Trochanteric Bursitis: Why the Side of the Hip Hurts

In most cases, the pain results from gluteus medius and minimus tendinopathy, with or without associated trochanteric bursa inflammation. This updated understanding led to the adoption of the term GTPS, which encompasses bursitis, gluteal tendinopathy, and lateral hip snapping syndrome.

Pathophysiology

The Trochanteric Bursa

The trochanteric bursa is a synovial structure that reduces friction between the gluteus maximus tendon and the bony prominence of the greater trochanter. When subjected to repetitive compression — as in walking with an unstable pelvis — the bursa can become inflamed, but MRI studies show that gluteal tendinopathy is present in more than 50% of cases diagnosed as "bursitis."

Gluteus Medius Tendinopathy

The gluteus medius is the main lateral pelvic stabilizer during gait. Its insertion at the greater trochanter bears significant compressive and traction loads with each step. Over time, these forces can degrade collagen fibers — especially in postmenopausal women, when falling estrogen reduces collagen synthesis and tendon repair capacity.

Anatomy of the greater trochanter: insertions of the gluteus medius and minimus, trochanteric bursa, and iliotibial band. Compressive force vectors shown.

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Risk Factors

In addition to female sex and age, other predisposing factors include obesity (elevated BMI increases mechanical load), hip or knee osteoarthritis (compensatory gait alteration), prior hip surgery, and repetitive activities such as running on inclined surfaces.

Symptoms

The classic presentation is lateral hip pain that may radiate along the lateral thigh down to the knee. It is important to distinguish it from groin pain, which suggests hip joint involvement.

Diagnosis

Diagnosis is predominantly clinical. Palpation of the greater trochanter reproducing the patient's pain is the most consistent finding. Specific tests help confirm the diagnosis and differentiate from other conditions.

Differential Diagnosis

Lateral hip pain is a symptom shared by several conditions. Precise diagnosis is essential, since each cause demands specific treatment. Systematic medical evaluation — including targeted physical examination and imaging studies when necessary — is fundamental to avoiding inadequate treatments.

Hip Osteoarthritis vs. GTPS: Pain Location Is Decisive

A fundamental and frequently underestimated distinction is the anatomic location of pain. Hip osteoarthritis causes pain predominantly in the groin (inguinal region) with radiation to the medial thigh and, sometimes, to the knee — reflecting coxofemoral joint dysfunction. GTPS, by contrast, is located laterally, over the greater trochanter, and can radiate along the lateral thigh. Patients with hip OA show limited internal rotation on passive mobilization and progressive worsening with weight-bearing activities, whereas in GTPS joint range of motion is frequently preserved.

Hip radiography is the initial test: joint space narrowing and degenerative bone changes confirm OA. In GTPS, the coxofemoral joint is radiographically normal, and ultrasonography or MRI reveals changes in the gluteal tendons and bursa.

Stress Fracture: An Emergency That Cannot Be Overlooked

In athletes — especially long-distance female runners and military personnel — stress fracture of the femoral neck or trochanteric region must be considered in the differential diagnosis of lateral hip pain. Stress fracture pain typically worsens progressively with activity and can be subtle on physical examination in early stages, mimicking GTPS. Risk factors such as relative energy deficiency in sport (RED-S), low bone mineral density, or a history of fractures should heighten suspicion.

Plain radiography may be negative in the first 2 to 6 weeks. MRI is the test of choice for early diagnosis — it reveals bone edema and the fracture line before any radiographic change. Failing to recognize and treat this condition can result in a complete displaced fracture, a serious complication that severely compromises the functional prognosis.

Piriformis Syndrome: Deep Gluteal Pain That Mimics GTPS

Piriformis syndrome occurs when the piriformis muscle — located in the deep gluteal region — compresses the sciatic nerve, causing gluteal pain that may radiate down the posterior thigh. Although the pain is gluteal and not strictly lateral as in GTPS, symptom overlap is frequent, especially in runners. Patients with piriformis syndrome typically report worsening with prolonged sitting on hard surfaces and with resisted external rotation of the hip.

The FAIR test (Flexion, Adduction, and Internal Rotation of the hip) is the most widely used provocative test — it reproduces compression of the sciatic nerve by the tense piriformis. Pelvic MRI with specific cuts can demonstrate piriformis hypertrophy or edema. Distinction from GTPS is important because piriformis syndrome treatment focuses on stretching and relaxing the piriformis, while GTPS requires gluteal strengthening — opposite approaches that can be mutually counterproductive if applied to the wrong diagnosis.

Treatments

Education and Behavior Modification

The first step is to avoid compressive postures: do not sleep on the affected side (use a pillow between the legs), avoid crossing the legs, and do not stand resting on a single hip. These simple modifications reduce the compressive load on the tendons and allow the repair process to begin.

Therapeutic Exercises

The GTPS exercise program was revolutionized by Grimaldi's studies (2015-2020). The modern approach emphasizes initial isometric exercises (such as standing isometric abduction against the wall) followed by progressive isotonic exercises of the glutes. Stretching exercises of the iliotibial band, previously considered essential, should be avoided in the acute phase as they increase compression of the tendons over the trochanter.

Injections

Ultrasound-guided corticosteroid injection in the trochanteric bursa offers relief in 60-75% of patients, but the effect is frequently temporary (4-12 weeks). A randomized study by Mellor et al. (2018) showed that supervised exercises produced superior results to injection at 12 months. Corticosteroid can be useful as a "bridge" to facilitate the start of rehabilitation.

Acupuncture as a Therapeutic Option

Acupuncture can contribute as part of a multimodal approach for GTPS. Proposed mechanisms include local analgesia tied to endogenous opioid release and segmental pain modulation at the corresponding spinal levels (L4-S1) — effects described in experimental literature and clinical studies.

Although studies specific to acupuncture in GTPS are limited, evidence for hip musculoskeletal pain in general suggests short-term benefits in pain reduction and functional improvement. Acupuncture can be especially useful in the initial phase for pain control, facilitating adherence to the exercise program.

Prognosis and Recovery

GTPS prognosis is usually favorable with appropriate treatment. Studies suggest that supervised exercise programs produce significant improvement in a good portion of patients over 12 months, although response rates vary between studies. The condition can become chronic if untreated, but rarely progresses to severe disability.

Myths and Facts

When to Seek Medical Help

Frequently Asked Questions