Hip strengthening intervention for a patient with greater trochanteric pain

syndrome: a case report

Justin C. O’Dowd
Central Michigan University
ABSTRACT
Background and Purpose. The purpose of this study was to investigate the effectiveness of hip
strengthening in a patient with greater trochanteric pain syndrome to reduce hip pain.
Patient Information. The patient was a 19-year-old female who was referred to physical therapy
with complaints of low back and left hip pain.
Intervention. The patient participated in 7 visits lasting 45 minutes in duration over the course
of 1 month. Treatment focused on core and hip strengthening, as well as a home exercise
program consisting of a stretching program.
Outcomes. There were 5 main outcome measures that were employed: (1) Modified Low Back
Pain Disability Questionnaire, to measure the patient’s functional disability experienced from
low back pain; (2) Lower Extremity Functional Scale, to measure lower extremity function; (3)
Numeric Pain Rating Scale, to measure pain of low back and hip; (4) manual muscle testing, to
measure core and hip strength; (5) single-leg foot reach to measure motor coordination. At
discharge, improvements in every outcome measure were found following the administration of
the intervention.
Discussion and Conclusions. The findings illustrated that a treatment program focusing
primarily on hip strengthening and stability is sufficient in decreasing pain caused from greater
trochanteric pain syndrome. For this patient, the intervention provided increased her hip strength
and stability, which presumably decreased the compression on her trochanteric bursa. The
decreased compression of the bursa seemingly decreased her pain which led to an improvement
in functionality.

Keywords: physical therapy, greater trochanter bursitis, GTPS, rehabilitation

INTRODUCTION
Lateral hip pain is a common complaint for patients that seek the help of a primary care
physician. In fact, it has been approximated that lateral hip pain will arise in 10% to 25% of the
overall population.1 One of the common sources of lateral hip pain is called greater trochanteric
pain syndrome (GTPS). This diagnosis is used to explain pain and tenderness near the greater
trochanter and the associated soft tissue surrounding it. 2 It is reported that the prevalence of
GTPS is higher in females than males (4 to 1 rate), and the incidence is highest amongst the age
groups from 40 to 60 years old.3 GTPS is a complicated syndrome which can upset many
patients and clinicians because of the many possible underlying pathologies. There are many
methods, both conservative and non-conservative, that can be used to treat GTPS. Without
understanding the proper treatment method, recurrence is common, and patients may only feel
temporary pain relief.4 Because of this fact, it is important to find the best intervention to treat
lateral hip pain as it relates to GTPS.
There are many studies that have been conducted on shockwave therapy, surgical
interventions, and injection therapy to the lateral hip area, but they have been explained
inadequately.5 Injection therapy has been used for numerous years in the past, but patients
reported symptom recurrence and inadequate alleviation. 6 Another study that was performed
looked at exercise training consisting of iliotibial band and piriformis stretching, as well as
gluteus maximus, adductor, and quadriceps strengthening.7 Rompe et al.7 found that exercise
therapy was superior to corticosteroid injection and shock wave therapy at the 15-month follow-
up. However, there were no exercises that specifically targeted gluteus medius. The gluteus
medius is an important hip stabilizer during ambulation, so strengthening it is necessary to
improve the muscle’s functionality and decrease pain. 8 Therefore, it is necessary to create a
treatment program that involves hip strengthening, including targeting glute medius.

PURPOSE
Considering the research previously discussed, the aim of this study was to investigate
the effectiveness of hip strengthening in a patient with greater trochanteric pain syndrome to
reduce hip pain.

