Refractory Trochanteric Bursitis and Gluteal Tendinopathy

Understanding persistent pain on the outside of the hip and the treatment options available

Pain over the outside of the hip is commonly called trochanteric bursitis. However, persistent lateral hip pain is often more complex than inflammation of a single bursa. The broader term greater trochanteric pain syndrome (GTPS) includes irritation of the trochanteric bursa, gluteus medius or minimus tendinopathy, partial tendon tearing and compression beneath the iliotibial band.

Most people improve with appropriate non-surgical treatment. In a smaller group, pain remains significant despite physiotherapy, activity modification, medication and injections. This is known as refractory greater trochanteric pain syndrome.

For carefully selected patients, minimally invasive surgery may be considered to address several potential sources of pain during the same procedure.

What is greater trochanteric pain syndrome

The greater trochanter is the prominent bone on the outside of the upper femur. Several important structures pass over or attach to this area:

The gluteus medius and gluteus minimus tendons, which help stabilise the pelvis and move the leg away from the body
The trochanteric bursa, a thin cushioning sac between the tendons, bone and overlying tissues
The iliotibial band, a strong layer of tissue running down the outside of the thigh
Small sensory nerve branches that transmit pain from the tissues surrounding the greater trochanter

Although the condition has traditionally been called trochanteric bursitis, gluteal tendon degeneration or partial tearing is frequently an important contributor.

Common symptoms

Pain and tenderness over the outside of the hip
Pain when lying on the affected side
Difficulty sleeping because of lateral hip pai
Pain when walking, climbing stairs or walking uphill
Pain when standing on one leg
Discomfort when getting out of a chair or car
Pain extending down the outside of the thig
Weakness or a limp when the gluteal tendons are significantly affected

Pain arising from the lower back, hip arthritis and other conditions can sometimes produce similar symptoms. Establishing the correct source of pain is therefore important before treatment is recommended.

What causes the condition

Greater trochanteric pain syndrome usually develops through a combination of tendon overload and compression. Contributing factors may include:

Degenerative change within the gluteal tendons
Partial tearing of the gluteus medius or minimus tendon
Repetitive compression beneath the iliotibial band
Inflammation and thickening of the trochanteric bursa
A sudden increase in walking, running or exercise
Reduced hip-abductor strength or altered walking mechanics
Previous hip surgery or injury
Coexisting hip, knee or lower-back problems

Imaging abnormalities do not always cause symptoms. Any ultrasound or MRI findings must therefore be interpreted alongside the location of the pain and the physical examination.

How is it diagnosed

Diagnosis begins with a detailed history and examination. Dr Jason Hockings will assess the location of your pain, hip movement, gluteal strength, walking pattern and response to specific clinical tests.

Investigations may include:

X-rays to assess the hip joint and exclude significant arthritis or other bony abnormalities
Ultrasound to examine the trochanteric bursa and gluteal tendons
MRI to assess tendon degeneration, partial or full-thickness tearing, muscle quality and other causes of hip pain
Image-guided injection, in selected cases, to help identify the principal source of pain

Non-surgical treatment

Non-surgical treatment remains the first step for most patients. A structured program of education, load management and targeted exercise has good evidence for gluteal tendinopathy.

Treatment may include:

Modification of activities and positions that compress the affected tendons
Physiotherapy focusing on pelvic control and progressive gluteal strengthening
Appropriate pain-relieving or anti-inflammatory medication
Gradual correction of walking and exercise loads
Avoiding prolonged lying directly on the painful side
Image-guided corticosteroid injection for selected patients
Shockwave therapy or other injection treatments in appropriate circumstances

The most suitable treatment depends on the diagnosis, duration of symptoms, tendon condition and treatments already attempted.

When might surgery be considered

Surgery is generally reserved for patients with persistent, function-limiting symptoms despite an appropriate course of non-operative treatment.

Factors considered include:

Pain continuing despite structured physiotherapy and load modification
Symptoms interfering with sleep, work, walking or daily activity
Examination and imaging findings that match the site of pain
Failure of appropriately selected injections or other non-operative treatments
The presence and extent of gluteal tendon damage
Whether hip arthritis, spinal disease or another condition may be contributing to the symptoms

Not every patient with lateral hip pain will benefit from surgery. Dr Hockings will discuss whether the findings suggest a surgically treatable problem and whether the likely benefits justify the risks.

Arthroscopic treatment for refractory lateral hip pain

This operation is performed through several small incisions around the outside of the hip. Although commonly described as hip arthroscopy, much of the procedure is performed in the peritrochanteric space, outside the hip joint itself. Depending on the findings and individual circumstances, treatment may include the following components.

Arthroscopic iliotibial band lengthening

A controlled lengthening or release of the iliotibial band is performed over the greater trochanter. The aim is to reduce excessive tension and compression over the underlying bursa and gluteal tendons while preserving the important overall function of the iliotibial band.

Trochanteric bursectomy

Thickened and inflamed bursal tissue is removed arthroscopically. This creates space around the greater trochanter and allows the gluteal tendons to be carefully inspected. Removing the bursa also enables treatment of other abnormalities that may be hidden beneath inflamed tissue.

TOPAZ gluteal tenoplasty

TOPAZ radiofrequency microtenotomy, sometimes called radiofrequency microdebridement, may be used for degenerative gluteal tendinopathy or selected partial-thickness tendon damage.

A specialised probe creates a series of small treatment points within the abnormal tendon. This is intended to stimulate a local healing response while avoiding the need to remove or detach the whole tendon.

