Assessing Hip Pain

Assessing and Managing Lateral Hip Pain: A Comprehensive Guide for Dealing with Hip Bursitis

Lateral hip pain, which manifests as discomfort on the outer side of your hip, can pose a significant challenge when it comes to diagnosis and management. It's a prevalent orthopedic issue that's often referred to by various names, such as;

hip bursitis
gluteal tendinopathy
tensor fascia lata tendinopathy,
or simply lateral hip pain.

These conditions are all encompassed under the broader term known as Greater Trochanteric Pain Syndrome (GTPS). GTPS is characterized by degeneration affecting the gluteal tendons and bursa, resulting in persistent pain along the outer aspect of the thigh.

Women around the age of 50-60yrs old in active wear being limited on a walk by hip pain down at the beach in Geelong

Understanding Greater Trochanteric Pain Syndrome (GTPS)

Etiology and Pathophysiology: Why Does It Happen?

GTPS is a condition with a complex, multifactorial origin, influenced by both intrinsic and extrinsic factors. For women grappling with GTPS, it's crucial to comprehend these underlying causes:

Intrinsic Factors of GTPS:

Muscle Weakness: Inadequate strength in muscles attaching to the greater trochanter, like the gluteus medius and minimus, can lead to added strain on the soft tissues around the hip.
Inflexibility: Tightness in the muscles of the hip and thigh may contribute to GTPS.
Muscle Strength Imbalance: An uneven distribution of strength among hip muscles, such as the gluteus medius and minimus versus hip abductors, can also be a factor in GTPS.

Diagram of a person's legs showing a typical and a femoral anteversion. The femur is the thigh bone. The tibia is the shin bone. In the typical leg, the femur is straight, with the head of the femur pointing forward. In the leg with femoral anteversion, the femur is twisted inward, with the head of the femur pointing inward. Additional notes: Femoral anteversion is a normal variation in anatomy. It is more common in children and adolescents. Femoral anteversion can cause a number of problems, including intoeing, knee pain, and difficulty with certain sports. This image may be used to educate people about femoral anteversion and its potential consequences.

Biomechanical Abnormalities: Certain biomechanical issues, like excessive femoral anteversion, hip internal rotation, increased pelvic width, or a higher Q angle, can elevate the risk of GTPS.

iagram of the Q angle of a male and female skeleton. The man has a small Q angle, while the woman has a large Q angle. Additional notes: The Q angle is the angle between the quadriceps tendon and the patellar tendon. A larger Q angle is associated with an increased risk of knee injuries. This image may be used to educate people about the Q angle and its implications for knee health.

Leg Length Discrepancy: A noticeable difference in leg length can amplify stress on the soft tissues surrounding the hip, potentially causing GTPS.
Increased Adiposity: Excess body weight can place greater stress on the hip's soft tissues, increasing the risk of GTPS.

Extrinsic Factors of GTPS:

Repetitive Activities: Engaging in activities that repeatedly involve hip abduction and external rotation (e.g., running, walking, swimming) may heighten the risk of GTPS.
Mechanical Overload: Overloading the soft tissues around the hip through excessive or intense training can also contribute to GTPS.
Training Errors: Errors in training, such as incorrect form or technique, may increase the likelihood of GTPS.
Sedentary Lifestyle: A lack of physical activity and prolonged periods of sitting can weaken the hip muscles, making them more susceptible to injury.

One noteworthy factor to consider is the role of abnormal pelvic width in causing repetitive microtrauma to the gluteal tendons. This condition is characterized by microtrauma at the greater trochanter insertion site, leading to local inflammation and tendon degeneration. This degeneration is associated with changes in collagen composition, notably a decrease in type 1 collagen and an increase in type 3 collagen, resulting in reduced tendon strength.

Clinical Presentation:

Women with GTPS typically present with lateral hip pain. They may experience tenderness around the greater trochanter, pain during hip rotation, abduction, or adduction, and discomfort when lying on the affected hip. Furthermore, patients may report radiating pain to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract. It's crucial to bear in mind that GTPS can sometimes be misdiagnosed due to its non-specific symptoms, especially in younger adults.

Evaluation and Diagnosis

Often there will be a dramatic change in load or activity change to trigger the pain.

It also often presents as lateral hip pain that worsens with weight-bearing activities and side lying.

