Greater Trochanteric Pain Syndrome: Diagnosis and Treatment of Lateral Hip Pain
Pain Spa | Dr Krishna | Specialist Interventional Pain Management
Greater Trochanteric Pain Syndrome
A comprehensive clinical guide to lateral hip pain, gluteal tendinopathy, bursitis, iliotibial band pathology, diagnosis and ultrasound-guided treatment options.
Overview: What is Greater Trochanter Pain Syndrome?
Greater Trochanteric Pain Syndrome (GTPS) is one of the most common causes of lateral hip pain, characterised by pain around the greater trochanter that may radiate down the outer thigh. Historically referred to as “trochanteric bursitis”, our modern understanding now recognises that most patients do not primarily suffer from isolated bursal inflammation. Instead, GTPS is predominantly driven by gluteal tendinopathy — particularly degeneration of the gluteus medius and gluteus minimus tendons at their insertion onto the greater trochanter. Iliotibial band friction, bursitis, and snapping hip syndrome may also contribute to the overall clinical picture.
GTPS is the most prevalent lower limb tendinopathy and disproportionately affects middle-aged women, with approximately 1 in 4 women over the age of 50 experiencing symptoms during their lifetime. The incidence is estimated at approximately 1.8 patients per 1,000 population per year. Despite being extremely common, GTPS remains frequently under-recognised and undertreated. The condition can produce substantial pain, sleep disturbance, impaired mobility, and reduction in quality of life — in some cases causing levels of disability comparable to end-stage hip osteoarthritis.
Patients commonly report pain when lying on the affected side, climbing stairs, walking for prolonged periods, or standing on one leg. Chronic cases may lead to significant functional impairment, altered gait mechanics, reduced physical activity, and secondary deconditioning. A modern evidence-based understanding of GTPS is therefore essential in order to guide accurate diagnosis, targeted rehabilitation, and appropriate interventional management.
Epidemiology and Risk Factors
Greater Trochanteric Pain Syndrome (GTPS) predominantly affects women between the ages of 40 and 60 years and is recognised as the most prevalent lower limb tendinopathy. Population studies demonstrate a marked female predominance, with the prevalence of unilateral GTPS estimated at approximately 15% in women compared with 6.6% in men.
Several important clinical and biomechanical associations have been identified, suggesting that GTPS is closely linked to altered lower limb loading patterns, pelvic control dysfunction, and co-existing musculoskeletal pathology.
Key Risk Factors Associated with GTPS
| Risk Factor | Clinical Relevance |
|---|---|
| Co-existing low back pain | Strong association with GTPS (odds ratio 2.79), likely reflecting altered biomechanics and shared pain pathways. |
| Ipsilateral knee osteoarthritis | Associated with abnormal gait mechanics and increased lateral hip loading (odds ratio 3.47). |
| Iliotibial band tenderness | May contribute to compressive forces over the greater trochanter and coexist with gluteal tendinopathy. |
| Hip osteoarthritis | Can alter pelvic mechanics and increase compensatory loading of the hip abductors. |
| Postmenopausal hormonal changes | May adversely affect tendon collagen structure and tendon healing capacity. |
| Poor pelvic and hip muscle control | Contributes to excessive hip adduction and abnormal compressive tendon loading. |
Interestingly, body mass index (BMI) was not independently associated with GTPS after adjustment for other variables. The condition occurs in both athletes and sedentary individuals, suggesting that the quality of biomechanical loading and pelvic control is more important than the absolute quantity of physical activity. This reinforces the modern concept that GTPS is fundamentally a load-management and tendon-loading disorder rather than simply an inflammatory condition.