The evidence for TOPAZ treatment of gluteal tendinopathy remains limited. A small randomised trial found improvement following arthroscopic bursectomy and IT band release both with and without radiofrequency microdebridement, but did not demonstrate a statistically significant additional benefit from the radiofrequency treatment itself. It should therefore be regarded as a potential adjunct rather than a guaranteed source of additional improvement.

Cooled radiofrequency ablation of trochanteric sensory nerves

Small sensory nerve branches supply the tissues surrounding the greater trochanter. In some patients with longstanding pain, these nerves may continue to transmit pain signals even after the original tissue irritation has become chronic.

Cooled radiofrequency ablation, sometimes referred to by the product name Coolief, uses controlled radiofrequency energy to treat selected sensory branches supplying the greater trochanter. The objective is to reduce pain transmission while avoiding the major motor nerves controlling the gluteal muscles.

Early case-series evidence is encouraging, but this remains an evolving application with limited high-quality long-term evidence. The potential role, uncertainties and alternatives should be discussed for each patient.

What results can be expected

Published studies report improvement in pain and function for many appropriately selected patients following endoscopic bursectomy and iliotibial band release. However, results vary and some patients continue to experience pain.

The evidence for the additional contribution of TOPAZ treatment and trochanteric sensory nerve ablation is less mature than the evidence for the underlying arthroscopic decompression procedure.

Factors that may influence recovery include:

The duration of symptoms
The degree of tendon degeneration or tearing
Muscle weakness or fatty change
Coexisting hip arthritis or spinal pain
General health, smoking and weight
Participation in rehabilitation
Previous surgery or injections

Surgery cannot guarantee complete resolution of pain.

Recovery after surgery

Most patients can return home on the day of surgery or after an overnight stay, depending on their health and individual circumstances. In general:

Crutches are used initially for comfort and to maintain a safe walking pattern
Many patients begin weaning from crutches during the first two weeks
Early gentle movement is encouraged
Physiotherapy progresses from restoring movement and gait to gluteal strengthening and functional exercise
Iliotibial band stretching and stronger exercises such as glute bridges are important later in recovery but should not be commenced aggressively until cleared by the physiotherapist
Return to work depends on the physical demands of the occupation
Improvement can continue over several months as inflammation settles and tendon function recovers

A personalised rehabilitation program will be provided according to the exact procedure performed.

Potential risks

All surgery has potential risks. These may include:

Infection
Bleeding or haematoma
Blood clots
Wound-healing problems
Injury to nearby nerves or blood vessels
Temporary or persistent numbness
Nerve irritation or neuroma pain following radiofrequency treatment
Weakness, stiffness or altered gait
Persistent or recurrent lateral hip pain
Incomplete tendon healing
The need for further surgery
Anaesthetic or medical complications

Your individual risks and the alternatives to surgery will be discussed before a decision is made.

Full-thickness gluteal tendon tears and open repair

A full-thickness tear occurs when the gluteus medius or minimus tendon is completely detached from its insertion on the greater trochanter. These tears may produce significant weakness, limping, difficulty standing on one leg and persistent lateral hip pain.

TOPAZ tenoplasty cannot reconnect a completely detached tendon.

Some smaller full-thickness tears can be repaired endoscopically. However, an open gluteal tendon repair may be recommended when a tear is large, substantially retracted, chronic, associated with poor-quality tissue or muscle wasting, or cannot be mobilised and repaired reliably through an endoscopic approach.

During open repair:

An incision is made over the outside of the hip
The damaged tendon is identified and mobilised
The attachment area on the greater trochanter is prepared
The tendon is secured back to the bone using surgical anchors
Additional reinforcement or graft augmentation may occasionally be required for poor-quality or revision tears

When might augmentation be required

Most gluteal tendon tears can be repaired directly back to the greater trochanter using the patient’s own tendon. However, augmentation may be required when the tear is large or chronic, the tendon is substantially retracted, the tissue is thin or poor quality, a previous repair has failed, or the tendon cannot reach the bone securely without excessive tension.

In these circumstances, Dr Hockings may reinforce the repair with a synthetic patch or donor tendon tissue called an allograft. The graft may be placed over the repair to provide additional support or used to bridge or reconstruct a tissue gap. The choice depends on the tear pattern, tendon quality and findings at surgery, so the need for augmentation can sometimes only be confirmed during the operation.

Augmentation is not required routinely and does not guarantee that the tendon will heal. Published evidence is still developing. If it may be relevant, Dr Hockings will discuss the intended benefit, alternatives and additional considerations associated with synthetic material or donor tissue before surgery.

Recovery after a full-thickness tendon repair is more protective than recovery after an isolated bursectomy or IT band lengthening. Crutches and restrictions on active hip abduction are commonly required while the tendon heals. Rehabilitation is progressed gradually over several months.

Dr Hockings will review the MRI findings, muscle quality and degree of tendon retraction before recommending an endoscopic or open procedure.

Assessment of persistent lateral hip pain

If pain over the outside of your hip is affecting sleep, walking or daily activity despite appropriate treatment, a detailed assessment can help clarify whether the problem arises from the bursa, gluteal tendons, iliotibial band, hip joint, lower back or another structure.

Treatment recommendations are tailored to the diagnosis, previous treatment and individual goals.

Contact Dr Jason Hockings

reception@drjasonhockings.com.au

(03) 9421 6133

If you’re experiencing ongoing pain, stiffness, or reduced movement that is affecting your daily activities or quality of life, a thorough orthopaedic assessment can help determine the cause and guide the most appropriate treatment options for your situation.

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