Journal of Clinical Neuroscience xxx (2018) xxx–xxx

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Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Case study

High prevalence of greater trochanteric pain syndrome among patients

presenting to spine clinic for evaluation of degenerative lumbar
pathologies
Lee A. Tan a, Barlas Benkli b, Alexander Tuchman b, Xudong J. Li c, Natasha N. Desai b,
Thomas S. Bottiglieri b, Jeffrey Pavel d, Lawrence G. Lenke b, Ronald A. Lehman Jr b,⇑
a
Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, United States
b
The Spine Hospital, Columbia University Medical Center, New York, NY, United States
c
Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA, United States
d
The Physical Medicine and Rehabilitation Center, Englewood, NJ, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Greater trochanteric pain syndrome (GTPS) is a relatively common diagnosis among the
Received 18 January 2018 general population.
Accepted 9 April 2018 Objective: We aim to determine the prevalence of GTPS among patients who presented to the spine clinic.
Available online xxxx
Methods: Medical records of patients who were evaluated in the spine clinic were reviewed over a
12-month period (4/1/2016 to 3/31/2017). Patient demographics, presenting symptomatology, physical
Keywords: examination findings, presence or absence of GTPS, medical imaging findings, and interventions were
Greater trochanteric pain syndrome
recorded analyzed. Statistical analysis was performed using SPSS Statistics 23.0 (Chicago, IL). Statistical
Trochanteric bursitis
Lumbar stenosis
significance is defined as p < 0.05.
Foraminal stenosis Results: A total of 273 consecutive patients (145 women, 128 men) were evaluated for degenerative lum-
Lumbar radiculopathy bar pathologies by a single spine surgeon over the study period. The average patient age was 61.9 years.
Pseudoradiculopathy Overall, there were 138/273 patients (50.5%) with GTPS (Group I), while 135/273 patients (49.5%) did not
Trochanteric injection have GTPS (Group II). There were 73 patients in Group I received trochanteric injection for GTPS treat-
ment and subsequently returned to clinic for follow-up, and there were 36/73 (49.3%) patients reporting
improvement in their symptoms after trochanteric injection. There was a statistically significant predilec-
tion for presence of GTPS in the female gender (60% vs 32.8%, p = <0.01). There was no statistically signif-
icant difference in the prevalence of low back pain, buttock, thigh or groin pain between the two groups.
Conclusion: GTPS is a very common but often unrecognized or misdiagnosed condition. Accurate diagno-
sis and differentiation of GTPS from lumbar spinal pathologies are essential in avoiding potential unnec-
essary spinal procedures.
Ó 2018 Published by Elsevier Ltd.

1. Introduction trochanter, active abduction or passive adduction of the thigh [3].

Greater trochanteric pain syndrome (GTPS), formerly known as
‘‘trochanteric bursitis”, is a relatively common diagnosis that can
affect up to 25% of the general population [1]. It can be very debil-
itating and patients with this condition have been found to have
lower quality of life compared to age-matched cohort [2]. GTPS is
characterize by pain over the lateral hip region that often radiating
to other areas including the groin, buttock, thigh, and knee. The
pain is usually exacerbated by direct palpation over the greater
⇑ Corresponding author at: NewYork-Presbyterian/Columbia University Medical
Center, 5141 Broadway, 3 Field West, New York, NY 10034, United States.
E-mail address: ronald.lehman@columbia.edu (R.A. Lehman Jr).
Because of its symptomatology overlaps many other pathological
conditions involving the lumbar spine, hip and knee, GTPS has
been called the ‘‘Great Mimicker” by various authors [1,4]. Many
patients may experience pain radiating from lateral hip to the
knee, or even occasionally below the knee, mimicking lumbar
radiculopathy often referred to as ‘‘psedoradiculopathy” [5,6].
Many anatomical structures in the great trochanter region may
be the source of pain in GTPS, which include the subgluteus max-
imus bursa (thus the term ‘‘trochanteric bursitis”), subgluteus
medius and subgluteus minimus bursae, tendons of gluteus
medius and gluteus minimus, the iliotibial band, as well as tensor
fascia latae [7]. Because of the overlapping symptomatology with
lumbar radiculopathy, GTPS is often undiagnosed or misdiagnosed,

https://doi.org/10.1016/j.jocn.2018.04.030
0967-5868/Ó 2018 Published by Elsevier Ltd.

