01Approach to the Critical Patient/attcp42

Alarm features requiring immediate evaluation

›Cannot-miss diagnoses to exclude first

›Hip fracture

›Acute trauma with inability to bear weight

›Risk highest in elderly with osteoporosis

›Plain radiograph AP pelvis mandatory

›Septic bursitis or septic arthritis

›Fever with warmth, erythema, and swelling over hip

›Bursal aspiration for cell count, Gram stain, and culture

›Empirical antibiotics if septic bursitis confirmed

›Femoral neck stress fracture

›Overuse history, female athlete triad, energy imbalance

›MRI if radiograph negative and high suspicion

›Non-weight-bearing status pending imaging

›Avascular necrosis

›Groin pain with limited internal rotation

›Risk factors: corticosteroid use, alcohol, sickle cell disease

›MRI gold standard for early detection

›Malignancy or metastatic disease

›Night pain with constitutional symptoms

›Weight loss, night sweats, or known primary malignancy

›Imaging and hematology referral as appropriate

Initial triage priorities

›Functional assessment at triage

›Weight-bearing status

›Inability to bear weight requires fracture exclusion

›Antalgic gait suggests significant pathology

›Hemodynamic stability

02History/hx62

Symptom characterization

›Location and radiation

›Lateral hip pain over the greater trochanter

›Classic point tenderness location

›Pain may radiate along the lateral thigh to the knee

›Radiation below the knee in up to 50% of cases

›Frequently misdiagnosed as lumbar radiculopathy

›63% of GTPS patients previously evaluated by spine surgeon

›Buttock pain as additional radiation pattern

›May mimic sacroiliac joint pathology

›Absence of dermatomal pattern distinguishes from radiculopathy

Aggravating factors and onset

›Positional and activity-related triggers

›Lying on the affected side

›Nocturnal pain is characteristic

›Sleep disturbance common complaint

›Stair climbing and descending

›Prolonged standing

›Rising from a seated position

›Sitting with legs crossed

›Running or repetitive hip-loading activity

›Onset pattern

›Usually insidious with no clear inciting injury

›Post-fall or hip arthroplasty onset

›GTPS occurs in up to 17% post-total hip arthroplasty

›Lateral or transgluteal surgical approach increases risk

›Onset following biomechanical change

›Gait alteration from contralateral hip or knee pathology

03Physical Exam/exam58

Vital signs and weight-bearing assessment

›Baseline functional status

›Gait analysis

›Antalgic gait pattern

›Trendelenburg gait suggesting gluteus medius weakness or tear

›Weight-bearing tolerance

›Full weight-bearing expected in uncomplicated GTPS

›Inability to bear weight mandates fracture exclusion

›Body mass index

›Obesity as modifiable risk factor

Palpation

›Point tenderness assessment

›Tenderness over the greater trochanter

›Highly sensitive and specific for GTPS

›Nearly pathognomonic finding

›Jump sign

›Exaggerated pain response to direct palpation

›Indicates significant bursal or tendinous irritation

›Peritrochanteric soft tissue

›Superior and posterior trochanteric tenderness

›Distal ITB tenderness along lateral thigh

Provocative maneuvers

›Hip function testing

›FABER test (Patrick's test)

›Lateral hip pain at end-range flexion, abduction, external rotation

›Positive in GTPS; groin pain suggests intra-articular pathology

›Resisted hip abduction in side-lying

›Pain and weakness suggests gluteus medius tendinopathy or tear

04Differential Diagnosis/ddx59

Life-threatening diagnoses

›Cannot-miss conditions

›Hip fracture

›ICD-10 S72.0

›Intracapsular or intertrochanteric

›Inability to bear weight; shortened externally rotated leg

›Femoral neck stress fracture

›ICD-10 M84.352

›Overuse or energy deficit history

›MRI required if plain films negative

›Avascular necrosis of femoral head

›ICD-10 M87.052

›Steroid use, alcohol, hemoglobinopathy risk factors

›Groin pain, limited internal rotation, MRI diagnostic

›Septic arthritis of the hip

›ICD-10 M00.052

›Fever, elevated inflammatory markers, restricted ROM

›Joint aspiration mandatory if suspected

Musculoskeletal mimics

›Regional soft tissue pathology

›Gluteus medius or minimus tendinopathy or tear

›Most common underlying diagnosis in GTPS (~50%)