Causes of Lateral Hip Pain
Lateral hip pain has a broad differential diagnosis. Although Greater Trochanteric Pain Syndrome (GTPS) is by far the most common cause, a number of spinal, intra-articular, neurological, and systemic conditions can produce similar symptoms. Accurate diagnosis is essential because treatment strategies differ significantly depending on the underlying pathology.
| Condition | Key Clinical Features |
|---|---|
| Greater Trochanteric Pain Syndrome (GTPS) | Pain over the greater trochanter; worse when lying on the affected side, climbing stairs, prolonged walking, or single-leg stance. |
| Hip Osteoarthritis | Groin and anterior thigh pain; restricted internal rotation; stiffness; difficulty putting on shoes and socks. |
| Lumbar Radiculopathy (L2–L4) | Associated low back pain, neurological symptoms, altered sensation, or tenderness above L5. |
| Iliotibial Band Syndrome | Activity-related lateral hip pain; common in runners; may be associated with snapping sensations. |
| Meralgia Paresthetica | Burning pain, tingling, or numbness over the lateral thigh without trochanteric tenderness. |
| Sacroiliac Joint Dysfunction | Buttock and lateral hip pain with tenderness over the sacroiliac joint. |
| Stress Fracture (Femoral Neck) | Seen in athletes or osteoporotic patients; antalgic gait; pain with hip range of motion and weight bearing. |
| Septic Arthritis | Acute severe pain, fever, inability to bear weight, systemic illness — urgent assessment required. |
Clinical Importance
Many patients with persistent lateral hip pain have overlapping pathology, including lumbar spine disease, hip osteoarthritis, pelvic dysfunction, or gluteal tendon pathology occurring simultaneously. A careful history, focused physical examination, and appropriate imaging are therefore essential to identify the dominant pain generator and guide targeted treatment.
What Causes Gluteal Tendinopathy?
Gluteal tendinopathy develops through a combination of excessive mechanical loading and age-related tendon degeneration affecting the gluteus medius and gluteus minimus tendons. Modern evidence suggests that the condition is not primarily inflammatory but instead represents a failed tendon healing response triggered by chronic overload and abnormal biomechanics.
The gluteal tendons are exposed to both tensile forces (stretching forces) and compressive forces against the greater trochanter during everyday activities. Over time, repetitive loading beyond the tendon’s capacity can lead to structural degeneration, pain, and impaired tendon function.
The Role of Hip Adduction
Excessive hip adduction is considered the central biomechanical driver of gluteal tendinopathy. In this position, the gluteal tendons become compressed against the greater trochanter while simultaneously being stretched under tension — a particularly damaging combination for tendon tissue.
Biomechanical studies demonstrate that individuals with gluteal tendinopathy exhibit significantly greater hip adduction moments during walking compared with asymptomatic controls. Poor pelvic control and sustained hip adduction therefore play a major role in symptom development and persistence.
Common Provocative Postures and Activities
- Standing with weight shifted onto one leg (“hip hanging out”)
- Crossing the legs while sitting or standing
- Sleeping on the affected side
- Sitting in low chairs or with legs crossed
- Walking or running with poor pelvic and hip control
Age-Related Degeneration and Tendon Biology
At a microscopic level, tendinopathy represents a failed healing response rather than a purely inflammatory process. Under excessive mechanical load, tendon cells (tenocytes) produce inflammatory cytokines — particularly IL-1β — together with matrix metalloproteinases, leading to progressive tendon degeneration and cellular apoptosis.
Histological studies demonstrate several characteristic features of gluteal tendinopathy:
- Disorganised collagen fibre architecture
- Increased microvasculature (neovascularity)
- Sensory nerve ingrowth (neoneurogenesis)
- Dysregulated extracellular matrix homeostasis
- Progressive tendon weakening and reduced load tolerance
Increased acetabular anteversion has also been associated with gluteal tendinopathy on MRI studies. This anatomical variation may alter hip biomechanics, increase hip adduction moments, and predispose the gluteal tendons to abnormal loading over time.
Pathology Distribution in GTPS
A landmark sonographic study involving 877 patients with Greater Trochanteric Pain Syndrome (GTPS) significantly changed our understanding of lateral hip pain. Historically, the condition was widely labelled as “trochanteric bursitis”, implying that inflammation of the trochanteric bursa was the primary pathology. Modern imaging evidence, however, demonstrates that gluteal tendinopathy is substantially more common than isolated bursitis.