Please cite this article in press as: Tan LA et al. High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for eval-
uation of degenerative lumbar pathologies. J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.04.030
2 L.A. Tan et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx

especially in patients who present to spine clinic for evaluation of

lumbar spine pathologies. Accurate diagnosis of GTPS in patients
with concomitant lumbar spine pathology require knowledge of
both disease processes and detailed history taking and thorough
physical examination.
We aim to investigate the prevalence of GTPS in patients who
presented to our clinic for evaluation of degenerative lumbar
pathologies over a 12-month period. To our best knowledge, this
is largest clinical series on this topic to date.

2. Materials and methods

2.1. Patient population

Medical records of patients who presented to the spine clinic

were reviewed over a 12-month period (April 1, 2016 to March Fig. 1. Prevalence of greater trochanteric pain syndrome in patients with
31, 2017). All patients had magnetic resonance imaging (MRI) find- degenerative lumbar pathology.

ings positive for degenerative lumbar pathologies prior to present-

ing to the spine clinic. Patient demographics, physical examination
findings, medical imaging findings, presenting symptomatology
and intervention were recorded analyzed. Institutional review
board (IRB) allowed the use of the de-identified data for this study;
individual patient consent was not obtained given no identifying
patient information was included in the study.

2.2. Physical examination

During clinic visits, we screened all patients for clinical findings

of GTPS on physical examination. The primary diagnostic criteria
for GTPS was the exacerbation of local pain and tenderness over
the region of greater trochanter on manual palpation [1,8,9]. In
addition, patients with worsening of pain on active abduction or
passive adduction of the thigh may also suggest the presence of
GTPS [3,9]. Furthermore, exacerbation of hip pain while lying on
the affected side is often another clue for GTPS [8,9], and it may
often disrupt patients with pain during their sleep.
2.3. Statistical analysis
Statistical analysis was performed using SPSS Statistics 23.0
(Chicago, IL). Statistical significance is defined as p < 0.05. Pearson’s
Chi square tests was used to compare patient characteristics
between the group with GTPS and the group without GTPS.
3. Results
A total of 273 consecutive patients (145 women, 128 men) were
evaluated for degenerative lumbar pathologies by a single spine
surgeon in clinic over the study period. The average age was
61.9 years. There were 138/273 patients (50.5%) with GTPS (Group
I), while 135/273 patients (49.5%) did not have GTPS (Group II). The
result is shown in Fig. 1. There were 73 patients in Group I received
trochanteric injection and subsequently returned for follow-up
Fig. 2. Clinical outcome after trochanteric injection for patients who had GTPS and
came back to clinic for follow-up visits.
= 0.002). There was no statistically significant difference in preva-
lence of low back pain, buttock, thigh or groin pain between Group
I and Group II. In addition, there was higher percentage of patients
with prior hip procedures in Group II compared to patients in
Group I (p = 0.036). There was no statistical significant difference
in the rate of prior lumbar or knee surgeries between the groups.
The results are summarized in Table 1.
4. Discussion
There are several intriguing findings from the current study.
Most importantly, more than half of the patients who presented
to our clinic for evaluation of lumbar pathology had GTPS. This is
a very important finding in that despite being such a highly
prevalent condition, many patients with GTPS may be undiagnosed
or misdiagnosed as lumbar radiculopathy unless the clinician
Table 1
Summary of patient characteristics.
Patient characteristics GTPS (+) GTPS ( ) p-Value

