPS, what would most likely cause pain?

AROM ABD & at ADD endrange

PROM ADD at endrange

RROM ABD & ER

What can provoke pain in Greater Trochanteric Pain Syndrome (GTPS)?

Compression of the greater trochanter, muscular contraction, muscular stretch, or external force

How can muscular contraction provoke pain in GTPS?

Contraction of the agonist muscle can compress/irritate the tissues around the greater trochanter

How can muscular stretching provoke pain in GTPS?

The agonist is lengthened, which can challenge the irritated tissue

What is the chain that leads to Trochanteric Bursitis?

1. Restriction of Tissue

2. Length of Tissue Challenged

3. Repetitive Compression of Bursa

4. Pain- Trochanteric Bursitis

How can repetitive compression lead to trochanteric bursitis?

A shortened tissue (such as the TFL from prolonged sitting) is challenged as it lengthens, increasing compression on the bursa and causing irritation and pain

What results are MOST expected in a patient presenting with suspected GTPS?

(+) Tri Hip with decreased Hip adduction and (+) Ober Test

What can contribute to increased stress on the ITB and compression over the greater trochanter in GTPS?

Persistent LE overpronation (medial collapse)

What movements contribute to lower-extremity overpronation (medial collapse)?

Hip internal rotation (IR) and hip adduction (ADD)

What muscle imbalance can contribute to GTPS?

TFL/ITB dominance over the posterior gluteals

What are the functions of the TFL?

Flexion and IR

What are the functions of the posterior gluteals?

ER, extends, abducts (Up and Out)

How can prolonged hip-flexed postures contribute to GTPS?

They can cause TFL tightness

How does TFL tightness perpetuate TFL/ITB dominance?

The TFL fires first, maintains its shortened position, and perpetuates the dominance cycle

What other functional factors can contribute to GTPS?

Impaired trunk muscle function, knee instability (pulls into medial collapse) , and limited ankle DF ROM (stealing motion somewhere else)

How can leg length inequality affect hip position?

The short side is relatively abducted, while the long side is relatively adducted

What types of leg length inequality can contribute to GTPS?

Structural and functional

How to treat a structural leg length inequality?

Give them a heel lift

What environmental or positional factors can contribute to functional leg length inequality?

Pelvic obliquity and uneven surfaces (e.g., road camber, beach, or indoor track)

How to treat a functional leg length inequality?

Educate on uneven surfaces and be clear about how they should even out their running

What may be found with palpation in GTPS?

Tenderness over the posterior greater trochanter

What should be assessed during a GTPS examination?

Posture, functional movement, and the lower-quarter (LQ) screen

What other regions should be assessed for contributing factors in GTPS?

The lumbar spine, knee, and ankle ROM

What movement may cause pain with muscle contraction in GTPS?

Resisted and active hip abduction, possibly with external rotation

What may be found with muscle stretch in GTPS?

Pain and limited ROM at end-range hip adduction, IR, during active or passive ROM (maybe even a little into extension)

Strength deficits in what muscles are MOST expected with GTPS?

Glute medius/minimus and Glute Max

Is iliopsoas most likely overactive in someone with GTPS?

Yes

What tissue length tests may be positive in GTPS?

Ober test and the 2-joint hip flexor test (TFL)

What tissue is commonly assessed for tightness in GTPS?

The TFL

What muscle impairments should be assessed in GTPS?

Control, endurance, and strength

What gluteal strength finding may be present in GTPS?

Bilateral gluteus medius weakness with pain

What does "play/tone" assessment examine in GTPS?

ITB mobility over adjacent structures and the tone of the posterior gluteals and TFL

Is there a special test or test cluster that can identify the specific structures involved or severity of GTPS?

No. There is currently no single test or cluster of tests that can do this

Can MRI findings alone be used alone to diagnose GTPS?

No. MRI findings should be corroborated with the patient's history and clinical test results

What should clinicians focus on when examining a patient with GTPS?