Distribution of Pathology in GTPS
| Underlying Pathology | Prevalence |
|---|---|
| Gluteal tendinosis (most common) | 49.9% |
| Thickened iliotibial band | 28.5% |
| Trochanteric bursitis | 20.2% |
| Gluteal tendon tears | 0.5% |
Clinical Significance
These findings explain why the older term “trochanteric bursitis” has largely been abandoned and replaced by the broader term Greater Trochanteric Pain Syndrome (GTPS). Although bursitis can occur, it is present in fewer than 1 in 5 patients and frequently coexists with gluteal tendon pathology rather than occurring in isolation.
This modern understanding has major treatment implications. Management should not focus solely on reducing inflammation but instead address tendon loading, hip biomechanics, pelvic control, and associated iliotibial band dysfunction. This is why education, rehabilitation, and targeted tendon-based interventions now form the cornerstone of evidence-based treatment.
Clinical Presentation
The typical patient with Greater Trochanteric Pain Syndrome (GTPS) is a woman aged between 40 and 60 years who develops gradually progressive lateral hip pain without a clear precipitating injury. Symptoms are often persistent, fluctuate with activity levels, and may progressively interfere with walking, sleep, exercise, work, and everyday function.
Common Clinical Features
- Lateral hip pain directly over the greater trochanter, often described as aching, burning, or deep in nature
- Pain radiating along the outer thigh, occasionally extending toward the knee or below the knee
- Night pain, particularly when lying on the affected side, frequently causing significant sleep disturbance
- Aggravation with stair climbing, prolonged walking, rising from a chair, or single-leg stance activities
- Insidious onset without a specific traumatic injury in the majority of patients
- Possible Trendelenburg gait or contralateral pelvic drop, reflecting gluteal muscle weakness and impaired pelvic control
Many patients report progressive restriction in daily activities due to pain when standing, walking, exercising, or sleeping. Sitting with crossed legs, prolonged single-leg standing, and walking on uneven ground commonly aggravate symptoms because these positions increase compressive loading across the gluteal tendons.
Impact on Function and Quality of Life
GTPS is not a minor pain condition. Studies demonstrate that the degree of disability and reduction in quality of life can be comparable to end-stage hip osteoarthritis. Patients with chronic GTPS are less likely to remain in full-time employment and often reduce physical activity because of pain and sleep disruption.
Chronic cases may also demonstrate widespread pressure hyperalgesia, suggesting the development of central sensitisation. Psychological and functional factors appear important in symptom severity, with depression, hip abductor strength, and stair-climbing performance together explaining approximately 26% of pain and disability variance in clinical studies.
Diagnosis
The diagnosis of Greater Trochanteric Pain Syndrome (GTPS) is primarily clinical and is based on a combination of symptom pattern, physical examination findings, and targeted imaging when required. No single clinical test is diagnostic in isolation; however, combining multiple examination manoeuvres significantly improves diagnostic accuracy.
Clinical Tests
The following examination tests are particularly useful when assessing patients with suspected gluteal tendinopathy, bursitis, or associated iliotibial band pathology.
| Test | Technique | Clinical Significance |
|---|---|---|
| Single-Leg Stance (30 sec) | Pain reproduced within 30 seconds of standing on the affected limb | Post-test probability of gluteal tendinopathy rises to approximately 98% if positive (specificity 100%) |
| Palpation of Greater Trochanter | Direct pressure over the posterolateral greater trochanter | Approximately 80% sensitivity; absence of tenderness makes tendinopathy unlikely |
| Resisted External Derotation Test | Hip and knee flexed to 90° while examiner internally rotates against resistance | Reproduces lateral hip pain in gluteal tendinopathy |
| FABER Test | Flexion, abduction, and external rotation of the hip | Lateral hip pain is considered positive; combined with palpation gives 81% sensitivity and 82% specificity for GTPS |
| Hip Lag Sign | Patient attempts to maintain passive hip abduction | 89% sensitivity and 97% specificity for gluteal tendon tear or hip abductor insufficiency |
| Trendelenburg Test | Observation for contralateral pelvic drop during single-leg stance | Suggests gluteus medius weakness or abductor insufficiency |
| Ober Test | Side-lying with passive hip abduction and extension followed by adduction | Assesses gluteus medius/minimus and hip capsule tightness |
| Hula-Hoop Test | Patient performs circular hip movement | A palpable or audible lateral snap suggests external snapping hip or ITB pathology |
Imaging
Ultrasound
Ultrasound is the preferred first-line advanced imaging modality for GTPS. It is dynamic, low cost, widely available, and allows real-time assessment of gluteal tendinopathy, tendon tears, bursitis, and iliotibial band thickening. Ultrasound also enables accurate image-guided interventions.