visit; 36/73 (49.3%) patients reported improvement in their symp- Mean age (years) 61.7 62.0 –
toms after the injection (Fig. 2). There was a prediction for the Female gender (%) 67.4% 40.3% <0.01
Low back pain (%) 85.5% 90.4% 0.22
female gender for presence of GTPS with statistical significance
Buttock pain 55.8% 52.6% 0.28
(60% vs 32.8%, p = <0.01). Thigh pain 58.0% 48.1% 0.10
In terms of symptomatology, the most common pain com- Leg pain (below knee) 66.7% 83.0% <0.01
plaints are located in the low back (87.9%), followed by leg Prior lumbar surgery 26.1% 19.3% 0.18
(87.5%), buttock (54.2%), thigh (53.1%) and groin (1.1%). Motor Prior hip surgery 4.3% 11.1% 0.04
Prior knee surgery 13.0% 11.9% 0.77
weakness was detected in 63.7% patients; the most commonly Any leg weakness 62.3% 74.1% 0.04
affected nerve root was L5 (58.2%), followed by S1 (25.3%), L4 Quadriceps weakness 8.7% 12.6% 0.30
(18.9%), and L3 (8.8%). Patients with GTPS (Group I) were less likely Tibialis ant. weakness 15.9% 30.4% <0.01
to have neurological deficits on physical examination (p = 0.037), EHL weakness 60.1% 79.3% <0.01
Gastroc weakness 11.6% 38.5% <0.01
and was less likely to have leg pain as part of the complaints (p

