Diagnosis and investigation

Physical examination reveals the point of tenderness over the greater trochanter on the affected side (typically elicited at a point overlying the site of the gluteus medius tendon insertion) (1,2).

The following tests which put tension on the muscles and tendons attached to the greater trochanter can be used to diagnose GTPS:

• resisted active abduction test
  • the patient lies supine and abducts the affected hip joint by 45 degrees with the examiner providing resistant. If pain is provoked the test is positive
• resisted internal rotation test
  • the patient lies supine with the affected hip joint at 45 degrees flexion and maximal external rotation. Pain on resisted active internal rotation indicates a positive result
• Trendelenberg's test
  • with the patient standing on the affected leg the examiner observes for any pelvic tilt (below the normal horizontal stance) when the unaffected leg is raised off the ground which indicates a positive test (2) The absence of pain during hip flexion and extension should indicate the examiner that the cause of pain is not an intraarticular disease of the hip (2).

Features of associated conditions may be seen during the physical examination e.g. - hip arthritis, leg length discrepancy etc (3)

Imaging

• often greater trochanteric pain syndrome is diagnosed based on history and examination (1,2,3,4). Investigations that might be considered are listed below:
  
  
  • X rays (calcification and screen hip osteoarthritis, avascular necrosis or sacroiliac joint)
    
    
  • US
    • abductor tendon thickening, tendinopathy, partial or complete tears
      
      
  • MRI
    • considered gold standard can detect tendinosis tendon tear partial/complete, bursal fluid, muscular fatty atrophy, bony changes, calcification
• use of thorough clinical exam, 'carefully selected special investigations and imaging indicated' (Hugo & de Jongh, 2012)

Reference:

• 1. Bird PA et al. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44(9):2138-45
• 2. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-70
• 3. Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc. 1996;71(6):565-9
• 4. Hugo, D, de Jongh, HR. Greater trochanteric pain syndrome, SA Ortho J 2012; 11(1): 28-33.