MRI
MRI is indicated when diagnostic uncertainty exists, when surgical referral is being considered, or when ultrasound findings are inconclusive. MRI is superior for identifying gluteal tendon tears, muscle atrophy, stress fractures, and co-existing intra-articular pathology.
Plain Radiographs
Plain X-rays of the pelvis and hip should usually be performed initially to exclude fracture, tumour, advanced osteoarthritis, and other bony abnormalities that may mimic GTPS.
The Role of the Iliotibial Band and Bursae
Iliotibial Band (ITB) and Lateral Hip Pain
The iliotibial band (ITB) is an important and frequently under-recognised contributor to Greater Trochanteric Pain Syndrome (GTPS). As the ITB courses from the iliac crest across the lateral hip and over the greater trochanter toward its distal insertions, it can generate pain through both frictional and compressive mechanisms.
Mechanisms by Which the ITB Causes Pain
- ITB friction over the greater trochanter — producing external snapping hip syndrome (coxa saltans externa), characterised by a perceptible or audible snap during hip flexion or rotation
- ITB thickening and tightness — compressing the underlying gluteal tendons and bursae against the greater trochanter during movement and weight bearing
ITB pathology frequently coexists with gluteal tendinopathy and bursitis rather than occurring in isolation. Dynamic ultrasound can often demonstrate thickening of the ITB, snapping phenomena, and associated gluteal tendon pathology in real time.
For refractory cases, combined percutaneous ultrasound-guided tenotomy of both the ITB and gluteus medius tendon has demonstrated approximately 83% treatment success at one year, highlighting the importance of addressing both tendon and fascial components of lateral hip pain.
Peritrochanteric Bursae
There are three to four clinically relevant bursae surrounding the greater trochanter. These bursae reduce friction between the gluteal tendons, iliotibial band, and bony surfaces during movement. Although bursitis can contribute to symptoms, it frequently occurs secondary to gluteal tendon pathology or ITB-related compression.
| Bursa | Location | Clinical Significance |
|---|---|---|
| Subgluteus Maximus (“Trochanteric”) Bursa | Between the ITB/gluteus maximus and the underlying gluteal tendons; covers the posterior facet of the greater trochanter | Largest and most commonly inflamed bursa; primary target for corticosteroid injection |
| Subgluteus Medius Bursa | Between the gluteus medius tendon and the superior lateral facet of the greater trochanter | May become inflamed secondary to gluteus medius tendinopathy |
| Subgluteus Minimus Bursa | Between the gluteus minimus tendon and the anterior facet; extends toward the anterior hip capsule | Often inflamed secondary to gluteus minimus tendinopathy |
| Gluteofemoral Bursa | Between the gluteus maximus and vastus lateralis posterolaterally | Less commonly implicated clinically |
Clinical Pearl
Evidence suggests that corticosteroid injection into the subgluteus maximus (“trochanteric”) bursa provides longer pain reduction compared with injection into the gluteus medius bursa or extrabursal sites. This reinforces the importance of accurate anatomical targeting during ultrasound-guided intervention.
Snapping Hip Syndrome (Coxa Saltans)
Snapping Hip Syndrome, also known as coxa saltans, refers to a perceptible or audible snapping sensation around the hip during movement. Although asymptomatic snapping occurs in approximately 5–10% of the population, it becomes clinically significant when pain, functional limitation, or recurrent irritation develops.