›Distinguished by weakness on resisted abduction

›MRI or ultrasound confirms

›Iliotibial band syndrome

›ICD-10 M76.3

›Lateral knee pain more prominent

›Positive Ober's test

05Laboratory Tests/lt42

Routine laboratory evaluation

›Standard presentation

›Routine labs not indicated for typical uncomplicated GTPS

›Diagnosis is clinical in classic presentation

›Imaging and labs reserved for atypical or complicated cases

›Clinical indicators that prompt laboratory evaluation

›Systemic symptoms (fever, weight loss)

›Failure to respond to conservative therapy

›High suspicion for alternative diagnosis

Infection workup

›When septic bursitis or arthritis is suspected

›Complete blood count

›Leukocytosis supports infection

›WBC >11.0 x10^9/L with left shift

›C-reactive protein

›Elevated in septic bursitis

›Non-specific; must be interpreted in context

›Erythrocyte sedimentation rate

›Elevated in inflammatory or infectious states

›Blood cultures

›Prior to antibiotics if systemic infection suspected

›Bursal fluid aspiration

›Cell count: WBC >2,000 cells/microL suggests infection

›Gram stain and culture to guide antibiotic therapy

›Glucose and protein as adjuncts

Inflammatory arthropathy workup

›When inflammatory joint disease is considered

›Erythrocyte sedimentation rate and CRP

06Diagnostic Tests/dt67

Scoring Systems

›Clinical diagnostic criteria for GTPS

›No universally accepted validated scoring system for GTPS

›Diagnosis based on clinical criteria

›Point tenderness over greater trochanter is the anchor finding

›Diagnostic injection test

›50% or greater pain relief after infiltration with local anesthetic

›Triamcinolone 40 mg in 4 to 6 mL bupivacaine 0.25%

›Confirms peritrochanteric pain source

›Global Rating of Change Scale

›Used in clinical trials to measure treatment response

›7-point Likert scale from much worse to complete recovery

›VISA-G score (Victorian Institute of Sport Assessment - Gluteal)

›Validated patient-reported outcome for gluteal tendinopathy

›Scores 0 to 100; higher scores indicate better function

MRI

›MRI of the hip and pelvis

›Indications

›Diagnosis uncertain after clinical assessment

›Failure to improve after 4 to 6 weeks of conservative therapy

›Suspected gluteal tendon tear or large partial tear

›Concern for avascular necrosis, stress fracture, or malignancy

›Protocol specifics

›Coronal and axial fluid-sensitive sequences (STIR or fat-suppressed T2)

›Axial T1 for tendon morphology and fatty atrophy

›No gadolinium required for standard assessment

›Findings in trochanteric bursitis and GTPS

›High T2 signal in trochanteric bursa confirms bursitis

›Gluteal tendinopathy: intratendinous T2 signal increase

›Gluteal tendon tear: partial or full-thickness discontinuity on T2

›Fatty atrophy of gluteus medius on T1 suggests chronicity

›Sensitivity and specificity

›MRI gold standard for soft tissue evaluation

›High sensitivity for gluteal tendon tears

›Superior to ultrasound for evaluating posterior bursal extent

CT

›CT of the hip and pelvis

›Indications

›Fracture characterization after plain radiograph identification

›Pre-surgical planning for hip fractures or THA complications

›Evaluation of bony abnormalities (periosteal reaction, lytic lesions)

