Photo: Pain in the outer hip can have a variety of causes
By Marjolein Groenevelt
Pain in the outer hip has over the years, commonly been called “bursitis” or “iliotibial band” pain. A more comprehensive term is lateral hip pain or GTPS (greater trochanteric pain syndrome) for reasons that are described below. It is common, with an incidence of between 10 and 25 per cent of the population.
Any time there is persistent pain in the hip and buttock area, a detailed examination is needed, since the pain can be coming from a number of sources. The problem could be referred pain from the lumbar spine (low back), the sacroiliac joint, osteoarthritis of the hip or a number of other hip issues. With GTPS, the pain is often localized to the outer side of the hip. It is usually described as achy or burning, can be deep or superficial, constant or intermittent and can range in intensity from mild to severe. It might radiate all the way down the outer leg to below the knee but does not go into the foot. There is often pain with walking, especially on inclines and stairs or while fast walking and running. The person may adopt a protective limp, leaning over to that side while reducing the weight bearing. There is almost always pain lying on that side, especially at night. Sleep may be disturbed, affecting quality of life. Exercise may be reduced, which also affects mental and physical health. With GTPS, symptoms of numbness or tingling are not usually associated. If these symptoms are present, other structures and diagnoses need to be considered.
There has been increased interest in and research on GTPS in the past decade. Magnetic resonance imaging (MRI) will show tendinopathy of gluteus medius and often gluteus minimus. These are hip muscles in the buttock that support the hip when weight-bearing. They become tendons as they attach to the outer part of the hip. Research shows that most people only have gluteal tendinopathy while about 30 per cent have gluteal tendinopathy as well as inflammation of the bursa at the outer hip, known as trochanteric bursitis. A few people also have thickening of the iliotibial band. This is why lateral hip pain, or GTPS, is the preferred term since it is an umbrella term that encompasses pathology of the soft tissues around the hip. Many people with osteoarthritis of the hip joint also have GTPS.
People of any age, body size and activity level can be affected, but GTPS is more common in women over the age of 40. The injury may have a gradual onset, or it may come on suddenly from an intense day of walking, hiking, climbing stairs, moving boxes, gardening or any activity that involves getting up or twisting, bending and lifting. The cause is also linked to weakness in supporting muscles, such as gluteus maximus and core muscles, as well as overactivity leading to excessive load in these smaller tendons.
The treatment approach called “wait and see,” which is to do no intervention and see if the problem will go away on its own, is not very effective for this condition. A large Australian study with 204 participants found that education and exercise had better outcomes than a single cortisone injection, and both of those were better than “wait and see.”
The key education was load management. Patients were taught how to keep strengthening and loading but not overworking the tendons. They were taught a home program including bridges and often gait modification. They were also instructed to avoid compression of the area. This means to avoid bringing the knee over the midline. Avoid crossing legs. Avoid sitting or lying on the couch with knees dropped to one side. Clients are especially instructed to avoid standing with the hip jutted out to the side. When standing, stand with feet shoulder-width apart and weight equally on both legs. Avoid a common stretch in standing, known as an iliotibial band stretch, with one leg is crossed in front of the other before bending forward or to the side.
If you have significant hip pain which limits your activity or your sleeping, book an appointment with your health-care practitioner. Current research clearly shows that GTPS responds well to exercise and, if needed, other interventions that can be provided at the clinic.
Marjolein Groenevelt is a sports physiotherapist who works at Glebe Physiotherapy and Sport Medicine Clinic at Lansdowne. She lives in the Glebe and you will often see her walking, poling, biking and going up and down porch stairs carefully, delivering the Glebe Report.