Sports Medicine Disorders of the Hip: Posterolateral

Author(s): Kameron Bazmi, MD, Andrew Beaufort, MD, Amrit Ahluwalia, MD, Brandon Maisel, MD

Originally published:04/04/2016

Last updated:10/14/2019

1. DISEASE/DISORDER

Definition

Sports related injuries to the posterolateral hip typically affect the greater trochanter (GT) and peritrochanteric soft tissue structures.

Etiology

Historically, lateral hip pain was believed to only involve bursal inflammation, but now it is better understood that bursitis comprises only a part of a complex pathological process1. The gluteus medius, gluteus minimus tendon, piriformis tendon and the iliotibial band (ITB) may be affected.2,3 This misnomer of sorts is seen in trochanteric bursitis, currently known as greater trochanteric pain syndrome (GTPS), where gluteal tendinopathy is now understood to be the primary contributory factor rather than true greater trochanteric bursitis.2

Epidemiology (risk factors and primary prevention)

In individuals between 50 and 79 years of age, GTPS has a reported prevalence of 15% in women and 6.6% in men with unilateral presentation, and 8.5% in women and 1.9% in men with bilateral presentation.4 In active military individuals, the prevalence was similar, but 5 times more common in women.3 Additionally, it has been found that 10-20% of hip pain presenting to primary care was due to GTPS, with an incidence of 1.8 patients per 1000 per year.5

Risk factors for GTPS include female gender, age greater than 40 years, obesity, low back pain, and knee pain.6 GTPS can be a complication of total hip arthroplasty, with a roughly 6% incidence. The occurrence is not influenced by the surgical approach, be it posterior or direct anterior. Other associated conditions include: osteoarthritis (OA), rheumatoid arthritis, low back pain, gluteal weakness, unfavorable pelvic morphology, ITB tightness, leg length discrepancy and foot hyperpronation.4,7

Pathoanatomy/physiology

The greater trochanter (GT) anatomy is similar to that of the greater tuberosity of the shoulder. The gluteus medius and minimus are referred to as the “rotator cuff” of the hip, functioning as the main hip abductors and stabilizing the pelvis during the stance phase of gait.8 The ITB is a thickening of the tensor fascia lata that extends from the iliac crest over the lateral femoral epicondyle and attaches to Gerdy’s tubercle. The ITB moves anteriorly over the GT with hip flexion and posteriorly during hip extension.9 Tightness of the ITB can inflame and irritate the bursae associated with the gluteal tendons.9

The subgluteus maximus or trochanteric bursa may be painful, as seen with repetitive compression or friction from the surrounding bony structures.

Disease progression including natural history. Phases or stages, trajectory, clinical features and presentation overtime

New onset/acute: Acute focal lateral hip pain is worse when lying on the involved side, ambulating, running, lateral movements, single leg activities, standing on the affected leg, and climbing stairs. This could be related to direct macrotrauma or repetitive microtrauma resulting in myotendinous injury and in some cases bursal inflammation.

Sub-acute: Gluteal tendinopathy with or without calcifications and a reactive bursitis may be present. Sub-acute pain may lead to biomechanical maladaptations, such as asymmetric pelvic stabilization affecting the contralateral hip and/or other joints along the kinetic chain.7

 Chronic/stable: The most common finding is gluteus medius or minimus tendinosis without active inflammation in the bursa. Tendon degeneration similar to that of the shoulder’s rotator cuff with chronic subacromial impingement is observed.7

Pre-terminal: Pain is usually present at rest, limiting function. Furthermore, the presence of gluteal tendon degenerative tears is common even unrelated to acute trauma.7,10. Gluteus medius tendon tears and trochanteric bursitis that have been associated with GTPS is analogous to pathologic features associated with supraspinatus tendinopathy and subacromial bursitis.6

Specific secondary or associated conditions and complications

GTPS is associated with obesity, low back pain, ipsilateral and contralateral knee pain and degenerative disease4. Moreover, untreated symptoms of lateral hip pain may lead to persistent biomechanical changes along the kinetic chain from the trunk to the lower extremities, ultimately leading to decreased functional activity.4