Radiating pain down the lateral thigh to the knee is common.

Sudden exercise, falls, or overuse, especially in activities like long-distance running, can trigger or exacerbate symptoms.

How can you assess yourself at home?

1. Pain Location Assessment:

Locate the area of pain on the outside of your hip, typically around the greater trochanter region.

Use a pain scale (0 to 10) to rate the severity of the pain, with 0 indicating no pain and 10 being the most severe pain imaginable.

2. Trendelenburg Test:

Stand in front of a mirror or have someone observe you.

Lift one leg off the ground while balancing on the other.

Note if your pelvis drops on the unsupported side (the side without the raised leg).

A noticeable drop of the pelvis on the unsupported side may suggest weakness in the hip abductor muscles.

3. Single-Leg Stance Test:

Stand on one leg while keeping the other foot slightly off the ground.

Attempt to maintain balance for 30 seconds.

Assess if you experience pain in the lateral hip area during this test.

4. Painful Movements Assessment:

Gently perform hip movements, such as hip rotation, abduction (lifting your leg sideways), adduction (bringing your leg back to center), and flexion (bringing your knee toward your chest).

Note if any of these movements provoke or worsen your hip pain.

5. Resisted Hip Abduction Test:

Sit in a chair with your feet flat on the ground.

Place a resistance band around your legs, just above your knees.

Spread your knees apart against the resistance band.

Feel for any pain or discomfort in the lateral hip area.

6. Lying on the Affected Hip Test:

Lie down on your affected hip, with your legs straight.

Pay attention to any discomfort or pain while lying in this position.

7. Palpation (Tenderness Check):

Gently press your fingers over the greater trochanter area on the outside of your hip.

Note if you feel tenderness, soreness, or pain when applying pressure.

8. Pain During Activities:

Keep a daily journal to record any activities, exercises, or movements that exacerbate your hip pain.

Include details about the duration and intensity of pain during these activities.

Remember that these self-tests are meant for informational purposes and can help you communicate your symptoms to a healthcare professional. A definitive diagnosis and personalised treatment plan should be obtained through consultation with a healthcare provider, typically a physiotherapist. At Move Sports Physio we can conduct a comprehensive evaluation to rule in or out GTPS and develop an appropriate course of action for your specific condition.

Physical Examination (For the junior clinicians reading):

This examination can be divided into four parts: standing, seated, supine, and prone evaluations.

Standing Examination: Observe the patient's gait, posture, and leg stance, looking for abnormal gait patterns such as antalgic gait or Trendelenburg gait, which may indicate hip or pelvic issues. Additionally, perform the single-leg stance test to assess hip abductor musculature and proprioception.

Seated Examination: Evaluate motor function, sensation, and circulation in a seated position. Assess muscles supplied by various nerves, including the femoral, obturator, superior gluteal, and sciatic nerves.

Supine Examination: Examine hip range of motion, focusing on flexion, extension, adduction, and abduction. Pay close attention to any limitations or pain during these movements. Perform specific provocative maneuvers like FADDIR, superiorolateral impingement test, DEXRIT/DIRI, FABER, and posterior rim impingement test.

Prone Examination: In the prone position, assess the precise location of pain related to the sacroiliac (SI) joint region and measure femoral anteversion using Craig's test.

OKAY, I'm all over that - but what else could it be?

It's important to consider other potential diagnoses and rule them out. These may include

Acetabular labral tear
Stress fracture, dislocation, or contusion
Osteonecrosis or avascular necrosis
Muscle strain or tear
Ligament sprain
Sacroiliac joint dysfunction
Snapping hip syndrome
Tendinopathy
Femoral acetabular impingement
Nerve entrapment syndrome
Inflammatory disorders like rheumatoid arthritis or seronegative arthropathy
Infection
Metabolic disorders
Malignancy
Childhood disorders such as Legg-Calve-Perthes disease
Primary or secondary osteoarthritis

Interested in what Sports Physiotherapy services we offer at Move to help with lateral hip pain?