CASE DESCRIPTION
Patient History
During the time of the intervention, the patient was a 19-year-old female who was
referred to physical therapy with complaints of low back and left hip pain. She had just finished
high school and was currently employed as a fast-food worker. She reported that she worked
approximately 6 days per week for an average of 48 hours. Based on a chart review, the patient
was currently taking 150 milligrams of Depo-Provera through injection every 3 months for birth
control. No allergies were reported at this time. Her past medical history was not significant,
other than a right humeral fracture, and multiple left ankle sprains. The patient’s self-reported
quality of life and health status was marked as “good.” Upon completing a systems review, her
body systems were normal and there was nothing of note. The patient’s vital signs were all
within normal limits for her age-related population. She was 65 inches tall and weighed 130

1
pounds, with a body mass index of 21.6, which is considered normal. The patient had no
previous history with the current complaints, so no previous therapy was conducted.
The patient noted the onset of left hip and low back pain approximately 1 year ago. She
stated the pain had been ongoing for about a year, but the pain worsened, causing limitations in
her activities. The patient reported the pain was primarily in her lateral left hip, however, after
prolonged standing, her low back pain increased. She rated her pain on the Numeric Pain Rating
Scale (NPRS) as a 4/10 for both her low back and left hip. The pain was described as achy,
sharp, and intermittent that worsened at night, or after prolonged periods of static positions.
Symptoms increased with quick turns, lying on the affected side, walking, and stair negotiation.
No imaging was ordered at the time, as the patient was advised to try physical therapy first.
The projected physical therapy goals for the following 6 weeks included a mixture of
both short and long-term goals. The short-term goals (to be completed in 4 weeks) included:
increasing left lower extremity and core strength to within function limits to improve walking
and standing tolerance, independence with her home exercise program to continue with
flexibility and strength once discharged from physical therapy, and left hip and low back pain to
decrease to 0/10 on the NPRS for ease with standing, walking, bending, and sleeping. Long-term
goals (to be completed in 6 weeks) included: The patient will demonstrate improvement in
single-leg foot reach to equal the unaffected lower extremity to demonstrate good coordination
and mechanics of her lower body during daily tasks, improvement in the Lower Extremity
Functional Scale (LEFS) to at least 65/80 and Modified Oswestry Low Back Pain Disability
Questionnaire to less than 10% impairment to perform daily activities without compensation or
pain, and increased standing and sitting tolerance to greater than 60 minutes without complaints
of pain or compensation to return to prior level of activity.

Clinical Impression 1
Initially, the physical therapist and student physical therapist thought the low back and
left hip pain could be stemming from greater trochanteric bursitis, which is a known pathology of
GTPS. The patient stated the pain increased with extended bouts of static positioning, and most
of her time was spent standing at work. When asked to demonstrate her standing stance, the
patient crossed her right leg over her left, leaving her left hip in a position of horizontal
adduction. This repetitive standing position could compress the bursa, which would irritate it and
be the probable source of her pain. Additionally, the pain started 1 year prior to the intervention,
which is the time that she graduated from high school and started her job as a fast-food worker.
Her complaints of pain in the lateral left hip also reinforces the idea that her pain could be greater
trochanteric bursitis. For potential differential diagnosis, we looked to explore piriformis
syndrome, and gluteus medius pathology.
This patient appeared to be an adequate candidate for hip strengthening interventions.
She was selected for multiple reasons, including reports of pain on the lateral side of the left hip,
pain increased with sustained static positions, compression on the affected side, and pain with
hip flexion. Derived from the physical therapy goals that included increasing hip strength to
within functional limits, decreasing left hip pain to 0/10 on the NPRS, and increasing her single-
leg foot reach, it was decided that this patient would benefit from an intervention to strengthen
her hips. This was thought to be the best intervention for the patient to decrease her left hip pain,

2
which in turn, was hypothesized to decrease the compensations that were happening at the low
back.

