Greater trochanter pain syndrome: A descriptive MR imaging study

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Abstract

Objective

Greater trochanter pain syndrome (GTPS) is a diverse clinical entity caused by a variety of underlying conditions. We sought to explore the impact of (1) hip morphology, namely the center-edge angle (CEa) and femoral neck-shaft (NSa) angle, (2) hip abductor tendon degeneration, (3) the dimensions of peritrochanteric edema and (4) bursitis, on the presence of GTPS, using MR imaging.

Materials and methods

The presence of pain was prospectively assessed blindly by the senior author. CEa and NSa were blindly measured in 174 hip MR examinations, after completion of the clinical evaluation by another evaluator. The existence and dimensions of T2 hyperintensity of the peritrochanteric soft tissues, the existence and dimensions of bursae, as well as degeneration and tearing of gluteus tendons were also recorded.

Results

Out of 174 examinations, 91 displayed peritrochanteric edema (group A) and 34 bursitis, all with peritrochanteric edema (group B). A number of 78 patients from both A and B groups, showed gluteus medius tendon degeneration and one tendon tear. CEa of groups A and B were 6° higher than those of normals (group C, P = 0.0038). The mean age of normals was 16.6 years less than in group A and 19.8 years less than in group B (P < 0.0001). Bursitis was associated with pain with a negative predictive value of 97% (P = 0.0003).

Conclusion

Acetabular morphology is associated with GTPS and the absence of bursitis was proved to be clinically relevant. Peritrochanteric edema alone was not associated with local pain.

Introduction

Greater trochanter pain syndrome (GTPS) is characterized by pain and tenderness over the great trochanter. Its diagnosis is based on a combination of data from medical history, physical examination and imaging findings. Female gender in the sixth decade, a femoral neck-shaft angle (NSa) less than 134°, and leg length discrepancies, have been described as risk factors for GTPS [1], [2], [3]. A variety of conditions, such as degenerative hip disease, femoroacetabular impingement, femoral head avascular necrosis, infection and conditions that can modify hip biomechanics, such as knee osteoarthritis, iliotibial band syndrome and lumbar spine degenerative disease, can clinically mimic GTPS, making the clinical differential diagnosis extremely complicated [4], [5].

Unlike the original belief that the term “GTPS” is synonymous to “trochanteric bursitis”, we nowadays accept that this syndrome may result not only by an inflamed bursa, but also by gluteus tendinopathy/tear and external coxa saltans, which refers to iliotibial band snapping [6], [7], [8]. Other rare disorders may also result in GTPS [9], [10], [11], [12]. Kong et al. described various findings associated with GTPS, as seen in hip MR imaging examinations and underlined the need of a specific diagnosis in order to optimize the treatment strategies [13]. Haliloglu et al. found that T2 peritrochanteric hyperintensity representing edema is by far the most common finding but is rarely related to clinical symptoms [14]. Various studies have reported association between MR imaging findings and the presence of pain [1], [15], [16], [17]. In the absence of peritrochanteric hyperintensity on fluid sensitive sequences, the GTPS is an unlike diagnosis [15]. On the other hand, large amounts of fluid within bursae, may correlate with clinical presentation [15], [18].

No study, to the best of our knowledge, has compared patients with isolated peritrochanteric T2 hyperintensity in the absence of tendinous tears, with patients demonstrating bursitis. Moreover, no study has evaluated the role of acetabular morphology in patients with GTPS.

We sought to assess the relation of acetabular morphology and NSa with the presence of GTPS and to evaluate the association between peritrochanteric edema and bursitis on MR imaging and the existence of pain. Secondly, we evaluated the impact of hip abductor tendon degeneration on the presence of pain. Finally, we explored whether the dimensions of peritrochanteric edema and bursitis, could imply the presence of a painful hip.

Section snippets

Patients

A total of 224 consecutive MR imaging examinations of hip joints from 141 patients, referred to our department for various clinical indications from June 2008 to April 2013, were prospectively evaluated. The most common indications included early and radiologically occult osteoarthritis, trochanteritis, early osteonecrosis, transient bone marrow edema, and labral abnormalities. Our study has been approved by our hospital's ethics committee, was performed in the context of the principles of

Results

Data analysis revealed that 91 (52.3%) hips displayed peritrochanteric T2 hyperintensity corresponding to soft tissue edema. Thirty-four (19.5%) hips had a distended bursa (18 trochanteric, 9 subgluteus medius, 6 trochanteric and subgluteus medius and 1 subgluteus minimus and medius). All the 34 hips of group B demonstrated associated peritrochanteric edema. In 49 hips, there were neither peritrochanteric edema nor bursitis. In addition, 78 out of 174 (44.8%) hips displayed gluteus medius

Discussion

Our study showed that a relationship exists between acetabular morphology and the presence of peritrochanteric bursitis. In addition, the NPV of bursitis on MR imaging, is a clinically important finding.

GTPS is a common cause of lateral hip pain with a broad differential diagnosis and is defined as pain and tenderness to palpation over the greater trochanter [21], [22]. The anatomy of the trochanteric region is extremely complex, including the tendons of gluteus muscles, the piriformis and

Conflict of interest

No conflict of interest to disclose.

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