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For the Physios/ Junior Clinicians;

This image shows a diagram of the causes of lateral hip pain. The three main causes are: Greater trochanteric pain syndrome (GTPS): This is a condition that causes pain around the greater trochanter, which is a bony prominence on the outside of the hip. It is often caused by overuse or inflammation of the tendons that attach to the greater trochanter. Hip osteoarthritis (OA): OA is a degenerative joint disease that can cause pain and stiffness in the hip joint. It is more common in older adults, but it can also occur in younger people, especially those who have had hip injuries. Lumbar spine (referred) pain: Pain from the lumbar spine can sometimes refer to the lateral hip. This is because the nerves that innervate the hip also innervate the lumbar spine. The image also shows some of the key symptoms of each of these conditions. For example, GTPS is often characterized by pain on activity, pain on side lying, and tender palpation of the greater trochanter. Hip OA is often characterized by morning stiffness, associated groin pain, and progressive course. Lumbar spine (referred) pain is often characterized by low back pain, radiation to the lateral hip, and reduced range of motion. If you are experiencing lateral hip pain, it is important to see a doctor or physical therapist to get a diagnosis and treatment plan. Additional notes: The image does not specify which of the three conditions is the most likely cause of lateral hip pain in each individual case. This is because the symptoms of the three conditions can overlap. The image also does not specify the best treatment for each condition. This will vary depending on the individual's specific circumstances. If you are experiencing lateral hip pain, it is important to see a doctor or physical therapist to get the best possible care.

Soucred: PMC full text: Br J Gen Pract. 2017 Oct; 67(663): 479–480. doi: 10.3399/bjgp17X693041

This image shows a table of key subjective and objective findings for different diagnoses that can cause pain in the hip and low back. The diagnoses include lumbar spine pathology, hip joint osteoarthritis, and femoral stress fracture. Subjective findings Pain that radiates below the knee Low back pain that increases with sitting or walking Pain that increases with movement of the lumbar spine Pain located in the anterior hip Morning stiffness that resolves in <1 hour Increased pain and difficulty with weight bearing activities Objective findings Pain located in the anterolateral hip that worsens with weight bearing Recent rapid increase in weight bearing activities Pain, weakness, or altered sensation in dermatomal or myotomal pattern Abnormal findings during lower extremity reflex testing Pain reproduced with motion testing of the lumbar spine Reproduction of pain during a FABER and/or Scour test Decreased range of motion in a capsular pattern Antalgic gait pattern Painful and limited hip range of motion Antalgic gait pattern If you are experiencing pain in your hip or low back, it is important to see a physiotherapist to get a diagnosis and treatment plan.

Sourced: Disantis AE, Martin RL. Classification Based Treatment of Greater Trochanteric Pain Syndrome (GTPS) with Integration of the Movement System. Int J Sports Phys Ther. 2022 Apr 1;17(3):508-518. doi: 10.26603/001c.32981. PMID: 35391855; PMCID: PMC8975585.

Physiotherapist helping client in side lying with strengthing her hip to reduce lateral hip pain

Imaging:

While clinical diagnosis remains crucial, imaging can be valuable in confirming the diagnosis and ruling out other pathologies. Plain film radiographs of the pelvis are useful for excluding fractures or osseous abnormalities. Magnetic resonance imaging (MRI) can distinguish between extra-articular and intra-articular causes of hip pain, aiding in identifying GTPS and ruling out suspected labral pathology.

Your physiotherapist at Move Sports Physiotherapy & Pilates will complete a thorough assessment and guide you if you require further imaging to manage your pain.

Stay tuned for our next article where we deep dive into the management of GTPS and what you can do about it.

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References

Disantis AE, Martin RL. Classification Based Treatment of Greater Trochanteric Pain Syndrome (GTPS) with Integration of the Movement System. Int J Sports Phys Ther. 2022 Apr 1;17(3):508-518. doi: 10.26603/001c.32981. PMID: 35391855; PMCID: PMC8975585.

Livingston JI, Deprey SM, Hensley CP. DIFFERENTIAL DIAGNOSTIC PROCESS AND CLINICAL DECISION MAKING IN A YOUNG ADULT FEMALE WITH LATERAL HIP PAIN: A CASE REPORT. Int J Sports Phys Ther. 2015 Oct; 10(5):712-22. [PMC free article] [PubMed] [Reference list]

Pumarejo Gomez L, Childress JM. Greater Trochanteric Pain Syndrome. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557433/

Speers CJ, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. Br J Gen Pract. 2017 Oct;67(663):479-480. doi: 10.3399/bjgp17X693041. PMID: 28963433; PMCID: PMC5604828.