Greater Trochanteric Pain Syndrome

Lower Limb

Overview

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain arising from pathology of the gluteal tendons, bursa, and associated soft tissues around the greater trochanter. It predominantly affects middle-aged and older adults, particularly women, and is often exacerbated by activities involving hip adduction and internal rotation. The condition results from cumulative microtrauma, muscle weakness, and altered biomechanics rather than a single traumatic event.

Pathophysiology

GTPS develops through chronic irritation and degeneration of the gluteus medius and minimus tendons where they insert on the greater trochanter. The primary mechanism involves excessive hip adduction and internal rotation—often from weak hip abductors, tight hip flexors, or altered pelvic mechanics—creating repetitive tensile and compressive stress on these structures. Secondary inflammation of the trochanteric bursa occurs as a consequence. Gluteal muscle weakness from prolonged sitting, altered movement patterns, or neuromotor dysfunction perpetuates the cycle, while lateral pelvic tilt and trunk instability amplify load distribution to the lateral hip structures.

Patient Education

GTPS typically improves with graded strengthening of the hip abductors and external rotators combined with activity modification and correction of movement patterns; avoid prolonged sitting, sleeping on the affected side, and repetitive hip adduction movements.

Typical Presentation

Site

Lateral hip at the level of the greater trochanter; may radiate along the lateral thigh to the knee

Quality

Sharp, aching, or burning pain; described as tenderness directly over the bony prominence

Intensity

Mild to moderate, often 4-7/10; varies significantly with activity and time of day

Aggravating

Prolonged standing, walking or running (particularly on slopes or cambered surfaces), climbing stairs, side-lying on the affected side, hip adduction activities, single-leg stance, rising from seated position, crossing legs

Relieving

Rest, avoiding provocative movements, side-lying on the unaffected side, analgesia, application of heat

Associated

Hip weakness on resisted abduction and external rotation; positive single-leg stance test; altered gait mechanics with pelvic drop on contralateral side; tight hip flexors and tensor fasciae latae; reduced hip internal rotation; possible referred symptoms into lateral thigh

Orthopaedic Tests

Single Leg Stance (Trendelenburg Test)

Procedure

Patient stands on one leg with the opposite hip flexed to 45°; observe for pelvic drop on the stance side. Perform for 30 seconds.

Positive Finding

Hip adductor weakness or pain; pelvis drops below horizontal on the non-stance side, or patient cannot maintain position due to lateral hip pain

Sensitivity / Specificity

null / null

Interpretation

Suggests gluteal (particularly gluteus medius) weakness or inhibition; commonly present in GTPS but not diagnostic alone. Helps identify proximal cause of lateral hip pain.

Single Leg Stance (Trendelenburg Sign with Pain Reproduction)

Procedure

Patient performs single-leg stance while examiner palpates the greater trochanter; assess for lateral hip pain reproduction.

Positive Finding

Sharp or aching lateral hip pain at the greater trochanter region during stance phase on the affected leg

Sensitivity / Specificity

null / null

Interpretation

Reproduces pain localised to GTPS; indicates load-related symptom provocation consistent with tendinopathy or bursitis at the GT region.

Resisted Hip Abduction (Sidelying)

Procedure

Patient lies on unaffected side; examiner resists hip abduction of the upper leg. Alternatively, perform seated or standing hip abduction resistance.

Positive Finding

Lateral hip pain at the greater trochanter or weakness of abduction, particularly in the first 15–20° of abduction

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Specific to gluteus medius/minimus dysfunction; pain indicates tendon irritation or muscle inhibition. Often reproduces patient's presenting complaint.

Ober Test

Procedure

Patient lies on side with hip flexed 45° and knee flexed; examiner abducts and slightly extends the hip, then slowly lowers the leg. Assess if knee falls below horizontal (abducted hip position).

Positive Finding

Hip remains abducted (knee does not cross midline or drops only slightly below horizontal); indicates iliotibial band tightness

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Detects ITB or tensor fasciae latae tightness, which can contribute to GTPS by increasing friction over the GT. Positive result suggests need for ITB mobility work.

Lateral Hop Test / Single-Leg Hop for Distance

Procedure

Patient performs single-leg hops on the affected leg, attempting to hop forward for maximum distance or hop repeatedly on the spot for 15–30 seconds while maintaining form.

Positive Finding

Reduced hop distance or inability to complete repetitions; pain at the greater trochanter or difficulty controlling the pelvis (pelvic drop)

Sensitivity / Specificity

null / null

Interpretation

Integrates strength, proprioception, and pain-free control; reflects functional capacity and dynamic gluteal stability. Useful for severity grading and progress monitoring.

Palpation of the Greater Trochanter (Tender Point)

Procedure

Patient lies on side (unaffected side down) or in supine; examiner palpates directly over the greater trochanter bony prominence, including the trochanteric bursa region. Apply gentle to moderate pressure.

Positive Finding

Focal tenderness over the GT or adjacent bursal region; patient reports sharp or dull pain consistent with their presenting complaint

Sensitivity / Specificity

null / null

Interpretation

Confirms localisation of pain to the GT region; helps differentiate GTPS from other causes of lateral hip pain (e.g. hip labral pathology, L5 radiculopathy). Mandatory part of clinical diagnosis.

