Brought to you by
ECR 2019 / C-0716
Greater trochanteric pain syndrome: clinical and radiological semiology
Congress: ECR 2019
Poster No.: C-0716
Type: Educational Exhibit
Keywords: Inflammation, Comparative studies, Ultrasound, MR, Musculoskeletal system, Musculoskeletal soft tissue
Authors: A. Solano1, A. Agustí2, I. García Duitama2, M. tey3, A. Rodriguez Baeza3, J. Ares Vidal2; 1BARCELONA, BARCELONA/ES, 2Barcelona/ES, 3Barcelona /ES
DOI:10.26044/ecr2019/C-0716

Findings and procedure details

CRITERIA FOR DIAGNOSIS OF GREAT TROCHANTERIC PAIN SYNDROME.

Pinpoint tenderness over the greater trochanter area is the hallmark physical finding in all symptomatic patients.
Tenderness may extend into the lower buttock and lateral thigh but not to a significant degree.

While the patient is standing, palpate the lateral hip area in a cephalic direction beginning below the greater trochanter eminence until the area of maximal tenderness is identified (“jump sign”)  (Fig 8 )

 

 

CLINICAL TESTS UTILIZED IN EVALUATION OF LATERAL HIP PAIN

 

There is a large amount of clinical test when assessing pain in the lateral aspect of the hip. A recent article by Charlotte Ganderton published in Journal of Women's Health found the Patrick’s or FABER test, palpation of the greater trochanter, resisted hip abduction, and the resisted external derotation test to have the highest diagnostic test accuracy for GTPS. All other tests were found to have moderate diagnostic test accuracy.

The use of standard Ober’s and modified Ober’s, to diagnose the condition is not supported ( Fig 9-11)

 

ROLE OF THE DIFFERENT IMAGING TECHNIQUES IN THE DIAGNOSIS OF THE GTPS

 

 

Plain radiography. (Fig 12-13)

 

The role of radiology lies basically in the exclusion of entities that can be confused with the GTPS, such as osteoarthritis or FAI.
Calcification adjacent to the greater trochanter may be seen in up to 40% of patients presenting with GTPS.
Trochanteric exostoses or osteophytes may be seen.in patients with chronic GTPS.

 

Ultrasound.

 

Ultrasound remains a dynamic and radiation-free diagnostic study and is a high positive predictive indicator for peritrochanteric abnormalities. Against the opinion of many experts authors The European Society of Skeletal Radiology Ultrasound Group summarized the value of US in terms of evidence in trochanteric pain as grade C evidence.

The patient is placed in lateral decubitus with the hip to be examined discreetly flexed. The concept of the four major trochanter facets is well demonstrated by US aiding in correct identification of the affected tendons.
The sonographic study must include coronal and transverse views of the previous facet of the greater trochanter at the gluteus minimus tendon insertion, the lateral and superoposterior facets at the gluteus medius tendon insertions, the iliotibial band, and the greater trochanteric bursa at the level of the posterior facet. The duration of the study usually does not exceed 15 minutes.

 

Fig. 14: Radiological Correlation.
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

 

The ultrasound technique and the morphological findings are perfectly summarized in the articles by Kong et al (European Radiology 2007), Long et al (AJR 2013), Klauser et al Semin Musculoskelet Radiol 2013), Chowdhury et al (Postgrad Med J 2014), Connell et al (European Radiology 2003) and Bass et al (Skeletal Radiol 2002)  Fig 16

 

Fig. 15: Morphological findings (text)
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

 

MRI

Studies that have compared MRI findings in GTPS with intraoperative pathological findings have revealed that MRI is a highly sensitive diagnostic investigation. MR imaging had sensitivity of 33% to 100%, specificity of 92% to 100%, positive predictive value of 71% to 100%, and negative predictive value of 50% for the detection of hip abductor pathology in a recent meta-analysis (Petchprapa et al 2013).
However, it has been observed that the same morphological findings have been found in asymptomatic patients and therefore their clinical correlation is required. (fig 20-22)

 

Haliloglu et al. found that T2 peritrochanteric hyperintensity representing edema is by far the most common finding but is rarely related to clinical symptoms. Bilateral peritrochanteric edema is a common finding on MR images of the patients over 40 years of age and this radiological finding does not always correspond with the clinical findings.In the absence of peritrochanteric hyperintensity on fluid sensitive sequences, the GTPS is an unlike diagnosis. 

 

Klontzas et al. showed that a relationship exists between acetabular morphology and the presence of peritrochanteric bursitis. In addition, the NPV of bursitis on MR imaging, is a clinically important finding.