Examination
Several standardized measurements were taken at the time of the patient’s initial
examination and at discharge. The initial measurements were performed by a physical therapist
serving as the clinical instructor. The discharge measurements were conducted by a student
physical therapist.
To objectively measure the patient’s low back and left hip pain, 2 standardized
questionnaires were used. The first test that was used was the Modified Low Back Pain
Disability Questionnaire. This was used to assess functional disability in relation to a patient’s
life who is suffering from low back pain. 9 The test-retest reliability of this test was found to have
an intraclass correlation coefficient of 0.90 and the Pearson correlation (r) was 0.82 between the
subjects’ and therapists’ global rating.10 The questionnaire gives a percentage of disability that
the patient has. In this case, the patient had a total score of 26% disability, which is considered
moderate. This specific test was chosen because the patient had complaints of low back pain
during her initial evaluation. The Lower Extremity Functional Scale (LEFS) was used to measure
the patient’s lower extremity function. This is a 20-question test containing 4 groups of questions
that increase in physical demands.11 The patient had a raw score of 45/80, indicating moderate
function of the lower extremity. The test-retest reliability of this test for the general population is
0.86 to 0.98 and a correlation of 0.80 for the validity. 12 The LEFS was used because of the
patient’s complaints of left hip pain and dysfunction. Both measures were only repeated at the
initial evaluation and at discharge.
Range of motion (ROM) measurements were assessed actively because the therapists
wanted to evaluate the range that the patient could attain by themselves. Lumbar ROM was taken
in standing and was within functional limits (WFL) in all planes of motion. The reliability of
active lumbar flexion, extension, right lateral flexion, and left lateral flexion is 0.96, 0.88, 0.88,
and 0.83, respectively.13 Left hip passive and active ROM was assessed using a goniometer and
were WFL as well. Hip flexion was measured in supine, hip extension, internal rotation, and
external rotation were measured in prone, and hip abduction and adduction were measured in
side-lying. Hip ROM reliability and validity for patients with GTPS has not been done.
However, a study examining the reliability and validity of patients with femoroacetabular
impingement showed reliability of 0.90 (hip abduction was 0.82 to 0.84), and 0.44 to 0.94 for the
concurrent validity.14 While the patient was prone for ROM measurements, basic palpation was
performed to the patient’s lumbopelvic region. Palpation was found to be insignificant, except
for tenderness and pain over the patient’s left greater trochanter. Manual muscle tests (MMT)
were performed to determine the strength of the patient’s core and hips (Table 1). A modified
Medical Research Council scale was used that graded the muscles from 0 to 5. The scale ranges
from 0.80 to 0.99 for its reliability.15 The validity for grades 4 and above has been reported as
poor correlation, and grades below a 4 have high correlation. 16 Core strength was taken to
determine if the patient could use her core to maintain a stable spine. Her hip strength was taken
to assess if her hip muscles were weak, which could lead to compensation at other parts of the
body. Place Table 1 somewhere here.

3
 The patient’s motor coordination was tested using the Total Gym Functional Testing
Grid. This is a mat that was placed on the floor which has standardized gridlines on it to assess
functional mobility. This was selected as a test to objectively measure how well the patient was
able to stabilize her hips while performing a single-leg reach. The patient would stand in the
center of the mat with one lower extremity and reach as far she could with the other while
staying in the center of the mat. The measurements taken are provided in Table 2. Although there
are no studies done to show reliability and validity of this test, it was thought that there could be
high reliability and validity because of the reproducibility of this test. As mentioned previously,
the NPRS was used to assess the patient’s pain intensity. There are many forms of the NPRS, but
the most common used is the 11-item version, 17 which is what the therapists’ used in this case
report. It is marked as an 11-point numeric scale, with 0 indicating no pain, and 10 indicating the
worst pain possible. The patient reported a NPRS score of 4/10 for both her low back and hip
pain. This was an appropriate test to use because of its high reliability. Although there was no
study of NPRS reliability and validity in patients with GTPS, the NPRS was found to be high in
literate and illiterate patients with rheumatoid arthritis (r=0.96 and 0.95) and ranged from 0.86 to
0.95 for the validity correlations.18 Place Table 2 somewhere here.

Clinical Impression 2
The information that was gathered from the examination confirms the initial clinical
impression. The next plan of action was to continue with the intervention of hip strengthening.
This patient continued to be an appropriate candidate as demonstrated through weak left hip
abductors, pain with compression to the left greater trochanter, pain with end-range hip flexion,
and decreased motor coordination of her left lower extremity when performing the single-leg
foot reach. It was our clinical hypothesis that the patient would exhibit changes in not only hip
strength, but hip stability as well. The idea was that the hip strengthening would decrease the
compression on the trochanteric bursa, thus decreasing the patient’s pain as a result.

Patient Consent
This patient gave written and verbal consent before administration of the intervention.
Because of the nature of the case report, the author used university approved consent.