Identifying the impairments responsible for the occurrence and persistence of GTPS

What nerve is MOST likely to mimic signs of GTPS?

Lateral Femoral Cutaneous

When should special tests be used during an examination?

Perform them at the end of the exam and only choose tests that are necessary and add meaningful information to clinical decision-making.

What is a differential diagnosis for GTPS?

Meralgia paresthetica

What is meralgia paresthetica?

Entrapment of the lateral femoral cutaneous nerve

What symptoms are associated with meralgia paresthetica?

Anterolateral thigh symptoms, including burning, coldness, lightning-type pain, deep muscle ache, tingling, and paresthesia

What positions or movements can worsen meralgia paresthetica?

Hip extension, lying prone, and prolonged standing

What interventions may be used for meralgia paresthetica?

Neurodynamic interventions and addressing restrictive clothing (tight jeans and janitor keychain)

What would not be present with meralgia paresthetica that would be present in GTPS?

Muscle Weakness and palpation pain of greater trochanter

What is the first goal of GTPS management?

Interrupt the pain cycle

What strategies can help interrupt the pain cycle in GTPS?

PRICE, active rest, and posture education for sleeping, standing, and sitting

What factors should be considered when managing GTPS?

Leg length differences and other extrinsic contributing factors (pregnancy)

What is the effect of corticosteroid injections for GTPS?

They may provide short-term improvement (~3 months), with no difference at 12 months

What impairments (contributing factors) should be addressed during GTPS rehabilitation?

Muscle length, kinetic-chain ROM, posterior hip strength/dominance, and triplanar movement

How should patients return to activity following GTPS?

With progressive tissue loading, movement re-education, and functional training

How can recurrence of GTPS be prevented?

A home exercise program (HEP), education, and independent self-management

What is more effective for long-term improvement in GTPS: education and exercise or corticosteroid injection?

Education and exercise show better improvement at 52 weeks

Why is iliopsoas (iliopectineal) bursitis considered analogous to GTPS?

Both involve similar irritation patterns, but GTPS occurs laterally while iliopsoas bursitis occurs anteriorly

What condition is associated with iliopsoas (iliopectineal) bursitis and anterior hip snapping?

Internal snapping hip

What structures can contribute to iliopsoas irritation/internal snapping?

The iliopectineal eminence, femoral head, pelvic brim, and bony ridge on the lesser trochanter

What conditions may be associated with iliopsoas (iliopectineal) bursitis?

Iliopsoas tendinopathy and subspine impingement

How does the iliopsoas contribute to anterior hip stability?

A slip of the iliopsoas attaches to the anterior hip capsule and quickly pulls the capsule out of the way during hip flexion to prevent it from being pinched

What is the typical clinical presentation of iliopsoas bursitis?

Insidious onset with anterior hip and/or groin pain

What movements can aggravate iliopsoas bursitis?

Lumbar extension and/or hip hyperextension

What conditions should be considered in the differential diagnosis of iliopsoas bursitis?

Hip joint pathology, anteromedial impingement, FAI, snapping hip, and lumbar nerve root pathology (L2-L3)

What factors increase the risk of iliopsoas bursitis?

Hip instability, DDH, and increased femoral anteversion

When performing STTT on someone with iliopsoas Bursitis, what would most likely cause pain?

AROM and RROM Flexion, as well as, PROM and AROM Endrange Extension

What asymmetry may be found with iliopsoas bursitis?

A "hot psoas"—palpation of the psoas causes the patient to "jump" and reproduces their specific pain.

What ROM findings may be present with iliopsoas bursitis?

Pain with resisted hip flexion and pain/limitation with end-range A/PROM hip extension and external rotation

What muscle function should be assessed with iliopsoas bursitis?

Lower abdominal and posterior hip muscle function

What tissue characteristics should be assessed in iliopsoas bursitis?

Psoas play and tone