Rotator Cuff of hip causes Greater Trochanter pains

Trochanteric side of hip pain is common yet rarely properly diagnosed. Actual Gluteal tears can be a cause and by age 60, 10% of people have them. Twenty Percent of chronic back pains (average age of 54 yrs) have trochanteric pain. Proper treatment depends on extent of tears yet they have eluded recognition up until now.

Lequesne M.
From “periarthritis” to hip “rotator cuff” tears. Trochanteric tendinobursitis. Joint Bone Spine. 2006 Jul;73(4):344-8. editorial

Symptoms:

  • It is more common in women and can occur as young as 37 years old. Mean ages are in 50’s or 60’s depending on study.
  • Lateral hip/buttock pain perhaps radiating to thigh
  • It usually develops gradually and hence diagnosis is delayed.
  • Stair and uphill climbing is painful as is getting up from a chair.
  • It hurts during the hip extension phase of walking.
  • In elderly this could precipitate falls.
  • NSAID’s, phsiotherapy and steroid injection often give a temporary benefit but may only last weeks if tears are present.
  • It could take 41 months to diagnosis though doctor familiarity and use of ultrasound can cut that to 6 months

Signs:

  • Trochanteric area tenderness
  • Pain on external rotation with hip flexed 90 degrees
  • Pain with standing on affected leg after 10- 30 sec. “virtually always present”
  • Trendelenburg gait is seen in ½ -3/4 of cases and is thought an important finding.
  • Pain on resisted abduction seen in 50-70% cases
  • abductor weakness
  • Calcifications near trochanter can be seen on Xray in 15-40% cases.

A survey of French Orthopedic surgeons found this condition was undiagnosed except if incidentally found at time of hip surgery.

abstract here

It was suggested Trochanteric pain lasting or recurring over a 3 month period should have an US. Bursitis is rarely isolated finding and is usually associated with tendonitis. In persistent cases would suggest there are unrecognized tears. Partial anterior gluteus medius and gluteus minimus tears are the typical pattern.

Diagnosis can be confirmed by Positive guided injection test – injected by radiologist under imaging.

Treatments include conservative –

  • NSAID’s
  • physio
  • weight bearing reduction
  • Steroid injection can be successful if tears not evident:
    abstract here
    “Peritrochanteric infiltration with glucocorticoids mixed with 2% lidocaine relieves patients from their symptoms for a long period of time. Recurrence should always be expected, but treatment may be repeated.”
  • Surgical repair works in 6/7 tear cases in selected patients.

If hip OA is seen on xray the chances of recovery are cut 4.8 times: abstract here

Comment – Gluteal/trochanteric pains are common in chronic pain sufferers. If tenderness is just isolated to the top of the trochanter, I would think trochanteric bursitis may be more isolated. Injecting one spot will hit the bursa only ½ of the time: abstract here

I circle the tender area and inject 10- 20 mls 0.5% lidocaine with 40 mg Kenalog into multiple spots until no tender areas persist.

Trochanteric pain with pains posterior or cranially is much more complex. Lack of early availability of Ultrasound and uncertainty of findings makes it even harder for me. I find patients with trochanteric pain almost always have back pain. Maybe it is natural to hike up the hip with lateral Quadratus lumborum back muscles to compensate for the trendenburg. Yet others may have pain coming from the back.

Addendum:

Physical findings in Gluteal tears:

Lack of trendenberg makes it safer to assume bursitis and inject with steroid ..

 I would be interested in other people’s management of these cases. I would also be interested on how often this happens post MVA as some patients can even develop pelvic fractures from such.

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