 

Cvitanic et al evaluated the abductor tendons of the hip using five major criteria: tendon discontinuity, tendon elongation, muscle atrophy and focal areas of T2 hiperintensity superior o lateral to great trochanter.
The strong negative predictive value of MRI, particularly when STIR or fat suppressed T2-weighted coronal sequences are used, can help obviate surgery in patients with greater trochanteric pain syndrome who have no abductor tear. 

Fig. 17: Cvitanic et al
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

Bogunovic et al showed shows that the Goutallier/Fuchs classification system may be applied to the preoperative evaluation of abductor tendon tears of the hip. In comparing preoperative muscle grading with postoperative patient pain and functional scores, our results show a strong correlation between increasing fatty infiltration and poor outcome after surgical repair, including patient-rated pain, satisfaction, and HOS and mHHS outcome scores.

 

Dwek et al showed pathologic findings of gluteal tendinopathy based on the analysis of morphology, signal intensity, and integrity of the tendon and adjacent bone.

Fig. 18: Dwek et al
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

Kong et al defined that peritendinitis, tendinosis, partial tear and complete rupture probably represents a pathologic continuum of gluteal tendinopathy.

 

Fig. 19: Kong et al
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

 

Management of the greater trochanteric pain syndrome

 

Fig. 23: Management of the greater trochanteric pain syndrome
References: RADIOLOGY, IDIMAS CRC MAR, HOSPITAL DEL MAR - BARCELONA/ES

 

Most cases of GTPS can be regarded as self-limiting. The initial or acute treatment of GTPS involves conservative modalities like non-steroidal anti-inflammatory drugs (NSAIDS), ice and rest. Rehabilitative and preventative measures like weight loss, behavioral modification and physiotherapy to improve muscle strength, flexibility and joint mechanics are part of many treatment regimens. The true efficacy of these ‘conservative’ treatments has not been reported in controlled studies.

 

When these interventions fail, bursa or lateral hip injections performed with corticosteroid and local anesthetics have been shown to provide pain relief, with response rates ranging from 60% to 100 %.
When recurrence of lateral hip pain develops after a previous strong response, injections may be repeated with similar effect ( Sayegh et al ).
Lievense et al showed that in a primary setting the long-term recovery rate is 2.7 times higher in patients who had been treated with corticosteroid injections.

 

Several studies reported extracorporeal shock wave therapy (ESWT) as a suitable alternative treatment option for refractory GTPS with satisfactory long-term maintenance (Mani- Babu et al, Rompe et al, Furia et al and Korakakis et al). Kyoung-Ho Seo showed in a recent article that ESWT seems to be an effective treatment option for pain relief in chronic refractory GTPS (83%) but its long-term effect appears to decrease with time (57%). Standard protocol of ESWT for GTPS is not yet established.

 

LD-EBRT is widely used in Germany to treat patients with GTPS after the failure of other therapeutic options. It is a well-accepted therapeutic option in daily clinical practice. However, randomized studies comparing LD-EBRT with shame irradiation or with other treatment modalities of GTPS to prove the efficacy of LD-EBRT have not been published to the best of our knowledge. (Kaltenborn et al).

 

There is a consensus to reserve surgery only to patients not responding to conservative treatment.!!!!

 

 

Trochanteric bursectomy: arthroscopic trochanteric bursectomy shows good improvement in outcomes for at least two years following bursectomy (Larose et al, Baker et al and Wieser et al ). The studies however are poor in terms of evidence level hierarchy and therefore need to be interpreted with caution. (Reid et al ).

 

Trochanteric reduction osteotomy: Govaert et al  proposed open trochanteric reduction osteotomy as an effective procedure for refractory GTPS . The proposed theoretical background was that this intervention could provide hyperhemia, and biomechanical benefits including a reduction in friction.

 

ITB release/lengthening: ITB is a cause of pain and inflammation secondary to trochanteric impingement and consequent development of trochanteric bursitis. ITB release is therefore important in treatment and prevention of recurrence of GTPS. ITB lengthening shows good long-term outcomes. The techniques of ITB lengthening varied between the studies, more frequently proximal, associated or not to bursectomy.
Khoury et al stated in a recent article that one of the most important causes of therapeutic failure in the GTPS is the thickening of the ITB band and therefore the surgical technique led to an important clinical improvement.

 

Gluteal tendon repair: most of the articles reviewed show very good long-term results, there being a subgroup (patients with hip arthroplasty) in which the post-surgical result is much worse. As in the other surgical techniques, studies of greater scientific rigor are required to validate their results. Fig. 24

POSTER ACTIONS Add bookmark Contact presenter Send to a friend Download pdf
SHARE THIS POSTER
2 clicks for more privacy: On the first click the button will be activated and you can then share the poster with a second click.

This website uses cookies. Learn more