Please cite this article in press as: Tan LA et al. High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for eval-
uation of degenerative lumbar pathologies. J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.04.030
 L.A. Tan et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
evaluating the patient is familiar with clinical manifestations of
GTPS and can differentiated it from other pathologies such as
lumbar radiculopathy.
There has been a paucity of literature regarding this common
problem. There was only one previous study published in 2002
by Tortolani et al. [6] that reviewed a series of 247 patients who
were referred to orthopedic spine surgeons and found a 20.2%
prevalence of GTPS. Our current study reviewed 273 consecutive
patients over a 12-month period, and we found a 50.5% prevalence
of GTPS in patients who presented to us for surgical evaluation. The
prevalence of GTPS were 60% in female patients compared to 32.8%
male patients, consistent with findings from existing literature
regarding GTPS in the general population [1,7,10,11].
In our series, patients with GTPS were less likely to have motor
weakness on exam and was less likely to have leg pain as part of
their overall complaints. Specifically, there were fewer patients
with weakness associated with L5 and/or S1 nerve roots on phys-
ical examination in the GTPS group. This finding should not be sur-
prising given that when there is a L5 and/or S1 motor weakness, it
is likely due to lumbar root compression rather than GTPS. Further-
more, patients in the GTPS group were less likely to have leg pain
as part of the overall complaints, hinting that leg pain is more
likely arising from true lumbar radiculopathy. Collee et al. [12,4]
demonstrated that GTPS is associated with low back pain in
patients referred to outpatient clinics in a prospective study. How-
ever, we did not find statistically significant difference in the
prevalence of low back pain, buttock, thigh or groin pain between
the GTPS and non-GTPS groups. However, GTPS and lumbar radicu-
lopathy are not mutually exclusive conditions, therefore both enti-
ties must be considered during clinical evaluation.
Pain symptoms from GTPS and lumbar radiculopathy can over-
lap. Several systematic reviews have suggested that corticosteroid
injections in the greater trochanter region is the most effective
conservation treatment for GTPS, with superior short-term clinical
outcome compare to other interventions such as NSAIDS, radial
shockwave therapy and other home training programs [8,13,14].
Typically it is our practice to refer all patients with physical exam
findings suggestive of GTPS for trochanteric injections, because
anecdotally we had seen many patients with significant improve-
ment or resolution of their pain symptoms after trochanteric injec-
tions. In the current series, there were 73 patients with GTPS
received trochanteric injections and subsequently returned to
clinic for follow-up visits. There were 36/73 (49.3%) patients
reported improvement or resolution of their symptoms.
GTPS is very condition that can mimic various lumbar, hip and
knee pathologies [15]. In our series, prior hip surgery appeared to
be more prevalent in patients without GTPS in our series (p =
0.036). This may be due to local anatomical alteration from prior
surgery in the region that may have removed various structures
that could be a source for GTPS. Prior lumbar and knee surgery
do not appear to have any effect on the prevalence of GTPS in
our study.
5. Conclusion
GTPS is a very common, but frequently overlooked or misdiag-
nosed condition. We found GTPS to be present in over half of the
patients who presented to our clinic for surgical evaluation lumbar
Please cite this article in press as: Tan LA et al. High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for eval-
uation of degenerative lumbar pathologies. J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.04.030
3
pathologies. Given the high prevalence of this condition, it is essen-
tial for spine surgeons to be familiar with the clinical diagnosis and
appropriate management of GTPS. Early recognition and accurate
diagnosis can avoid potential unnecessary surgical intervention
which could result poor clinic outcome and patient satisfaction.
Conflict of interest
Dr. Lenke is a consultant for and a patent holder with Medtro-
nic. Dr. Lehman receives is a consultant for Medtronic. These are
not relevant to this manuscript. None of the other authors have
anything to disclose. All aspects of ethical considerations have
been strictly adhered to while writing this manuscript.
Funding
No funding was received for this study.
Ethics
The IRB allowed use of the research data and results.
References
[1] Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of
anatomy, diagnosis and treatment. Anesth Analg 2009;108:1662–70. https://
doi.org/10.1213/ane.0b013e31819d6562.
[2] Fearon AM, Cook JL, Scarvell JM, Neeman T, Cormick W, Smith PN. Greater
trochanteric pain syndrome negatively affects work, physical activity and
quality of life: a case control study. J Arthroplasty 2014;29:383–6. https://doi.
org/10.1016/j.arth.2012.10.016.
[3] Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric
bursitis: a systematic review. Clin J Sport Med 2011;21:447–53. https://doi.
org/10.1097/JSM.0b013e318221299c.
[4] Farr D, Selesnick H, Janecki C, Cordas D. Arthroscopic bursectomy with
concomitant iliotibial band release for the treatment of recalcitrant
trochanteric bursitis 905.e1-5. Arthroscopy 2007;23. https://doi.org/10.1016/
j.arthro.2006.10.021.
[5] Swezey RL. Pseudo-radiculopathy in subacute trochanteric bursitis of the
subgluteus maximus bursa. Arch Phys Med Rehabil 1976;57:387–90.
[6] Tortolani PJ, Carbone JJ, Quartararo LG. Greater trochanteric pain syndrome in
patients referred to orthopedic spine specialists. Spine J 2002;2:251–4.
[7] Chowdhury R, Naaseri S, Lee J, Rajeswaran G. Imaging and management of
greater trochanteric pain syndrome. Postgrad Med J 2014;90:576–81. https://
doi.org/10.1136/postgradmedj-2013-131828.
[8] Barratt PA, Brookes N, Newson A. Conservative treatments for greater
trochanteric pain syndrome: a systematic review. Br J Sports Med
2017;51:97–104. https://doi.org/10.1136/bjsports-2015-095858.
[9] Mulligan EP, Middleton EF, Brunette M. Evaluation and management of greater
trochanter pain syndrome. Phys Ther Sport 2015;16:205–14. https://doi.org/
10.1016/j.ptsp.2014.11.002.
[10] Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, et al. Greater trochanteric
pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil
2007;88:988–92. https://doi.org/10.1016/j.apmr.2007.04.014.
[11] Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med
Arthrosc Rev 2010;18:113–9. https://doi.org/10.1097/JSA.0b013e3181e0b2ff.
[12] Collée G, Dijkmans BA, Vandenbroucke JP, Cats A. Greater trochanteric pain
syndrome (trochanteric bursitis) in low back pain. Scand J Rheumatol
1991;20:262–6.
[13] Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the
greater trochanteric pain syndrome: a systematic review. Br Med Bull
2012;102:115–31. https://doi.org/10.1093/bmb/ldr038.
[14] Reid D. The management of greater trochanteric pain syndrome: a systematic
literature review. J Orthop 2016;13:15–28. https://doi.org/10.1016/j.
jor.2015.12.006.
[15] Mulford K. Greater trochanteric bursitis. J Nurse Pract 2007;3:328–32. https://
doi.org/10.1016/j.nurpra.2007.03.001.