Three distinct forms of snapping hip syndrome are recognised: external, internal, and intra-articular. Accurate differentiation is important because the underlying pathology, examination findings, and treatment strategies differ considerably.
| Type | Structure Involved | Mechanism | Key Clinical Finding |
|---|---|---|---|
| External (most common) | Iliotibial band (ITB) and/or gluteus maximus fascial complex | Thickened ITB snaps over the greater trochanter during hip flexion or rotation | Palpable or visible lateral hip snap; positive hula-hoop test |
| Internal | Iliopsoas tendon | Tendon snaps over the iliopectineal eminence or femoral head during hip extension from flexion | Anterior hip snapping sensation; positive Thomas test |
| Intra-articular | Labral tears, loose bodies, cartilage flaps | Mechanical catching from pathology within the hip joint | Deep hip catching sensation; positive FADIR test; restricted range of motion |
Clinical Significance
External snapping hip is the form most closely associated with Greater Trochanteric Pain Syndrome (GTPS). The snapping typically occurs as the thickened iliotibial band or gluteus maximus fascial fibres move abruptly across the greater trochanter during hip movement.
Importantly, intraoperative studies demonstrate that isolated ITB release resolves snapping in only 22.6% of patients. In the majority of cases, release of both the ITB and the gluteus maximus fascial complex is required, highlighting that the gluteus maximus fascial component is a frequently underappreciated contributor to persistent snapping hip syndrome.
Treatment: A Modern Evidence-Based Approach
Modern treatment of Greater Trochanteric Pain Syndrome (GTPS) has moved away from the older concept of simply treating “bursitis” with repeated steroid injections. Current evidence strongly supports a tendon-focused and load-management approach, with rehabilitation forming the cornerstone of treatment.
Most patients improve with a combination of education, biomechanical correction, progressive strengthening, and carefully selected interventions when required. Treatment should be individualised according to symptom duration, severity, tendon pathology, functional impairment, and response to rehabilitation.
First-Line Treatment: Education and Progressive Exercise
Education combined with progressive exercise remains the most effective first-line treatment for GTPS and consistently outperforms corticosteroid injection and “wait-and-see” approaches in long-term outcomes.
Key Principles of Load Management
- Avoid sleeping directly on the affected side
- Avoid prolonged standing with weight shifted onto one hip (“hip hanging out”)
- Avoid crossing the legs while sitting or standing
- Maintain good pelvic alignment during walking and daily activities
- Use gradual activity progression rather than complete inactivity
Rehabilitation usually progresses through staged strengthening, beginning with pain-controlled isometric exercises, followed by isotonic hip abductor strengthening, pelvic control exercises, and eventually heavy slow resistance and functional rehabilitation.
Typical Rehabilitation Progression
| Phase | Focus |
|---|---|
| Phase 1 | Pain reduction, isometric hip abduction, pelvic control, education |
| Phase 2 | Progressive strengthening, controlled loading, single-leg control |
| Phase 3 | Heavy slow resistance, functional rehabilitation, return to activity |
Recent evidence suggests that supervised heavy slow resistance programmes are safe, well tolerated, and associated with meaningful improvements in pain and function.
Corticosteroid Injections
Ultrasound-guided corticosteroid injection can provide useful short-term pain relief, particularly in highly irritable cases or when pain is preventing participation in rehabilitation. However, modern evidence suggests that steroid injection should be viewed primarily as a temporary adjunct rather than a definitive treatment.
Pain relief is often most noticeable during the first 1–3 months, but long-term outcomes are generally inferior to structured education and exercise programmes. Injection accuracy is improved with ultrasound guidance, particularly in patients with obesity, complex anatomy, or failed landmark-guided injections.
Important Clinical Points
- Best used as a bridge to rehabilitation rather than a stand-alone treatment
- Injection into the subgluteus maximus bursa appears to provide the best outcomes
- Repeated steroid injections should be used cautiously
- Avoid intratendinous injection because of the risk of tendon weakening or rupture
Platelet-Rich Plasma (PRP)
Platelet-rich plasma (PRP), particularly leucocyte-rich PRP injected directly into areas of gluteal tendinopathy under ultrasound guidance, has emerged as a promising option for chronic or refractory cases.
