English

Abstract

Introduction Proximal lateral thigh pain is a common musculoskeletal complaint. Tenderness at the femoral greater trochanteric area is often diagnosed as trochanteric bursitis. This term is probably a misnomer because of evident non-inflammatory pathologies, particularly of the abductor tendons of the hip and is currently referred as the greater trochanteric pain syndrome. Although the clinical presentation seems straightforward it is important to differentiate this extra-articular source from an intraarticular or a lower back source of pain. Non-traumatic acute pain does not require the use of imaging modalities. Imaging of the lower spine and pelvis should be ordered in cases of prolonged pain or uncertain diagnosis. Non-operative treatment that involves modifying activities, physiotherapy, analgesics, steroid injections and shock wave therapy is usually helpful. Nevertheless, despite the above treatments about one-third of the patients suffer from chronic pain and disability. These patients may be candidates for operative intervention such as local decompression, bursectomy and suture of torn tendons. The aim of this review was to discuss trochanteric bursitis of the hip. Conclusion The differential diagnosis for greater trochanteric pain syndrome includes pathologies around the hip and lower back. Usually non-operative treatment that includes modified activity, physiotherapy, local injections and shock wave therapy is helpful. Introduction Greater trochanteric pain syndrome (GTPS) is a common clinical diagnosis. Typically, the pain is at the lateral side of the hip around the greater trochanter (GT) region, mostly in middleaged women and disturbs the activities of daily living. The pathophysiology is not completely understood. One of the earliest descriptions was published by Partridge1 in 1948 and was often termed the ‘great mimicker’ because of its similarities to other pathologies. The more familiar term ‘trochanteric bursitis’ that implies an inflammatory process is probably inaccurate. Recent histological2, radiological3 and surgical4 investigations showed tendinopathy and tears of the gluteal tendons around the GT with no significant inflammation of the bursae. Currently, the more acceptable term is GTPS5,6. This article reviews the anatomy, aetiology, diagnosis and updated treatment modalities of GTPS. Discussion Anatomy The gluteus medius, gluteus minimus and tensor fascia lata muscles are the main abductors of the hip joint and stabilise the femoral head inside the acetabulum during motion and weight bearing7. The pain in GTPS is related to various pathologies in these tendons with secondary involvement of the surrounding bursae. There are some similarities in function and malfunction between the hip abductors and the rotator cuff tendons of the shoulder8. The abductor muscles originate from the posterior aspect of the iliac bone and insert into the femoral GT. Specifically, the gluteus medius inserts into the superolateral aspect and the gluteus minimus into the anterior aspect of the GT. Bursa is a small fluid-filled sac that reduces friction between bone and soft tissue. Four bursae were described around the GT and deep to the gluteal muscles (Figure 1) while two are consistently found in most people9: the subgluteus medius bursa (between the gluteus medius and the GT) and the subgluteus maximus bursa (between the gluteus medius and gluteus maximus, lateral to the GT). The latter is the largest and often accused in causing the pain of ‘trochanteric bursitis’. There are other minor bursae that decrease the friction between gluteal muscles, tensor fascia lata and iliotibial band (ITB). The subgluteus minimus bursa is small and located superior and anterior to the GT while, the gluteofemoral bursa is inferior to the GT, adherent to the ITB at the insertion site of the gluteus maximus. Aetiology The aetiology of GTPS is variable. Direct injury to the proximal thigh or repeated irritation of the gluteal muscles and ITB against the GT can trigger symptoms. Limb length differences whether static or temporary (i.e. running on uneven surfaces) create mechanical imbalance that may influence the abductor muscles. Although sometimes there is no obvious cause, many related factors were found to be correlated with GTPS such as age, female sex, overweight, gait disturbances and lower back pain10. Schapira et al.11 found that GTPS was correlated with arthritis of the lower back or lower limbs in 91.6% of the cases. *Corresponding author Email: barak_haviv69@hotmail.com Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petach-Tikva,