›Not first-line for soft tissue GTPS diagnosis

›Findings relevant to differential diagnosis

›Cortical breach at femoral neck suggests stress fracture

›Periosteal reaction or lytic lesion raises malignancy concern

›Calcific deposits in peritrochanteric soft tissue

›THA component loosening or periprosthetic fracture

›Limitations in GTPS

›Poor soft tissue contrast compared to MRI

›Bursitis and tendinopathy not reliably visualized on CT

›Ionizing radiation; not preferred over MRI for soft tissue evaluation

Ultrasound

›Musculoskeletal ultrasound

›Indications

›Best first-line advanced imaging modality for GTPS

›Guides injection therapy for improved accuracy

›Dynamic assessment of ITB snapping

›Sonographic findings

›Bursal fluid: anechoic collection in the peritrochanteric bursa

›Gluteal tendinopathy: hypoechoic tendon with loss of fibrillar pattern

›Gluteal tendon tear: anechoic cleft or discontinuity in tendon

›Calcific tendinitis: hyperechoic foci with acoustic shadowing

›Ultrasound-guided injection

›Improves accuracy over landmark-guided technique

›Allows real-time confirmation of needle placement in bursa

›May provide longer-lasting pain reduction than blind injection

›Plain radiographs

›First-line imaging in most presentations

›AP pelvis and lateral hip views

›Rules out hip OA, fracture, calcific tendinitis, bony lesions

›Typically normal in isolated GTPS

07Disposition/dispo37

Discharge criteria

›Standard outpatient disposition

›Discharge appropriate for the vast majority of presentations

›GTPS is predominantly an outpatient condition

›No indication for routine hospital admission

›Conditions met for safe discharge

›Hip fracture, stress fracture, and septic process excluded

›Weight-bearing preserved

›Adequate pain control with oral analgesia

›Reliable follow-up arranged

Admission indications

›Criteria requiring inpatient management

›Septic bursitis with systemic sepsis

›Intravenous antibiotics and possible surgical debridement

›Septic arthritis of the hip

›Orthopedic surgical washout and intravenous antibiotics

›Hip fracture or femoral neck stress fracture requiring surgery

›Orthopedic admission for operative management

›Avascular necrosis with collapse

›Orthopedic evaluation for arthroplasty planning

Follow-up and referral

›Outpatient follow-up plan

›Primary care or sports medicine in 4 to 6 weeks

›Reassess response to conservative therapy

›Decision regarding imaging if symptoms persist

›Physiotherapy referral at discharge

›Education plus exercise is the most effective long-term intervention

›NNT = 2 at 8 weeks compared to corticosteroid injection alone (BMJ 2018 RCT)

08Treatment/t81

Conservative first-line therapy

›Activity modification

›Avoid lying directly on the affected side

›Pillow between knees when side-lying to reduce trochanteric pressure

›Avoid prolonged standing or sitting with legs crossed

›Avoid repetitive hip-loading activities during acute phase

›Ice application to lateral hip

›15 to 20 minutes several times daily during acute phase

Oral pharmacotherapy

›Non-steroidal anti-inflammatory drugs

›Ibuprofen

›400 to 600 mg three times daily with food

›Duration 2 to 4 weeks

›GI protection with PPI in high-risk patients

›Naproxen

›500 mg twice daily with food

›Duration 2 to 4 weeks

›Topical NSAIDs

›Diclofenac topical gel as alternative or adjunct

›Preferred in older adults or those with GI risk

›Acetaminophen

›500 to 1000 mg every 6 to 8 hours as needed

›Maximum 4000 mg per 24 hours in adults

›Adjunct for patients who cannot tolerate NSAIDs

Exercise and physiotherapy

›Education plus exercise program

›Most effective intervention for GTPS

›Superior to corticosteroid injection at 8 weeks and 52 weeks (BMJ 2018 RCT)

›NNT = 2 at 8 weeks compared to injection alone

›Load management education

›Avoid compressive loading of the gluteal tendons

›Sitting with legs uncrossed reduces tendon compression

›Progressive hip abductor strengthening

›Side-lying hip abduction exercises

›Clamshell exercises with progressive resistance

›Single-leg stance progression when tolerated

›Biomechanical correction

›Gait retraining to reduce pelvic drop

›Orthotic assessment for leg length discrepancy

›Weight management counseling

›Obesity is a significant modifiable risk factor

Corticosteroid injection

›Peritrochanteric corticosteroid injection

›Triamcinolone acetonide

›40 mg in 4 to 6 mL local anesthetic

›Bupivacaine 0.25% or lidocaine 1% as vehicle

›Injected at point of maximal tenderness

›Prednisolone alternative

›25 mg in 4 to 6 mL local anesthetic

›Technique

›Ultrasound guidance improves accuracy and outcomes

›Direct visualization of needle tip in bursa confirmed before injection

›Landmark-guided technique acceptable if ultrasound unavailable

›Efficacy

›Provides faster short-term relief (1 to 3 months) than exercise alone

›No long-term superiority over exercise at 52 weeks

›One RCT showed no significant difference versus saline at 1 month

›Limitations and precautions

›Avoid repeated injections (risk of gluteal tendon weakening)

