Pain on the outside (trochanteric region) of the thigh or hip is the most common location for hip pain. Hip pain can also occur in the groin or the buttock. Many of you with pain in this area are miserable. The pain interferes with your sleep and with many of your activities.
In decades gone by it was always thought that the pain on the outer side of your hip was due to bursitis… or inflammation of a small space adjacent to a number of powerful muscles around the hip. Our understanding of the cause of hip pain has matured significantly. It appears that most of the pain on the outer side of your hip is likely due to one of the muscles attaching to the hip bones. That muscle is called the gluteus medius. The gluteus medius is being referred to as the rotator cuff of the hip. That’s because the rotator cuff is the most common cause of pain in the shoulder and the most common cause of rotator cuff pain is degeneration and tearing. The gluteus medius is wearing out (tendinosis), and during that degenerative process it can start hurting.
Greater trochanteric pain is a common orthopaedic complaint. In the past, this was thought to be from an unexplained irritation of the bursa on the outside of the hip joint. Recently, it has been recognized that many cases of hip “bursitis” is actually from wear and tear (called tendinosis), or even complete tears, of the gluteus medius and minimus tendons, that attach just deep to the greater trochanteric bursa. The bursa becomes irritated secondarily to the partial or complete tears. This situation is directly analogous to “rotator cuff bursitis”, where the bursa becomes inflamed and irritated secondary to underlying rotator cuff disease. Thus, some have called the gluteus medius and minimus tendons the “rotator cuff of the hip”. Nowadays, many of us use the term greater trochanteric pain syndrome instead of “greater trochanteric bursitis”, since the underlying issue typically is more from a tendon issue.
Patients with gluteus medius or minimus partial or complete tears typically have pain on the outside or lateral area of their hip, as opposed to patients with hip arthritis, where the pain is typically near the groin. Patients typically complain of pain rolling over in bed on the affected side. Patients may note that they fatigue easily with prolonged walking. Most often, there is no “cause” or acute trauma they have suffered before having the pain.
If a patient has greater trochanteric pain syndrome, typically he/she will try anti-inflammatories or Tylenol, and note some, but incomplete, pain relief with this. Physical examination testing and possibly X-rays can rule out other causes of lateral sided hip pain. If the diagnosis is confirmed, initial treatment consists of physical therapy for stretching the IT Band (a band of tissue running down the outside of the hip) and strengthening of the typically weak gluteal muscles. If this does not help, the physician may perform an ultrasound guided hip injection to alleviate the pain, and help the patient progress with physical therapy.
Should the pain persist despite multiple cortisone injections and quality physical therapy exercise, an MRI may be appropriate. A high quality MRI can visualize the gluteal tendons, and discern whether there is tendinosis or a partial or complete tear of the tendons. Partial or incomplete hip gluteal tears can sometimes be treated with PRP injection directly into the diseased tendon. Other times, surgery may be appropriate.
Hip arthroscopy surgeons have transferred the expertise gained from shoulder arthroscopic rotator cuff repair to the hip, and hip gluteus medius or minimus tears can now be treated and repaired arthroscopically. Thin cameras and instruments are used through poke holes in the skin, allowing visualization of the deep structures. Anchors and sutures are then used to tie the gluteus medius and minimus back down to the bone, in anatomic position. This procedure is rather new, but the preliminary results have been promising. The bottom line is our understanding and treatment of the most common cause of hip pain is expanding rapidly. If you are having lateral sided hip pain, the treatment options for you are expanding, and our techniques are improving the quality of your life significantly.
Due to the overwhelming success of his first post, I am pleased to offer you another guest blog post by Derek Ochiai, MD.
He is a Sports Medicine trained Orthopedic Surgeon with a particular interest focus on the hip.