One of my colleagues likes to say “the hips are the engine of the body”. The hips are incredibly important for health, however with great responsibility comes unique issues. Many people experience pain over their greater trochanter, which is a part of the femur (thigh bone) on the outer or lateral aspect of the hip (FIGURE 1).
(FIGURE 1: The Greater Trochanter of the femur)
Outer hip pain has been traditionally referred to and diagnosed as hip bursitis. This is because there are number of bursae (fluid filled sacs) near the greater trochanter which are very good at producing pain due to their high level of innervation. Recent research, however, has demonstrated that outer hip pain may have a muscular component as well. People with lateral hip pain can sometimes have weakness or tears in their gluteal muscles which function to support the outer hip.
Is it the bursa or gluteal muscles that are causing my hip pain?
So how can you tell whether it is a bursitis or muscular issue? People with a true bursitis will generally present with a painful, warm to touch, red, and swollen hip. I find this to be incredibly rare in my clinical practice. More often, patients present with a painful outer hip but have no other signs of a true bursitis. Usually I find that patients will have weakness or dysfunction in their gluteus medius muscle (FIGURE 2) which will change the way they move and subsequently irritate the bursa. This has made many clinicians change their diagnosis labels from hip bursitis to a more accurate term “greater trochanteric pain syndrome” (GTPS).
(FIGURE 2: The Gluteus Medius muscle is typically involved with outer hip pain)
Now that we have a better understanding of the lateral hip structures it is important to understand that not all pain in this area comes from the bursa and gluteal muscles. Two other areas that can refer pain here is the hip joint and the lumbar spine. Deciphering whether the pain is truly coming from the outer hip or remote areas is key for successful rehab.
How can I determine where my pain is coming from?
People with pain referring from the hip joint itself may have confirmed osteoarthritis (OA) on x-ray and may also complain of stiffness into the thigh and groin. Additionally, a key distinguishing feature between hip OA and GTPS is that people with OA will have pain with bending over to put on their shoes and socks, whereas people with GTPS will not. In the case of lateral hip pain being from the lumbar spine, patients will often times complain of both back and hip pain. It’s also more likely the pain is coming from your back if you find that your hip pain becomes worse with prolonged sitting.
If you don’t think your pain is coming the hip joint or your back, how can you tell if you have GTPS? People with GTPS will often complain of pain when laying on the affected side and during tasks like walking or stair climbing. You can also perform a few at-home tests to see if you have GTPS. The first test is to palpate or apply pressure to the greater trochanter itself. You can palpate this bone by finding the top of the outside of your hip. Next run your fingers down the thigh until you get to the bone that sticks out (FIGURE 3). Compare both hips to see if there is more pain on the affected side vs. the non-affected side. Research tells us that this is a very sensitive test, meaning that if you do not feel pain when palpating this area, it is less likely that you have GTPS. But what if there is pain? Research also tells that pain on palpation alone is not enough to diagnose GTPS.
(FIGURE 3: You can find your greater trochanter by finding the outside of your pelvis and then running your fingers down the outside of your thigh until you hit the bony projection)
Another test you can complete to determine the presence of GTPS is the single leg stand test. This test involves standing on the affected leg for 30 seconds. If balance is an issue for you, you can rest your hand on a surface but try to create the majority of your stability from the stance leg. If pain comes on during or soon after the completion of the test, you may have GTPS. Research tells us that this test is specific, meaning that if pain is produced it is very likely that the pain is truly coming from the gluteus medius and bursa. However, research also tells us that more tests are needed to be completed if you have pain with the single leg stand test, but not with palpation.
Interpreting the Results
To recap, if you have a:
- Painful palpation test and single leg stand test: You are likely to have GTPS
- Painful palpation test and non-painful single leg stand test: Further testing is needed
- Non-painful palpation test and painful single leg stand test: Further testing is needed
- Non-painful palpation and single leg stand test: You are unlikely to have GTPS
If further testing is warranted, a therapist can help you complete additional strength testing of the gluteal muscles to rule GTPS in or out. Once a diagnosis has been made, rehab can begin for the specific tissues involved with your pain.
If you have outer hip pain and want to know if it is GTPS and how to treat it, please give the clinic a call at (416) 925-4687 and book a physiotherapy assessment with Taylor Sipos, PT.
Additionally, if you want to learn more about how to strengthen the glutues medius muscles, take a look at our Youtube page.