Several studies suggest that PRP may provide more durable improvement than corticosteroid injection, especially in patients with MRI-confirmed gluteal tendinopathy who have failed conservative management. However, results across studies remain mixed, and ongoing debate continues regarding the relative contribution of PRP itself versus the biological effect of tendon needling.
Patients Most Likely to Benefit
- Chronic symptoms persisting beyond 4 months
- MRI-confirmed gluteal tendinopathy
- Failure of rehabilitation or recurrence after steroid injection
- Patients seeking a tendon-focused regenerative approach
Extracorporeal Shockwave Therapy (ESWT)
Extracorporeal Shockwave Therapy (ESWT) is a non-invasive treatment option increasingly used for refractory GTPS. Focused ESWT appears more effective than radial ESWT and may provide superior long-term outcomes compared with corticosteroid injection in selected patients.
ESWT is often most useful in patients with chronic tendinopathy who wish to avoid injection therapy or who have persistent symptoms despite rehabilitation.
Treatment Summary
| Treatment | Role | Best Indication |
|---|---|---|
| Education + Exercise | Foundation treatment with best long-term evidence | All patients with GTPS |
| Ultrasound-Guided Steroid Injection | Short-term pain reduction | Highly irritable pain limiting rehabilitation |
| PRP Injection | Potential regenerative tendon treatment | Chronic tendinopathy refractory to rehabilitation |
| Focused ESWT | Non-invasive tendon stimulation | Persistent or refractory symptoms |
| Percutaneous Ultrasound Tenotomy | Targeted tendon and ITB intervention | Selected refractory cases |
Nerve Supply to the Lateral Hip
The lateral hip has a complex and overlapping sensory nerve supply arising from both the lumbar and sacral plexuses. This anatomy is clinically important because persistent lateral hip pain is not always purely tendon or bursal in origin. In some patients, pain may arise from periosteal, capsular, or cutaneous nerve irritation and may mimic or coexist with Greater Trochanteric Pain Syndrome (GTPS).
Understanding the nerve supply to the lateral hip is therefore essential when considering diagnostic nerve blocks, targeted interventions, or radiofrequency procedures in refractory cases.
| Layer | Nerve | Origin | Territory / Clinical Relevance |
|---|---|---|---|
| Periosteal / Bursal | Trochanteric branch of nervus femoralis | Femoral nerve (L2–L4) | Supplies the greater trochanter periosteum and bursae; primary target for cooled radiofrequency ablation in refractory GTPS |
| Capsular / Articular | Superior gluteal nerve (sensory branch) | L4, L5, S1 | Innervates the superior hip capsule and contributes to gluteus medius/minimus function |
| Capsular / Articular | Nerve to quadratus femoris | L4, L5, S1 | Important sensory supply to the posterior-inferior hip capsule |
| Cutaneous | Lateral cutaneous branch of the iliohypogastric nerve (LCBIN) | T12–L1 | Supplies skin anterior to the greater trochanter; entrapment may mimic GTPS (“pseudotrochanteric bursitis”) |
| Cutaneous | Lateral cutaneous branch of the subcostal nerve | T12 | Cutaneous innervation around the superior trochanteric region; another possible source of pseudotrochanteric pain |
| Cutaneous | Lateral femoral cutaneous nerve (LFCN) | L2–L3 | Supplies the anterolateral thigh; more distal distribution than typical GTPS |
| Cutaneous | Superior cluneal nerves | Dorsal rami L1–L3 | Supply the upper buttock and posterolateral hip; entrapment may mimic lateral hip pathology |
| Cutaneous | Inferior gluteal nerve (cutaneous branch) | L5, S1, S2 | Sensory contribution to the posterior greater trochanter region in many individuals |
Why This Matters Clinically
Persistent or atypical lateral hip pain may sometimes arise from nerve irritation rather than purely from gluteal tendon or bursal pathology. This explains why some patients fail to respond to conventional GTPS treatment and why targeted diagnostic nerve blocks or radiofrequency procedures may occasionally play an important role in carefully selected refractory cases.
