Greater Trochanteric Pain Syndrome: Gluteal Tendinopathy and Lateral Hip Pain

What Is Greater Trochanteric Pain Syndrome?

Greater trochanteric pain syndrome (GTPS) is an umbrella term for lateral hip pain arising from the tendons and bursae at the greater trochanter — the bony prominence on the lateral femur. The primary pain generator in most cases is gluteal tendinopathy: degeneration and pain within the gluteus medius and gluteus minimus tendons at their insertion on the greater trochanter. Trochanteric bursitis — historically the default diagnosis — is now understood to be a secondary finding in most presentations; the bursal irritation typically follows, rather than causes, the tendon pathology. GTPS affects approximately 1.8 per 1000 people annually, is two to four times more common in women, and has a peak incidence between 40 and 60 years. It is frequently misdiagnosed or managed inadequately, leading to chronicity that is entirely preventable with correct early management.

The Compression Mechanism

Gluteal tendinopathy at the greater trochanter is fundamentally a compressive tendinopathy. Unlike mid-portion tendinopathies such as Achilles tendinopathy, which are driven primarily by tensile load, the gluteal tendons are compressed against the greater trochanter by the iliotibial band — the thick fibrous band crossing the lateral hip — particularly when the hip is in adduction (crossing the midline). This compressive mechanism is provoked by specific positions: crossing the legs, sitting with hips adducted, walking with a wide pelvic drop (Trendelenburg gait), sleeping on the affected side with the top leg crossing the lower, and stretching the hip in adduction and internal rotation — including standing hip crossover stretches, which are intuitively attempted by patients but consistently aggravate the condition. Understanding and modifying these compressive loads is the foundation of early management.

Clinical Presentation

The hallmark presentation of GTPS is lateral hip pain over or just posterior to the greater trochanter, typically described as a deep ache or burning sensation. The pain is consistently worse with: prolonged walking, particularly on inclines or uneven surfaces; single-leg standing; climbing stairs; lying on the affected side; and sitting with the legs crossed. It may radiate down the lateral thigh, mimicking referred pain from the lumbar spine or ITB syndrome — careful clinical differentiation is necessary. Palpation directly over the greater trochanter reproduces localised tenderness. The single-leg stance test (standing on the affected leg for 30 seconds) and the FABER test are useful provocative assessments. Hip adduction strength is commonly reduced, reflecting gluteal tendon involvement and guarding.

Rehabilitation: Loading the Tendon Correctly

Management of GTPS requires a two-phase approach. Phase one — load modification: eliminate compressive hip positions, educate the patient on posture (stand with feet hip-width apart — not with hip hitched to one side), sleep with a pillow between the knees to prevent hip adduction, and avoid aggravating stretches. This phase rapidly reduces tendon reactivity and pain. Phase two — progressive tendon loading: isometric gluteal contractions (wall press in standing, side-lying hip abduction held) as the entry point for pain inhibition, progressing to isotonic hip abduction and external rotation, then single-leg loading (step-ups, single-leg deadlifts) under careful load monitoring. The evidence strongly supports heavy, progressive gluteal strengthening for resolving gluteal tendinopathy — with the critical caveat that end-range hip adduction must be avoided throughout the loading programme until the tendon is fully rehabilitated. Shockwave therapy is an effective adjunct for refractory cases.