Intervention
The goal of this patient’s intervention procedure was to establish an appropriate
strengthening program to address the patient and therapist’s goals. This intervention plan
included exercises to strengthen the patient’s core and hip musculature (Table 3a). The primary
focus of the program was to increase not only strength, but stability with dynamic movements as
well. Initially, the progression of the protocol was determined by the patient’s pain level on that
given day. As the pain decreased, the protocol was progressed based on the patient’s ability to
stabilize her core and hips with the given resistance. If the stability was sufficient, the number of
repetitions were increased, as well as the amount of resistance. This was important because the
therapists’ wanted to ensure that the patient could stabilize the weight and control the position
before increasing the difficulty of the exercises. These resistance exercises were integrated with a

4
home exercise program that included stretches to increase muscular extensibility (Table 3b).
Place table 3a and 3b somewhere here.

OUTCOMES
Following the initial evaluation, outcomes were only assessed at discharge, as the patient
only required 7 visits before being discharged. Outcomes were measured by the student physical
therapist approximately 1 month after the initiation of the treatment program. The patient’s
Modified Low Back Pain Disability Questionnaire score decreased from 26% to 0%, indicating
minimal disability. There is no minimal detectable change for this test, but it is reasonable to
assume that the deduction to 0% disability was significant. This decrease in raw score met the
goal of less than 10% disability set forth at the initial evaluation. The patient’s LEFS score
increased from 45/80 to 76/80, indicating significant improvement in functionality. This met the
initial goal of improving the LEFS score to at least 65/80.
The patient’s MMT measurements improved in all domains (Table 1), as well as a
decrease in pain with end-range hip flexion. The improvements in core and hip strength met the
original goal of increasing left lower extremity and core strength to within function limits to
improve walking and standing tolerance. The patient’s single-leg foot reach score also increased
across all areas (Table 2). This increase met the preliminary goal of improvement in single-leg
foot reach to equal the unaffected lower extremity to demonstrate good coordination and
mechanics of lower body during daily tasks. The patient’s NPRS score decreased from 4/10 for
low back and hip pain to 2/10 for hip pain, and 0/10 for back pain.

DISCUSSION
In this case, the findings illustrated that a treatment program focusing primarily on hip
strengthening and stability is sufficient in decreasing pain caused from GTPS. It should be stated
that these findings are unique to this patient and her case and cannot be generalized to other
patients. However, the results show that the intervention used proved to be successful with
increasing strength and stability and decreasing lateral hip pain and which led to improved
functionality. It is believed that the hip strengthening decreased the pressure on the greater
trochanteric bursa, which led to a reduction in the pain felt by the patient. The hip stability
exercises were beneficial in strengthening her hips with dynamic movements to ensure proper
body alignment and reduce compensations at other parts of the body.
It is important to note, however, that the home exercise program that was given contained
stretches to increase muscular extensibility. Therefore, it is difficult to conclusively determine
that the hip strengthening protocol was the reason for the reduction in pain. This fact shows the
necessity for future research to determine the best method for the treatment of greater
trochanteric pain syndrome. A study comparing stretching only, strengthening only, or both
would be necessary to conclude the best way to treat this diagnosis.

5
Table 1: MMT measurements

Initial Discharge

Movement Right Left Right Left

Hip flexion WFL 4/5a WFL 4+/5b

Hip extension WFL 4/5 WFL 5/5
Hip abduction WFL 3+ WFL 4+/5
Hip adduction WFL 4/5 WFL 5/5
Hip internal WFL 4/5 WFL 5/5
rotation
Hip external WFL 4/5 WFL 5/5
rotation

Trunk flexion 3/5 5/5

a
Pain noted at end range
b
No pain noted at end range

Table 2: Single-leg foot reach scores

Initial Discharge

Direction Right Left Righta Left

Anterior 55 40 N/a 60
Lateral 50 50 N/a 70
Posterior 65 55 N/a 65
a
Reach standing on right lower extremity was not assessed at discharge

Table 3a: Interventions for treatment protocol

Exercise Description Dosage Progression of exercise

(set x reps)