Nerve Blocks and Targeted Interventions for Refractory GTPS
Most patients with Greater Trochanteric Pain Syndrome (GTPS) improve with rehabilitation, load management, and targeted injection therapy. However, a smaller subgroup develop persistent or refractory lateral hip pain despite appropriate conservative treatment.
In these patients, targeted nerve blocks and neuromodulation procedures may help identify the dominant pain generator and provide longer-term symptom relief. These interventions are particularly useful when pain appears disproportionate to imaging findings, when conventional injections have failed, or when neuropathic or periosteal pain mechanisms are suspected.
Cooled Radiofrequency Ablation of the Trochanteric Branch of the Femoral Nerve
This is currently the most GTPS-specific neuromodulation procedure and targets the sensory nerve supply to the greater trochanter periosteum and bursae. The procedure is performed under fluoroscopic guidance, targeting the inferomedial aspect of the greater trochanter where the trochanteric branch enters the periosteum.
A diagnostic local anaesthetic block is usually performed first. If the patient achieves meaningful temporary pain relief, cooled radiofrequency ablation (RFA) may then be undertaken for longer-lasting benefit.
- Targets a purely sensory nerve without causing motor weakness
- Steroid-sparing option for chronic refractory pain
- Particularly useful when deep periosteal tenderness is prominent
- Published studies demonstrate meaningful pain reduction lasting beyond one year in selected patients
Superior Gluteal Nerve Fascial Plane Block
This ultrasound-guided procedure targets the superior gluteal nerve within the fascial plane between the gluteus medius and gluteus minimus muscles. The technique is anatomically appealing because the superior gluteal nerve contributes both sensory and motor supply to the lateral hip region.
Cadaveric studies demonstrate accurate spread around the nerve without significant spread to the sciatic or inferior gluteal nerves. Although formal clinical outcome data remain limited, this block may have a role in carefully selected patients with chronic gluteal tendinopathy-related pain that has failed conventional tendon-focused treatment.
LCBIN Diagnostic Block (“Pseudotrochanteric Bursitis”)
Entrapment of the lateral cutaneous branch of the iliohypogastric nerve (LCBIN) can produce pain that closely mimics GTPS. Patients may present with superficial burning or hypersensitive pain around the lateral hip despite relatively unremarkable tendon or bursal imaging.
Ultrasound-guided diagnostic blockade of the LCBIN at the iliac crest can help identify this overlooked pain source. Recognition of LCBIN neuropathy is important because it may redirect treatment away from repeated trochanteric injections toward a more appropriate nerve-targeted strategy.
- Burning or hypersensitive lateral hip pain
- Minimal tendon pathology on imaging
- Failure of standard GTPS treatments
- Pain extending more superficially or anteriorly than typical gluteal tendinopathy
Diagnostic Approach to Refractory Lateral Hip Pain
A structured stepwise approach is often helpful when patients fail to respond to conventional rehabilitation and injection therapy.
Step 1: Ultrasound or MRI to define structural pathology and exclude alternative diagnoses.
Step 2: Ultrasound-guided peritrochanteric bursal injection if bursitis is suspected clinically or on imaging.
Step 3: LCBIN diagnostic block if pain appears superficial, neuropathic, or disproportionate to imaging findings.
Step 4: Diagnostic block of the trochanteric branch of the femoral nerve when deep periosteal tenderness predominates.
Step 5: Consider superior gluteal nerve fascial plane block or cooled radiofrequency procedures in carefully selected refractory cases.
Expert Care at Pain Spa
Why Choose Pain Spa for GTPS?
Dr Krishna is a highly experienced Consultant in Pain Medicine with specialist expertise in the diagnosis and treatment of Greater Trochanteric Pain Syndrome (GTPS). His approach combines detailed clinical assessment, advanced understanding of lateral hip anatomy, and precise ultrasound-guided intervention techniques to deliver truly individualised care.
