Lateral Hip Pain

Tackle Your Pain

With Evidence

 

 

LATERAL

HIP PAIN

WAS YOUR HIP INJECTION LESS EFFECTIVE THAN YOU HOPED?

There is a good reason why…
…and a good answer to the problem

 

This article discusses the evolving understanding of lateral hip pain/trochanteric bursitis and new exciting approaches to it’s treatment. It is deliberately written to be approachable, but also has links to the research articles from which the information is drawn if you fancy some deeper reading. Please also check out the links at the end to the many experts who work extremely hard to not only research these areas, but who also generously help to disseminate their findings. 

 

What Is Lateral Hip Pain
Lateral hip pain goes by many names, it can be variously described as Trochanteric Bursitis, Greater Trochanteric Pain Syndrome, Gluteal Tendonitis, Gluteal Tendinopathy, Gluteal Pain Syndrome and others.

It is characterised by a pain over the side of the upper part of femur (thigh bone). The pain can radiate down to the knee, into the buttocks or into the groin

 

20%
of cases are male
80%
of cases are female
of people with Low Back Pain who also have Lateral Hip Pain

 

Trochanteric Bur-WHATS-IT?

Trochanteric Bursitis is a common diagnosis for people suffering with lateral hip pain.

The Greater Trochanter is a small outcrop of bone on the side of femur (upper leg bone).

Normally tissue slides painlessly over the top of this boney outcrop.

A bursa is small fluid filled sack that forms between tissues that glide over each other; they are normal, useful and common in the body.

Bursitis is when this sack becomes irritated and filled with inflammatory fluid.

The Trochanteric Bursa sits just over the Greater Trochanter.

Trochanteric Bursitis used to be thought of as the primary cause of this painful syndrome, but as we will see, this is probably not the full picture.

 

What is Injection Therapy and why might I be treated with it?

Corticosteroid injections are anti-inflammatory and so can be used to help alleviate an inflamed bursa. They can be effective in the short term and in many people will give immediate symptomatic relief. They are useful, but also have drawbacks as they may have negative effects on tendons and it is noted that the beneficial effect is reduced in the medium term and may actually be less than no treatment at 1 year.

Steroid injections have their place, but there is a strong argument that they should primarily be seen as a short term pain relieving tool to be used when pain is a major limiting factor.

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial.

 

 

Quality Of Life
Lateral Hip Pain can be very painful, with advanced versions of it causing a similar reduction in quality of life those suffering from advanced Osteo-Arthritis

Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control study.

 

So why did my pain come back?

Trochanteric Bursitis is becoming better understood.

There is some evidence to suggest that it may not be the primary cause of pain, it is increasingly being seen as a secondary effect and is almost always found in conjunction with a tendinopathy.

Current research suggests that the primary problem is not the Bursitis, but rather a specific Tendon problem called Gluteal Tendinopathy.

 

What's a Tendinopathy when it's at home?

Tendinopathy is a more current understanding of what we used to refer to as tendonitis.

There are subtle but important distinctions.

A tendonITIS means inflammation is the cause of the pain, whereas tendinOPATHY means disorder of the tendon. A tendinopathy is characterised by disordered collagen strands and an infiltration of small blood vessels, which causes the tendon to appear swollen.

When related to the hip, this is known as Gluteal Tendinopathy, and will often affect Gluteus Medius in particular.

 

 

 

and what is a Gluteal Tendinopathy?

This is a tendinopathy of your gluteal tendons and in many people is reason why the pain relief from the steroid injection either returns, or isn’t effective in the first place.

Gluteal Tendinopathy is now thought of as the primary cause of the pain as well as the bursitis. It is characterised by pain to the outside of the hip which may radiate down the outside of leg, or to the groin. It is often exacerbated by sitting or walking for long periods.

Gluteal Tendinopathy does not have to have an associated bursitis, but a trochanteric bursitis is rarely found without it.

Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis.

 

 

What Can I Do?

 

The good news is that through constant research, tendons, tendinopathies and more importantly their rehab, are becoming much better understood.

 A graduated loading program for the gluteal muscles (and related muscles) for gluteal tendinopathy and trochanteric bursitis is now thought of  as the best recommended form of physical treatment.

Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management.

 

5 TIPS TO REDUCE YOUR PAIN

1 Keep moving! When we’re in pain, we don’t want to move, and sometimes rest can feel like the best recourse. Some rest, when the pain is too much is advisable, but constant rest will have a negative effect on the very structures we want to work on.

Changes in mechanical loading lead to tendonspecific alterations in MMP and TIMP expression: influence of stress deprivation and intermittent cyclic hydrostatic compression on rat supraspinatus and Achilles tendons.

2 Don’t stretch! Another myth is that the pain should be somehow “stretched out”, however, we now know that over stretching a painful tendon can be aggravating for it and can actually increase in your pain.

Is compressive load a factor in the development of tendinopathy?

3 Try an isometric exercise. Isometric exercises (muscle contraction, but with no movement) are proven to have a pain relieving component and are a great way to load the painful structures. See the video below

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.

4 Pace your self. The recommended loading is to occur at no more than 4/10 pain and with no increase in pain within 24 hours. Pain is not something to be afraid of, if it happens, don’t worry, you probably haven’t damaged anything. We just want to avoid continually overloading the painful structures. So a little ache is good and normal, lingering pain probably means you need to adjust to a lower load.

The challenge of managing tendinopathy in competing athletes.

5 Don’t worry! Tendons are slow healers. Healing times may be in the order of months not weeks. So if your pain is proving stubborn, don’t worry. It’s probably normal stubborn tendon behaviour

Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome.

What Can a Physio Do?

 

At Heaton Moor Physio we are well placed to guide you through your progressive rehab programme.

Your physio will help to motivate you and keep you on track as you tackle this painful condition head on. They will also continually review your condition as a number of other problems may present with a similar pattern of pain, issues such as referred pain from the lumbar spine or muscular tears.

 We will also encourage you to become more active as your pain subsides, helping you to tackle any metabolic reasons for your pain (article coming soon on this).

We will make sure that by the end of your rehabilitation you know as much about your condition as we do. 

The real positive to the this approach is that you can be sure you are much less likely to suffer a relapse, and even if you do, you have the tools to be able to tackle it again.

STAY PAIN FREE

Gluteal tendinopathies are implicated in a number of common problems, including some knee problems, so understanding how to maintain your health in this region will help you live an active and fulfilling life.

 

Tackle Your Pain

With Evidence

 

References and Further Reading

Infographic – Gluteal Tendinopathy with Benoy Mathew
Physio Edge 063 How to assess and treat posterior hip and gluteal pain with Benoy Mathew
Function2Fitness Benoy Mathew’s Website
Dr Alison Grimaldi’s Website
Dr Angela Fearon’s Website
Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial.
Are child bearing hips a risk factor for Greater trochanteric pain syndrome?
Changes in mechanical loading lead to tendonspecific alterations in MMP and TIMP expression: influence of stress deprivation and intermittent cyclic hydrostatic compression on rat supraspinatus and Achilles tendons.
Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control
Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain
Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis.
Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management.
Is compressive load a factor in the development of tendinopathy?
Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.
The challenge of managing tendinopathy in competing athletes
Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome.
Single leg stance control in individuals with symptomatic Gluteal Tendinopathy
The pain of tendinopathy: physiological or pathophysiological?
Greater Trochanteric Pain Syndrome Diagnosis and Treatment4
The management of greater trochanteric pain syndrome: A systematic literature review.
Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management.

 

Author Info

Mark McGillian

Lead Physio at Heaton Moor Physiotherapy

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