Abdominal The patient was supine with her 2x10 with Alternating arm and leg
bracing knees bent up. She was instructed to 10-second reaches: The patient
draw belly button into the spine hold performed an abdominal
while maintaining proper breathing brace, then initiated
alternating arm and leg
reaches

6
Table 4- The patient performed hip flexion in
way hip supine, hip extension in prone, hip
kicks abduction and adduction in side-
lying with knee extended
Supine The patient started with abdominal
bridges brace. She bent her knees with her
feet flat on the table and lifted her
buttocks into the air and then slowly
lowered down
Side-lying The patient had her knees bent to 90
Theraband degrees with Theraband around her
clamshells knees. She slowly spread her knees
out to create tension on band
without rolling her pelvis
Cable The patient abdominal braced while
suitcase standing and grabbed onto the
marches handle attachment that was in the
low position. The patient stepped
back so there was tension on the
cable, and slowly alternated
marching
7
1x10 Standing 4-way hip kicks:
bilaterally The patient performed these
in standing with a Theraband
placed in a shut door and
looped around her ankle
2x10 with Supine bridges with
5-second Theraband hip abduction:
hold Similar to the supine bridges
with the exception of a
Theraband placed around the
patient’s knees. She
performed the bridge, and
while at the top of the
motion, performed bilateral
hip abduction with the band,
and then lowered her
buttocks
2x10 with Static hip abduction against
5-second ball with clamshells: The
hold patient was in a half-
bilaterally squatting position
perpendicular to the wall,
with a Theraband placed
around her knees. Her leg
closest to the wall pressed a
rubber ball against the wall,
creating static hip abduction.
While maintaining that static
position, the patient
performed clamshells with
the free leg
2x10 No progression of the
exercise. However, the
amount of resistance
increased by 3 pounds, if
appropriate
Cable The patient abdominal braced and
Palloff faced perpendicular to the cable.
press Using the handle attachment, the
patient walked the cable out while
keeping the handle in the middle of
her body. Once sufficient tension
was reached, the patient slowly
pressed the handle out away from
her body, while maintaining core
stabilization
Lateral The patient stood approximately 3
plank with feet away from the wall. She bent
hip dip on her elbow and placed her arm on the
wall wall at shoulder height. She slowly
let her hips dip toward the wall, and
then returned to starting position
Single-leg The patient was on a foam pad in a
balance on single-leg stance and balanced
foam pad without upper extremity assistance
Alternating The patient is standing and performs
mini lunges alternating lunges in a reduced
ROM
8
2x10 each No progression of the
side exercise. However, the
amount of resistance
increased by 3 pounds, if
appropriate
2x10 each Lateral plank with hip dip on
side table: Instead of performing
this on the wall (gravity
minimized position), the
patient performed this in a
side-lying position on the
table (gravity maximized
position). She completed this
with the same technique as
she did on the wall
2x30 Single-leg rotations on foam
bilaterally pad: The patient assumed a
single-leg stance on the foam
pad. This time, a weighted
medicine ball was used, and
she completed side-to-side
rotations with it
2x10 Lunges with Theraband leg
bilaterally pulls: The same technique
was used as the alternating
mini lunges. A Theraband
was looped around the
patient’s knee. The therapist
provided tension on the band
and pulled her into hip
adduction. The patient was
required to use her hip
abductors to resist this
motion.
Table 3b: Interventions for treatment protocol

Exercise Description Dosagea

(sets x secs
held)

Home exercise program:

Seated hamstrings The patient extended her knee onto a stool or step. 3x30
stretch While keeping her chest tall, the patient leaned
forward by bending at the hip

Seated piriformis stretch The patient crossed one leg over the other, assuming a 3x30
figure 4 position. Keeping her chest tall, the patient
leaned forward by bending at the hip. She also
increased the stretch by pushing down on her knee

Supine quadricep and The patient moved to the edge of the table or bed, and 3x30
hip flexor stretch slowly lowered one leg off of the table. Using a dog
leash, the patient attached one end to her ankle and
held onto the other end. She slowly pulled on the dog
leash to increase the stretch of her quadriceps
a
Stretches were performed twice per day

9
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