2. ESSENTIALS OF ASSESSMENT

History

Pain about the GT and the peri-trochanteric area of acute or insidious onset is associated with physical activity. Pain is exacerbated when lying on the involved side, or with repetitive hip flexion-extension movements, prolonged standing, and single leg activities. A snapping sensation when ascending stairs, performing sit to stand, or exercising may be noticed. Posterolateral thigh pain during transitional movements (e.g., sit to stand) should elevate clinical suspicion of greater trochanteric pain or hip osteoarthritis based on patient age.11 Labral tears may be accompanied by reports of clicking or catching at the hip as well as pain with terminal flexion or extension at the hip.11 Avascular necrosis may be reported as a deep seated pain within the hip in context of chronic steroid use.11 Pain in the posterolateral gluteal region with occasional radiation into the posterolateral thigh and calf may be indicative of piriformis syndromes, hamstring pathology, or possible ischial bursitis.11  Further posterolateral hip etiologies include ischiofemoral impingement, lumbar radiculopathy and peripheral neuropathy. As such, if the patient presents with a history of high energy trauma investigation for a Morel-Lavalée Lesion, a soft tissue degloving injury is warranted.12

Physical examination

Initial evaluation includes observation for anatomic asymmetries or tissue deformities, and direct palpation to the affected area to elicit pain and/or symptoms. Passive adduction and active internal rotation may reproduce symptoms, while passive internal rotation usually does not. Active external rotation and abduction with pain or symptom reproduction may be present in gluteal muscle-tendon injury.7 The FABER test can help differentiate intra-articular pain from lateral hip pain6, while the Ober’s test evaluates for ITB contracture7. A snapping sensation with hip motion from extension to flexion and vice versa suggests ITB friction; a positive finding can be confirmed by manually compressing proximal to the GT with symptom relief.13 Conversely, by externally rotating the hip along with adduction and external rotation may elicit pain seen in ischiofemoral syndrome.13 Additionally, lower back etiologies may be assessed by performed lumbar flexion, extension and side bending. Further manual testing may include straight leg test, Lasegue’s test and Braggard’s sign.

Clinical functional assessment: mobility, self care cognition/behavior/affective state

Poor tolerance to single leg stance, although not specific for lateral hip pain, is useful in identifying symptomatic hip pathology.6 Gait analysis can evaluate for a Trendelenburg sign, muscle tear, or neurologic injury, as well as dynamic leg length discrepancy. Patients with osteoarthritis demonstrate decrease range of motion during gait analysis as compared to healthy controls.14 As such, patients suffering from osteoarthritis ultimately have reduced hip internal rotation, extension and high abduction moment during ambulation causing limping gait.  Furthermore, ambulation duration can help differentiate lateral hip pain from hip osteoarthritis as patient’s with osteoarthritis on average have reduced maximum walking distances when compared to GTPS patients.6

Laboratory studies

If an infectious process is suspected, then a complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein should be obtained to elucidate any active inflammatory processes.

Imaging

Radiographs (pelvic AP, and hip AP/lateral-cross table and frog leg) help screen for avulsion fractures, or intra-tendinous calcifications. In the setting of acute trauma, computed tomography (CT) scanning may be useful to assess acute fractures or for those who cannot undergo magnetic resonance imaging (MRI).15 MRI may reveal a combination of peritrochanteric edema, gluteus minimus or medius tendinosis, and fluid in the local bursae.16 Ultrasound (US) may reveal similar findings to MRI for multiple conditions at the posterior hip while providing real-time, dynamic assessment. The utility of ultrasound imaging continues to expand as both a diagnostic tool and as guidance for locally directed treatment. At the posterior hip, multiple clinical indications support the use of ultrasound imaging as a first line diagnostic tool including: the detection of effusions, extra-articular snapping hip, Morel-Lavalée lesions, high-grade muscle injuries.12 Furthermore, use of ultrasound guidance for injections, rather than landmark guidance, appears to confer greater accuracy in delivery of the injectate with potentially greater benefit and cost-effectiveness.17

Supplemental assessment tools

Proposed diagnostic criteria for GTPS includes at least 2 of the following: lateral hip pain, tenderness about the GT, or one of the following: pain at extremes of rotation, abduction, and/or adduction, pain on strong contraction of hip abductors, or pain radiating to the lateral aspect of the thigh.6,16 Gluteal tendinopathy may be detected by using Modified Resisted Internal Rotation Test which may distinguish hip tendinopathy versus GTPS.7 This test is performed by flexing the knee and hip to 90 degrees while externally rotating to 15 degrees.7 The test is considered positive if lateral hip pain is elicited.18