›Maximum 2 to 3 injections per site per year recommended

›Exclude infection before injecting

›Temporary post-injection flare in up to 10% of patients

Second-line interventions

›Extracorporeal shockwave therapy (ESWT)

›Similar efficacy to corticosteroid injection at 3 months

›Potentially superior at 12 months in comparative studies

›3 to 5 sessions at weekly intervals

›Appropriate for patients who cannot tolerate or have failed injection

›PRP injection

›Emerging evidence for sustained benefit at 2 years

›Particularly effective for gluteal tendinopathy component

›Longer-lasting benefit than corticosteroid injection

›2 to 3 mL leukocyte-poor PRP injected under ultrasound guidance

›Appropriate for refractory cases after failed corticosteroid injection

Surgical management

›Surgical indications and options

›Refractory to at least 6 months of conservative management

›Trial must include physiotherapy and at least one injection

›Endoscopic bursectomy

›For isolated bursitis refractory to conservative care

›Gluteal tendon repair

›For large partial or complete gluteus medius or minimus tears

›Orthopedic referral required

›ITB release or lengthening

›For significant ITB tightness contributing to symptoms

›Expected outcomes

›Good to excellent outcomes in 80% of carefully selected surgical patients

09Special Populations/sp67

Pregnancy

›Pregnancy-specific considerations

›Increased prevalence during pregnancy

›Hormonal laxity increases peritrochanteric stress

›Altered gait and weight distribution aggravate symptoms

›Pelvic girdle pain complex often overlaps

›Pharmacological safety

›NSAIDs contraindicated after 20 weeks gestation

›Risk of premature closure of ductus arteriosus

›Oligohydramnios risk with prolonged use

›Acetaminophen is the preferred analgesic in pregnancy

›500 to 1000 mg every 6 to 8 hours as needed

›Corticosteroid injection

›Limited evidence but generally considered low systemic risk

›Fluorinated steroids (triamcinolone) not preferred in first trimester

›Discuss risk-benefit with obstetrics before injection

›Non-pharmacological priority

›Physiotherapy with modified exercises remains first-line

›Pelvic support belt may reduce hip loading

›Sleep positioning with pillow between knees

Geriatric

›Geriatric-specific considerations

›Highest prevalence group

›Most common in women aged 40 to 60; persists into older age

›Age-related tendon degeneration increases severity

›Fracture must be excluded

›Osteoporosis markedly increases fracture risk

›Low energy mechanism may still produce hip fracture

10Background/b63

Epidemiology

›Prevalence and incidence

›Affects approximately 10 to 25% of the population

›Incidence approximately 1.8 per 1,000 per year

›One of the most common causes of lateral hip pain

›Demographics

›Most common in women aged 40 to 60 years

›F:M ratio approximately 4:1

›Prevalence increases with age

›Associated conditions

›20 to 35% of patients with chronic low back pain have concurrent GTPS

›Occurs in up to 17% of patients post-total hip arthroplasty

›ICD-10 coding

›M70.6 Trochanteric bursitis

›M70.60 Unspecified trochanteric bursitis

›M70.61 Right trochanteric bursitis

›M70.62 Left trochanteric bursitis

›M76.3 Iliotibial band syndrome (when contributing)

Pathophysiology

›Anatomical basis

›Greater trochanteric bursal complex

›Multiple bursae in the peritrochanteric region

›Subgluteus maximus bursa: largest and most commonly involved

›Subgluteus medius and minimus bursae: less commonly primary site

›Gluteal tendon anatomy

›Gluteus medius inserts on superior and lateral facets of greater trochanter

›Gluteus minimus inserts on anterior facet

›Gluteus maximus inserts via ITB onto iliotibial tract

›Mechanistic understanding

›True isolated bursitis is less common than previously thought

›Only ~20% of GTPS cases represent pure bursitis

›Gluteal tendinosis accounts for ~50% of cases

›Thickened ITB contributes in ~28.5%

›Gluteal tendon tears present in significant proportion

›Compressive load mechanism

›Compression of gluteal tendons against greater trochanter

›Worsened by hip adduction (legs crossed, lying on side)