⚠ Red Flags

  • •Acute traumatic onset with severe pain or inability to weight-bear suggesting fracture or acute bursitis
  • •Unintentional weight loss, fever, or systemic symptoms suggesting systemic disease or infection
  • •Night pain at rest unrelated to movement suggesting malignancy or severe inflammation
  • •Progressive neurological deficit, saddle anesthesia, or bowel/bladder changes suggesting cauda equina syndrome
  • •Hip pain associated with significant swelling, erythema, or warmth suggesting septic arthritis
  • •History of inflammatory arthropathy with morning stiffness >1 hour suggesting rheumatological condition

⚡ Yellow Flags

  • •Catastrophizing beliefs about pain or movement ('my hip is permanently damaged')
  • •High pain-related kinesiophobia leading to activity avoidance and deconditioning
  • •Prolonged work absence or social withdrawal secondary to pain
  • •Significant psychological distress, anxiety, or depression concurrent with symptom onset
  • •Frequent healthcare seeking with poor response to multiple interventions suggesting illness anxiety
  • •Litigation or compensation claims related to the hip condition
  • •Discordance between reported pain severity and functional limitations observed during examination

Osteopathic Techniques

Region

Gluteus medius and minimus

Technique

Soft Tissue

Rationale

Direct soft tissue treatment reduces muscular tension, improves tissue extensibility, and addresses myofascial trigger points in these key abductor muscles; enhances local circulation and promotes neuromuscular re-education

Region

Greater trochanter and trochanteric bursa

Technique

Soft Tissue

Rationale

Gentle transverse friction and soft tissue mobilization addresses bursal irritation and promotes healing without excessive inflammation; reduces adhesion formation around tendinous insertions

Region

Hip joint and surrounding musculature

Technique

Articulation

Rationale

Gentle hip articulation in ranges that avoid internal rotation and adduction maintains joint mechanics, improves synovial fluid distribution, and prevents secondary stiffness; supports gluteal muscle activation patterns

Region

Tensor fasciae latae and iliotibial band

Technique

Soft Tissue

Rationale

Releasing tension in the TFL and ITB reduces compressive forces on the greater trochanter and lateral hip structures; addresses the proximal-distal relationship affecting lateral hip mechanics

Region

Hip flexors (iliopsoas and rectus femoris)

Technique

MET

Rationale

Muscle energy techniques to hip flexors restore reciprocal inhibition of gluteal muscles, improve anterior hip extensibility, and correct altered pelvic mechanics that contribute to excessive hip adduction stress

Region

Lumbar spine and sacroiliac joint

Technique

Articulation

Rationale

Addressing segmental restrictions in the lumbar spine and sacroiliac joint restores pelvic stability and reduces compensatory lateral hip loading; corrects postural asymmetries that perpetuate GTPS

Add-On Approaches

Chinese Medicine

Acupuncture to local points (GB31 Fengshi, GB34 Yanglingquan) and distal points (GB40, LV3) to reduce pain and improve qi flow along the Gallbladder meridian; moxibustion for chronic cold-pattern presentations; cupping over gluteal region to relieve stagnation

Chiropractic

Manipulation of the sacroiliac joint and lumbar spine to restore pelvic alignment; adjustment of hip mechanics; mobilization with movement techniques for hip external rotation; gait analysis and orthotics prescription

Physiotherapy

Progressive hip abductor and external rotator strengthening (including side-lying abduction, clamshells, lateral band walks, single-leg stance exercises); core stabilization and lumbar-pelvic control; gait retraining; activity pacing and load management; iliopsoas stretching

Remedial Massage

Deep transverse friction massage to gluteal tendons; sustained pressure release of gluteus medius trigger points; soft tissue mobilization of tensor fasciae latae and iliotibial band; myofascial release techniques; gentle stripping massage of gluteal muscles

Rehabilitation Exercises

Sidelying Hip Abduction

StrengtheningBeginner

Clamshells (Hip External Rotation)

StrengtheningBeginner

Lateral Band Walks

StrengtheningBeginner

Glute Bridges

StrengtheningIntermediate

Single-Leg Glute Bridge

StrengtheningAdvanced

Single-Leg Stance

BalanceIntermediate

Hip Flexor Stretch (Modified Thomas Position)

StretchingBeginner

Tensor Fasciae Latae and ITB Stretch

StretchingBeginner

Pelvic Tilts and Core Activation

PosturalBeginner

Hip Internal and External Rotation in Sidelying

Range of MotionBeginner

Sidelying Hip Internal Rotation with Adduction

StrengtheningIntermediate

Single-Leg Romanian Deadlift

BalanceAdvanced

Referral Criteria

  • •Presentation of red flag features suggesting fracture, infection, or malignancy requiring imaging and medical investigation
  • •Failure to improve after 6-8 weeks of conservative management and structured rehabilitation suggesting need for imaging (ultrasound or MRI) and possible injection therapy
  • •Severe pain limiting function and activities of daily living unresponsive to analgesia; consider physiotherapy intensification or injection
  • •Signs of neurological deficit or nerve entrapment (e.g., superior cluneal nerve or lateral femoral cutaneous nerve) requiring specialist assessment
  • •Suspected underlying inflammatory arthropathy or systemic condition requiring rheumatology referral
  • •Symptoms consistent with labral pathology or intra-articular hip joint pathology requiring orthopedic assessment and imaging
  • •Significant psychological distress, catastrophizing, or suspected chronic pain syndrome requiring pain psychology or multidisciplinary pain management