Early prediction of outcomes

No studies have reported early predictors of outcome. Age and pre-injury activity level may positively influence recovery. Additionally GTPS is associated with low back pain and knee osteoarthritis that could affect clinical improvement.7 Moreover, no association has been found with body mass index.16

Environmental

Active or relative rest is the mainstay of activity modification. Severe injuries may limit ADLs, as well as athletic activity, therefore avoidance of prolonged walking, standing, stairs, and repetitive sit to stand movements is important. Modifiable sport-related extrinsic risk factors include decrease sport-specific demands, correcting training errors, evaluating equipment, and modifying the environment.19

Social role and social support system

The patient, family, coaches, or caregiver need education and counseling about risk factors, activity modification, and injury recovery process.  An adequate support system is often helpful to maintain compliance with treatment, especially rest in active individuals. Communication within the treatment team is of utmost importance.

Professional issues

A multi-disciplinary treatment approach may be needed for some patients affected by this disorder. The treatment team may include a non-surgical musculoskeletal specialist, a physical therapist, an athletic trainer, coaching staff, and, in refractory cases, an orthopedic surgeon. In varsity or professional athletes, special care must be taken as there may be organizational pressures to return to play sooner. The priority and focus should always be the health and safety of the athlete.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

A multimodal approach for the treatment of GTPS is needed. Initial treatment focuses on pain management with oral, topical, or infiltrated medications (acetaminophen, non-steroidal anti-inflammatory medications). Physical therapy is often recommended as the first-line of treatment for the acute presentation. This consists of physical modalities, stretching and soft tissue massage. Locally, bursal infiltration (corticosteroids) may be performed as part of the treatment. Peritendinous, rather than GT bursa ultrasound-guided corticosteroid injections have been demonstrated to be effective in gluteus medius tendinopathy.20 Most patients respond to conservative management. However, patients presenting with muscle-tendon tears or chronic pain may undergo surgical interventions sooner.10 Open surgical techniques have been standard of care in past, but newer endoscopic techniques are increasingly utilized for bursectomies, ITB release, and trochanteric reduction osteotomy.10

At different stages

New onset/acute: Pain control modalities such as relative rest including partial weight bearing, avoidance of the lateral decubitus position, and limiting repetitive hip movements, ice, and anti-inflammatory medications (for analgesia rather than anti-inflammatory effect) or oral analgesics.7 Modalities such as electrical stimulation, ultrasound, and low-level laser therapy (studied in other tendinopathies21) can be used for symptom relief.

Sub-acute: Continue with activity modification by avoiding potentially painful hip movements, especially repetitive hip flexion-extension, active rotation (internal/external), and resisted abduction. If hip abductor weakness is present, then a strengthening program with focus on the hip abductors, progressing from isometric contractions to eccentric exercises, should be implemented. Stretching or manual decompression of the ITB needs to be started and continued through the rehabilitation course in patients with tight iliotibial bands, or asymptomatic snapping, avoiding foam rolling over a painful GT.13 At this point, lumbo-pelvic deficits (core) need to be addressed as well. In the context of suspected tendinopathies about the hip, including GTPS, conservative management that includes ITB stretching may cause further compression of the gluteus medius tendon, thereby exacerbating symptoms.22

Chronic/stable: Activity specific exercises should be started. Exercise should progress to multi-planar controlled eccentric exercises and postural re-education.13 Orthotics, bracing, or taping may be used to correct any biomechanical deficits.13 Shockwave therapy has yet to offer consistent benefit due to lack of standardization of its use but may be beneficial in the context of GTPS.23,24

Pre-terminal: Finally, correction of kinetic chain biomechanical deficits, training techniques, equipment, and other extrinsic risk factors need to be addressed in order to prevent re-injury.15,16,17

Coordination of care

Referral to the physical therapist is common to implement a supervised office based 1-3 times/week or unsupervised home-based exercise program. The main focus is core and hip girdle strengthening, but training errors must be assessed as well.  Other patients may benefit from referral to the orthopedic surgeon due to the severity of the injury and failed conservative care.