›ITB compression on gluteal tendon insertion site

›Degenerative tendinopathy pathway

›Reactive tendinopathy → tendon dysrepair → degenerative tendinopathy

›Load-related microtrauma without adequate healing

›Associated with altered collagen structure and neovascularization

Therapeutic Considerations

›Evidence hierarchy for treatment

›Education plus exercise is the most effective intervention

›Prospective RCT (Mellor et al., BMJ 2018) vs corticosteroid injection and wait-and-see

›Superior outcomes at both 8 weeks and 52 weeks

›NNT = 2 at 8 weeks; Class I level evidence recommendation

›Corticosteroid injection: faster short-term relief but not superior at 1 year

›Provides meaningful benefit for 1 to 3 months

›American Society of Regional Anesthesia 2025 guidelines support judicious use

›Avoid repeated injections due to tendon weakening risk

›ESWT comparable to corticosteroid injection at 3 months

›Systematic review (Bremer et al., Clinical Rehabilitation 2025) supports efficacy

›May be superior to injection at 12 months

›PRP emerging as option for gluteal tendinopathy

›Sustained outcomes at 2 years in preliminary evidence

›Not yet standard of care; appropriate in refractory cases

›Conceptual framework

›Avoid compressive loading as a treatment principle

›Distinguishes GTPS management from other tendinopathies

›Patient education on hip adduction avoidance is fundamental

›Long-term prognosis

›Most cases resolve within 6 to 12 months

›Psychological comorbidities and obesity predict chronic course

›Surgical outcomes favorable in carefully selected refractory cases

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Diagnosis explanation

›Diagnosis: Greater Trochanteric Pain Syndrome (Trochanteric Bursitis)

›Inflammation and irritation of the bursa and tendons on the outside of the hip

›A common, benign condition that usually improves with conservative treatment

›Expected course

›Most people recover within 6 to 12 months

›Consistent adherence to exercises is the most important factor

›Activity instructions

›Sleep positioning

›Avoid lying directly on the painful hip

›Place a pillow between your knees when sleeping on your side

›Posture and positions to avoid

›Avoid sitting with your legs crossed

›Avoid prolonged standing on one leg

›Avoid repetitive hip-loading activities such as running until symptoms improve

›Ice therapy

›Apply ice pack to the outer hip for 15 to 20 minutes several times daily

›Protect the skin with a thin cloth between ice pack and skin

›Medication instructions

›Anti-inflammatory medication

›Take ibuprofen or naproxen with food as directed

›Do not exceed recommended doses

›If you have kidney disease, heart disease, or stomach ulcers, use acetaminophen instead

›Acetaminophen

›500 to 1000 mg every 6 to 8 hours as needed for pain

›Do not exceed 4000 mg in 24 hours

›Do not take with other acetaminophen-containing products

12References/r43

Guidelines and key sources

›Primary evidence base

›Mellor R, Bennell K, Grimaldi A, et al.

›Education Plus Exercise Versus Corticosteroid Injection Use Versus a Wait and See Approach on Global Outcome and Pain From Gluteal Tendinopathy

›BMJ 2018; prospective single-blinded randomised clinical trial

›PMID 29720374

›Bremer T, Nicklen P, Fearon A, Morrissey D.

›The Efficacy of Gluteal Tendinopathy Treatments: A Systematic Review

›Clinical Rehabilitation 2025

›PMID 40223303

›Benzon HT, Provenzano DA, Nagpal A, et al.

›Use and Safety of Corticosteroid Injections in Joints and Musculoskeletal Soft Tissue

›Regional Anesthesia and Pain Medicine 2025 guideline

›PMID 40015722

›Chamberlain R.

›Hip Pain in Adults: Evaluation and Differential Diagnosis

›American Family Physician 2021

›PMID 33448767

›Williams BS, Cohen SP.

›Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment

›Anesthesia and Analgesia 2009

›PMID 19372352

Supporting references

›Additional literature

›Bateman EA, Fortin CD, Guo M.

›Musculoskeletal Mimics of Lumbosacral Radiculopathy

›Muscle and Nerve 2025

›Jorgensen SP, Chiodo AE.

Evidence & Review

Evidence & Review