Lateral

Lateral hip pain has been traditionally diagnosed as Trochanteric Bursitis but recent evidence now suggests it is primarily caused by pathology of the gluteal tendons, particularly gluteus medius and minimus. Gluteal Tendinopathy can be associated with trochanteric bursal ‘distension’ but research does not support the presence of an inflammatory bursitis. Isolated bursal pathology is rare and if present is almost always associated with a tendinopathy.

Onset of symptoms is normally gradual and insidious and is commonly associated with an increase in activity and a resultant increase in tendon loading. Trauma is rare.

Pain is located at the lateral hip around the greater trochanter and can travel down the lateral thigh, occasionally into the lower leg. Common aggravating factors include lying on the affected side, walking, sitting with legs crossed, stair climbing and rising from a chair.

There will be no associated neurological symptoms present but it can co-exist with osteoarthritis of the hip and/or lumbar spine pathology.

Prevalence

Females are more commonly affected than males at a ratio of around 4:1. It normally presents in those greater than 40 years old and although it occurs in sedentary individuals, younger athletes can also be affected, particularly runners (Del Bueno et al, 2011).

There is currently a lack of evidence regarding the diagnostic utility for the most frequently used objective tests. A number of tests can be used in clinical practice with an increasing number of positive tests more likely to indicate gluteal tendon pathology.

Direct Palpation

It is generally agreed that pain on palpation directly over or around the greater trochanter in the region of the gluteal tendon insertions would be required for a diagnosis of gluteal tendinopathy or bursal pathology to be made (Grimaldi et al, 2015).

Single Leg Stand (Lequesne et al, 2008) (Video Link)

Reproduction of lateral hip pain within 30 seconds while standing on the affected leg is indicative of tendon pathology and is regarded as a positive test (Sensitivity 100%, Specificity 97.3%).

Trendelenburg’s Sign (Bird et al, 2001) (Video Link)

A positive Trendelenburg Sign occurs when the pelvis drops on the non-weight bearing side during stance. If present during both gait and single leg standing on the affected side it is indicative of a gluteal tendon tear (Sensitivity 72.7%, Specificity 76.9%).

FADER (Flexion, Adduction, External Rotation) (Video Link)

In supine, passively flex the hip 90°, adduct and externally rotate. A positive test occurs with reproduction of lateral hip pain due to the compressive loading of the gluteal tendons in this position (Grimaldi et al, 2015).

Resisted External Derotation Test (Lequesne et al, 2008) (Video Link)

While in the FADER position, resist active internal rotation of the hip. Both compressive and tensile loading of the gluteal tendons are believed to occur and reproduction of lateral hip pain is a positive test (Sensitivity 88% and Sensitivity 97.3%).

FABER test (Video Link)

Flexion to 90°, combined with abduction and external rotation. Reproduction of lateral hip pain and NOT limitation of range of motion is indicative of a positive test (Grimaldi et al, 2015).

Ober’s Test + Resisted Abduction (Video Link)

Patient is positioned in side-lying on non-affected side. Place hip in end-range adduction in extended position. Resist hip abduction with hip in adducted position. Both compressive and tensile loading of the gluteal tendons are believed to occur and reproduction of lateral hip pain is a positive test (Grimaldi et al, 2015).

Hip Lag Sign (Kaltenborm et al, 2014) (Video Link)

Patient is positioned in side-lying on non-affected side. Examiner passively abducts hip to 20°, extends to 10° and internally rotates fully. A positive test is when the foot drops more than 10cm when the patient is asked to actively remain at this point, thus indicating weakness. This should be repeated 3 times and as is used to diagnose hip abductor damage which includes tendinosis, partial rupture and rupture (Sensitivity 89.4%) (Specificity 96.5 %).

Active Abduction in Side-Lying

An inability to actively abduct the hip in side-lying would likely indicate a large abductor tear or possible rupture.

Patient reported Outcome Measures

The VISA G is a validated questionnaire (Fearon et al, 2015).

MRI can be requested by Orthopaedics and is seen as the ‘gold standard’ to confirm presence of a tendon tear, tendinopathy or bursitis/bursal distension.

• Optimise pain management
• Minimise tendon compression
• Muscle re-training (isometrics → functional exercise)

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment, based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Lustenberger et.al 2011 reviewed all available research in relation to efficacy of treatment. To date there has only been one controlled trial (Level 2 evidence) which investigated exercise for lateral hip pain (Rompe et al, 2009). 41% of patients improved after 4 months and 80% at 15 months following a 12 week home exercise programme with 81% of subjects reporting to have continued with their home programme on their own after 12 weeks.