Pain Spa manages the full spectrum of GTPS — from early gluteal tendinopathy to complex refractory cases involving tendon tears, bursitis, iliotibial band pathology, and neuropathic lateral hip pain.
- Extensive experience in ultrasound-guided treatment of GTPS and gluteal tendinopathy
- Expertise in differentiating GTPS from mimicking conditions such as lumbar radiculopathy, hip osteoarthritis, meralgia paresthetica, and cutaneous nerve entrapment syndromes
- Comprehensive evidence-based management including rehabilitation guidance, PRP, nerve blocks, and cooled radiofrequency procedures
- Real-time ultrasound and fluoroscopic guidance used for all interventional procedures
- Collaborative multidisciplinary approach involving physiotherapists, radiologists, and orthopaedic hip specialists where required
Ultrasound-Guided Interventions Available at Pain Spa
Pain Spa offers a comprehensive range of image-guided interventions for GTPS, tailored to the individual pain generator and clinical presentation.
✔ Trochanteric bursa corticosteroid injection — for short-term pain relief and diagnostic confirmation of bursitis.
✔ Peritendinous / subgluteus medius injection — for gluteus medius tendinopathy, avoiding intratendinous steroid placement.
✔ PRP injection — regenerative tendon-focused treatment for chronic gluteal tendinopathy.
✔ Ultrasound-guided dry needling / fenestration — to stimulate a healing response within degenerative tendon tissue.
✔ Diagnostic nerve blocks — including LCBIN, SGN and LFCN blocks for atypical or neuropathic lateral hip pain.
✔ Superior gluteal nerve fascial plane block — diagnostic and therapeutic option for refractory gluteal tendinopathy-related pain.
✔ Cooled radiofrequency ablation — targeting chronic periosteal and bursal pain after a positive diagnostic block.
References
1. Mellor R, Grimaldi A, Wajswelner H, et al. Exercise and load modification versus corticosteroid injection versus wait and see for persistent gluteal tendinopathy (the LEAP trial). BMJ. 2018;361:k1662.
2. Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life. Journal of Arthroplasty. 2014;29(2):383–386.
3. Fearon AM, Stephens S, Cook JL, et al. The relationship of greater trochanteric pain syndrome to pelvic biomechanics and hip abductor strength. British Journal of Sports Medicine. 2012;46(6):422–426.
4. Woodley SJ, Nicholson HD, Livingstone V, et al. Lateral hip pain: findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy. 2008;38(6):313–328.
5. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine. 2015;45(8):1107–1119.
6. Connell DA, Bass C, Sykes CA, et al. Sonographic evaluation of gluteus medius and minimus tendinopathy. European Radiology. 2003;13(6):1339–1347.
7. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Medicine and Arthroscopy Review. 2010;18(2):113–119.
8. Fitzpatrick J, Bulsara M, O’Donnell J, et al. Leukocyte-rich platelet-rich plasma treatment of gluteus medius and minimus tendinopathy. American Journal of Sports Medicine. 2018;46(4):933–939.
9. Atchia I, Kane D, Reed MR, et al. Platelet-rich plasma versus placebo for gluteal tendinopathy. Journal of Bone and Joint Surgery (JBJS). 2025.
10. Rompe JD, Segal NA, Cacchio A, et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. American Journal of Sports Medicine. 2009;37(10):1981–1990.
11. Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of endoscopic gluteus medius repair. American Journal of Sports Medicine. 2015;43(5):1077–1083.
12. Bird PA, Oakley SP, Shnier R, et al. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism. 2001;44(9):2138–2145.
13. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Archives of Physical Medicine and Rehabilitation. 2007;88(8):988–992.
14. Fearon AM, Ganderton C, Scarvell JM, et al. Development and validation of a clinical classification system for gluteal tendinopathy. British Journal of Sports Medicine. 2019;53(12):770–777.
15. Baker CL, Massie RV, Hurt WG, et al. Arthroscopic bursectomy for recalcitrant trochanteric bursitis. Arthroscopy. 2007;23(8):827–832.
16. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(11):910–922.