What is it?
Pain over the greater trochanteric region (the bony part at the side of the hip region) traditionally used to be diagnosed as trochanteric bursitis, but due to more information from radiological studies the bursa is often not found to be the primary issue. It is now thought to be an inflammatory problem in the tendons of the gluteus medius and /or minimus (muscles in your bottom). Therefore previous treatment approaches were frequently ineffective as they were aimed at targeting an inflammatory problem of the bursa when it was more likely an issue with the underlying tendons.
Causes
By the time someone presents to a clinician with pain, the tendons have often advanced into a degenerative stage where changes will have occurred within the tendon structure and commonly there will be a compression issue. The ITB (Iliotibial band a strong tissue attached to the gluteus muscles and then stretching down to attach at the outside of the knee) can place too much compression around the outside of hip. While tendons are good at absorbing tensile load they don’t like compression. So in any position where the ITB crosses the greater trochanter and is held in tension, for example when the hip is in adduction (crossing the midline of the body as in crossing the legs), this will result in compression.
Within the tendon structure, compression will cause cell changes. Thickening of the tendon and disorganisation of the fibres occurs and the tendon starts weakening and ultimately tears can occur.
Common symptoms
- Pain over the greater trochanter
- Symptoms can refer down the outside of the leg, possibly below the knee, into the buttock and occasionally into the groin.
- Painful to sleep on at night whether lying on it and also with sore hip uppermost as the hip drops into adduction (causing compression)
- Uphill walking, or climbing up stairs.
- If symptoms are severe then just standing on one leg can be painful.
- Sitting can be painful, or particularly the first few steps after sitting can be stiff and sore
- Comfortable low chairs, & crossing legs can cause more compression pain
- Pain to the foot means its not just a tendon problem & there may be coexisting issues.
- May have a Lumbar spine issue, if chronic = poor recruitment patters, poor gluteal function and then can lead to tendon problems.
Who does it affect?
- Largest group affected are peri/post menopausal woman (typically after a period of weight-gain coupled with an increase in exercising)
- A sudden change in loading on the tendon can start the pain off, i.e an increase in training load, or a sudden unaccustomed amount of activity.
- Sedentary people who then start exercising more.
- Often runners, with symptoms particularly aggravated by hill running.
- More females affected than males
Predisposing factors?
- How you stand, sit with legs crossed, and even the way you sleep can contribute to the problem
- Classically those who sit for long periods of time in leg abduction (knees out to the side) – once you start to walk, run, cycle, and have to bring the legs more to midline, there’s instantly more compressive loading to the outer hip region.
- Standing hanging onto one hip (like when carrying a baby on one hip)
- Overall poor postural and movement habits; Over time you get changes in muscle recruitment patterns, so muscles become less efficient in certain positions. For example in movement patterns like walking and stair climbing the pelvis will tilt and shift more than it should consequently causing more compressive loading. The superficial muscles such as TFL (tensor fasciae latae) and upper gluteus maximus (that join into the ITB), then work harder and this can cause excessive compressive loading.
- Runners: those who run on the same camber all the time, i.e. track running, and various aspects of running style for example, legs crossing over the midline during the stance phase
- Hormonal factors… Estrogen is an important factor for the health of your collagen fibres (an important structure of tendons). That’s why peri/post menopausal woman have a higher incidence of this tendinopathy.
- Post-menopausal can also involve weigh gain particularly around the tummy and higher abdominal fat has been linked with higher incidence of tendon problems.
When to seek help
If symptoms have been present for more than a couple of weeks without showing signs of improvement and/or if your walking pattern and sleep become affected then it is time to seek help.
Treatments available
We can help by identifying the causal factors and supporting you to alleviate pain and eradicate the movements or habits that lead to the problem.
Your Physiotherapist will…
- Look at the way you stand, walk and function on one leg
- During single leg actions, the degree of pelvic tilt and how much it shifts during standing and squatting should be assessed.
- Use several specific pain provocation tests to help determine the correct diagnosis and rule out the source of the problem coming from elsewhere for example the lower back or hip joint.
- They will also assess your muscle function & teach you how to recruit the right muscles and start to improve your motor patterns
Stretching
Understanding it’s a compression issue means stretching will be the last thing you do! As it creates more compression!
Massage in the area may still be beneficial.
Notably most people have long weak abductor systems but they can get trigger points in the muscles.
Some specific self-release techniques may be useful to do at home after being instructed by your physiotherapist.
Hands on treatment….
The most important part of initial treatment is getting educated… learning what the problem is and what causes it. Then treatment should focus on decompression of the area followed by specific guided exercises with your Physiotherapist.
Some simple things YOU can do to help….
In standing avoid hanging off one hip
In sitting, don’t cross legs or have knees together. These habits tend to be strongly engrained so use friends and family to look out for it!
In low seats – use a (wedge) cushion to raise hips higher than the knees
The nighttime issue – if lying on the affected side, try and pad out the mattress with more cushioning like another thin quilt. When the affected side is up, place a big fat pillow between the legs for the hip knee ankle to be horizontal.
When walking – avoid hills, power walking, and over striding. If symptoms are severe you may need a complete break from exercise for a while. If not too severe, find a level of exercise that’s comfy, on the flat, that doesn’t significantly increase the pain.
The biggest indicator if you’re doing too much is if night pain gets worse.
TAKE HOME MESSAGE….seek out an assessment with a Physiotherapist before this problem becomes a lot worse! Ignoring these types of conditions will only worsen the symptoms and prolong the recovery time.