ShockWave/ ESWT for Greater Trochanteric Pain (GTPS)
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1. What is GTPS?
GTPS is a common cause for pain on the side of the hip, particularly in middle age females. The hip joint is a ‘ball and socket’ joint with the ‘ball’ ( head of the thigh bone (femur) and the ‘socket’ your pelvis ).. The greater trochanter (GT) is the bony protuberance on the side which serves as the attachment site for tendons namely your gluteus medius and gluteus minimus. Above the tendons is a thin fluid filled layer called the bursa and the iliotibial band (ITB). The role of the bursa is to prevent friction of the tendon’s as they move over the bone with hip movements and the role of the ITB is to move and stabilise the hip and pelvis.
Historically, it was suggested that the pain was linked to inflammation of the trochanteric bursa. However, this rather simplistic explanation is incorrect and the condition is best referred to as greater trochanteric pain syndrome (GTPS). This term encompasses numerous structures around the outside of the hip, the gluteal tendons specifically the gluteus medius tendon. Pain is generated from both the tendons and the bursa. It is essential to consider both of these structures in the treatment plan, and I always evaluate the tendon with ultrasound in the office
The condition causes pain on the side of the hip that can radiate into the buttock region and/or down the leg. GTPS does not normally limit or cause pain when taking off shoes and socks. Pain on removing shoes and socks is more associated with hip joint issues such as osteoarthritis or femoral acetabular impingement (FAI).
Patients will commonly complain of pain while lying on their side in bed combined with pain while standing on one leg and climbing stairs. It is important it be diagnosed correctly with a physical exam and imaging such as xray and ultrasound or mri to ensure the pain is not coming from other sources such as your lower back or hip joint itself.
2. What causes GTPS?
GTPS is more common in female patients aged 40-60 years of age and with those with pre-existing low back pain, osteoarthritis of the knee and knee pain. Sometimes. GTPS can be associated with a specific injury such a falling onto the hip and/or overuse such as increasing your running too quickly.
3. How do we treat GTPS?
Nearly all patients with GTPS have evidence of gluteus tendinopathy, a thickening of the tendon often with partial tearing. Sometimes calcific deposits are also present. It is rare to see isolated bursal swelling. Because the pain is from the tendon the best treatment to start with is a program to help unload the tendon from stress. This is accomplished by multiple measures. The first priority when treating GTPS is to get the pain under control. This may include the use of oral medication, modification of activities and targeted prescriptive exercises. This may initially consist of:
Reducing the aggravating activities
Avoid standing on one leg for prolonged periods of time
Modifying sleeping positions – we would advise not sleeping on the painful side and placing a pillow between your knees
Targeted hip and core strengthening exercises
General lower leg strengthening exercises
Here are some links to home exercise programs, though a more detailed program directed by a physiotherapist is preferred.
Home exercise program https://www.youtube.com/watch?v=Lmjidcc5ccA
In some patients, a ultrasound guided steroid injection may be a short term help to settle the problem down but is not a good long term solution for the problem.
4. Is Shockwave Therapy effective for GTPS?
A recent Level 1 randomized controlled multi center study was published in the leading orthopedic journal (Journal of Bone and Joint Surgery) looking at ESWT / shockwave for GTPS. This is the strongest type of medical study that can be done. This study looked at a specific type of ESWT, which we are one of the few providers to have, called focused eswt. It showed significant improvements in pain, function, quality of life and satisfaction with treatment. Here is a reference to the article and an excellent commentary. https://journals.lww.com/jbjsjournal/Abstract/2020/08050/Focused_Shockwave_Treatment_for_Greater.7.aspx. commentary: https://journals.lww.com/jbjsjournal/Fulltext/2020/08050/Shockwave__Does_It_Work_Like_Magic_for_Greater.19.aspx
Three treatments of a specific dose of focused shockwave were used. Some patients will require additional sessions, but this will depend on the patients response to treatment. I have been using this protocol for awhile with my patients with excellent success.
5. Is PRP / Plasma helpful for GTPS?
If severe tendonosis or a significant tear of part of the tendon is noted, I usually recommend the patient consider PRP / Plasma therapy either alone or addition to ESWT/ shockwave. Below is an summary of a recent issue of American Journal of Sports Medicine for a Level I study using Platelet Rich Plasma for gluteal tendinopathy treatment compared to a control group who had injection of a corticosteroid. In this randomized control trial, “patients with chronic gluteal tendinopathy >4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.” These results further support our anecdotal successes we have seen in our clinic when treating. This well done article showed excellent results with prp in specific cases of GTPS. https://doi.org/10.1177/0363546517745525
In cases or severe GTPS or high demand individuals, a combination of eswt with prp works quite well and I believe is a great treatment option for many. In all cases, prp should be done under direct ultrasound visualization by a provider with extensive experience in PRP. The studies show that ultrasound guidance and prp preparation (specific types of prp) are critical to good outcomes. I have extensive experience with this condition and treatment with both eswt, and prp and am nationally recognized for my work with ultrasound guided procedures.
Summary:
In summary, GTPS is from a wear of the gluteal tendons on the outside of the hip. It is often confused with bursitis. It should be evaluated with a physical exam and an assessment of the gluteal tendon, usually by xray and ultrasound or mri. If the patient fails an appropriate course of therapy, then an ultrasound guided injection or treatment with eswt/shockwave and/or prp can give excellent long term results.