Minimise Tendon Compression

Both hip adduction (Birnbaum et al, 2004) and hip flexion greater 90° (Grimaldi et al, 2015) are believed to compress the gluteal tendons against the greater trochanter at its insertion point. Therefore, both postural re-education and avoidance of static gluteal and ITB stretching are believed to be key components of a rehabilitation programme (Grimaldi et al, 2015).

1. Postural Re-education:

• Standing - no ‘hanging on hip’
• Sitting - avoid cross legged and lower chairs where hip is > 90° hip flexion
• Sleeping - supine or pillow(s) between knees in side lying

2. Static Stretching:

Although included in the programme by Rompe et al (2009), gluteal and ITB stretching may not be as effective as previously believed due to the compression of the gluteal tendons that occurs during hip adduction. Therefore, prior to initiating a stretching programme, ensure muscle length testing confirms true muscle shortening.

Optimise Muscle Function and Tendon Loading

• Modification of activity to reduce tendon loading may be required initially
• Muscle re-training (isometrics -> concentric/eccentric -> functional exercise)
• All advice and treatment should not cause symptoms to ‘flare’

Exercise Management

• Improve abductor function with muscle re-training (isometrics -> concentric/eccentric -> functional exercise)
• Consider isometrics if very painful +/- weak
• Progress as symptoms allow
• Generally 3 – 4 months to see significant improvement

Corticosteroid Injection

Corticosteroid injections into the lateral hip are often used as a first-line treatment as historically it has been believed that the pain is secondary to a bursitis. Studies have shown that they can be effective in the short-term but there is a risk of recurrence. (Del Bueno et al, 2011). In the study by Rompe et.al 2009, a single steroid injection resulted in 75% of patients being significantly improved at one month follow-up but this fell to 51% after 4 months and 48% after 15 months.

Non evidence based strategies

• Acupuncture
• Ultrasound
• Shortwave
• Heat
• Ice

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

• Discuss with senior member of staff
• Consider referral to Orthopaedics for imaging, steroid injection or surgical opinion if conservative measures are failing or large tear or rupture is suspected
• Surgery is rare, but can be effective when a gluteal tendon tear is visible on MRI and conservative management has been unsuccessful (Lequesne et al, 2008)

VISA G

Bird, P.A., Oakley, S.P., Shnier, R. and Kirkham, B.W. 2001. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis and Rheumatism, 44(9): 2138-2145 Link Here (link correct as of 22/01/2021). NHS Scotland Athens username and password may be required.

Del Bueno, A., Papalia, R., Khanduja, V., Denaro, V. and Maffulli, N. 2011. Management of the Greater Trochanteric Pain Syndrome: a systematic review. British Medical Bulletin. 102: 115-131 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be requi red.

Fernon, A,M., Ganderton, C., Scarvell, J.M., Smith, P.N., Neeman, T., Nash, C. and Cook, J.L. 2015. Development and validation of a VISA tendinopathy questi-nnaire for greater trochanteric pain syndrome, the VISA-G. Manual Therapy, 20(6): 805-813 Link here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Grimaldi, A. Mellor, R., Hodges, P., Bennell, K., Waiswelner, H. and Vicenzino, B. 2015. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine, 45(8) 1107-1119 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Lequesne, M., Mathieu, P., Vuilemin-Bodaghi, V., Bard, H. and Dijian, P. 2008. Gluteal tendinopathy in refractory greater trochanteric pain syndrome: diagnostic value of two clinical tests. Arthritis and Rheumatism, 59(2): 241-246 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Lequesne, M. Dijan, P., Vuilemin, V. and Mathieu, P. 2008. Prospective study of refractory greater trochanteric pain syndrome. MRI findings of gluteal tendons tears seen at surgery. Clinical and MRI results of tendon repair. Joint Bone Spine, 75: 458-464 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Birnbaum, K., Pandorf, T., Schopphoff, E., Prescher, A. and Niethard, F.U. 2004. Anatomical and biomechanical investigations of the iliotibial tract. Surgery, Radiology and Anatomy 2004. 26. 433-446 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Lustenberger, D. Ng, V.Y., Best, T.M, and Ellis, T.J. 2011. Efficacy of treatment of trochanteric bursitis. Clinical Journal of Sports Medicine 21(5): 447-453 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Rompe, J.D., Segal, N.A., Cacchio, A., Furia, J.P., Morral, A. and Maffulli, N. 2009. Home training, local corticosteroid injection or radial shockwave therapy for greater trochanteric pain syndrome. American Journal of Sports Medicine, 37(10): 1981-1990 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

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