Patient and family education

A home exercise/stretching program may be an effective long-term solution to symptoms related to GTPS.26 In addition, education regarding risk factors can be helpful for early identification of injury and future prevention.

Measurement of treatment outcomes

The main outcome measure used is pain reduction. Most studies use the visual analog scale (VAS) to measure pain reduction after an intervention. Due to the variability on study methodology, no specific percentage of improvement has been established for this disorder. Recently, the Victorian Institute of Sport Assessment – Gluteal tendon (VISA-G), a GTPS modified version of the VISA questionnaires appears to be a reliable and valid score for measuring the severity of disability-associated GTPS.27 In the broader context of posterolateral hip conditions, the number of missed sport-related activities (practices/games) and timing of return to previous activity level could be a useful tool to measure treatment success.

Translation into Practice: Pearls/Performance improvement in practice/ change in clinical practice behaviors and skills

Early recognition is essential in order to establish an adequate treatment plan. Identifying modifiable risk factors such as muscle imbalances in the pelvic/hip girdle muscles, fatigue secondary to muscle weakness, and training errors (equipment, surface, and overtraining) may help in establishing an early injury specific rehabilitation program. The use of diagnostic ultrasound in the office setting represents a point of care diagnostic tool with possible therapeutic application.28 Recognition of bursal inflammation may suggest that an ultrasound guided infiltration could be beneficial early in the rehabilitation process to promote better tolerance and adherence to the treatment.16 Options for locally directed treatment include corticosteroids in combination with a short or long acting local anesthetic, viscosupplementation, and orthobiologics (platelet-rich plasma, stem cell, and placental tissue matrix injections). Among these options, corticosteroid injections are widely accepted as part of conservative management for conditions about the posterior hip including hip osteoarthritis.29

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

The increased use of ultrasonography for diagnostic purposes has been able to better determine the etiology of posterolateral hip pain. For example, it was demonstrated that the vast majority of patients who present with greater trochanteric pain did not have true bursitis under ultrasound. Instead, gluteus medius and minimus tendinosis as well as ITB thickening were more common causes of posterolateral hip pain.30 The use of musculoskeletal ultrasound for procedural guidance has led to more non-surgical treatment options for athletes and patients who decline surgical intervention or are not ideal candidates. Regenerative medicine procedures involving ultrasound-guided dry-needling or tenotomy, platelet rich plasma, show early promise in treatment of chronic tendinopathies.31,32 Recently, monoclonal antibodies, like Tanezumab, targeting nerve growth factor (NGF) have shown benefit in the treatment of chronic hip osteoarthritis pain in multiple clinical trials.33 Biologic therapies like anti-NGF, anti-TNF, and anti-IL-6 antibodies represent a growing effort to identify potential targets for immunomodulation at large joints like the hip and knee.33 Low energy shock wave therapy (SWT) appears to be another non-surgical option with results of 64% and 76% return to normal activity.26,34 Surgical procedures such as GT bursectomy alone or combined with ITB release or partial resection can now be done with an endoscopic techniques, especially in refractory cases.35There is a lack of studies comparing surgical techniques, however regardless of the method, satisfaction rates ranges from 72% to 100% when examining decrease or resolution of pain, as well as return to normal activities.36,37

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Controversies and gaps in the evidence based-knowledge

The use of ultrasound to identify gluteal tendinopathy has been well established30 and is now being demonstrated to have similar accuracy to MRI.38,39 Further well-designed studies will be needed in order to completely appreciate the diagnostic accuracy of ultrasonography in patients with GTPS. The multifactorial etiology of posterolateral hip pain makes an isolated diagnosis unlikely, thus study uniformity is lacking. The efficacy of multiple treatment options is unclear; including ultrasound-guided bursal infiltration, platelet-rich plasma or whole blood regenerative therapies, prolotherapy, percutaneous needle tenotomy, focused scar tissue aspiration (FAST) procedure, and open versus endoscopic surgical technique.31,32,35

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Original Version of the Topic

Gerardo E. Miranda Comas, MD. Sports Medicine Disorders of the Hip: Posterolateral. Original Publication Date: 04/04/2016

Author Disclosure

Kameron Bazmi, MD
Nothing to Disclose

Andrew Beaufort, MD
Nothing to Disclose

Amrit Ahluwalia, MD
Nothing to Disclose

Brandon Maisel, MD
Nothing to Disclose

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