pathology: trochanter major syndrom GTPS

yogabook / pathologie / trochanter-major-syndrom GTPS

Trochanter Major Syndrome / Greater Trochanteric Pain Syndrome (GTPS) / Trochanteric Tendinosis / Gluteal Tendinopathy

Definition of

Major trochanter syndrome is a group of symptoms of various disorders in the area of the major trochanter. These include: bursitis trochanterica, which affects the three bursa bursa subgluteus maximus, bursa subgluteus medius and bursa subgluteus minimus, insertional tendopathies or tears of the gluteus medius or Gluteus minimus. The categorisation according to Thomas differentiates into three degrees:

  1. 1: no tear of the gluteal tendons, intact function, pressure pain
  2. 2: partial rupture of the gluteal tendons, limited function, severe pressure pain
  3. 3: Tearing of the gluteal tendons, no function, permanent pain

The course is often progressive: tendinitis, tendinosis, rupture. The gluteus medius is more frequently affected than the gluteus minimus. Epidemilogy: 10-25% of the population are affected, W:M 4:1.

Insertional stenopathies of the small glute at the trochanter major are one of the most common causes of laterally localised hip pain and are often associated with bursitis trochanterica. These muscles are also referred to as the rotator cuff of the hip joint. In a French study, 58% of orthopaedic surgeons surveyed were unfamiliar with tendinosis or rupture of gluteal tendons. Bursitis trochanterica rarely occurs alone, usually involving the gluteal tendons. The most common term for this is GTPS. GTPS occurs more frequently after the age of 40, with women being affected more often than men. In addition to the primary disorder of the degenerative tendons with a tendency to tendinosis and rupture, there are also secondary disorders after hip arthroplasty, depending on the approach chosen during the operation. According to the study, 50% of patients undergoing surgery suffer from this. The pain symptoms occur in the area of the trochanter major, also with radiation along the iliotibial tract into the lateral knee joint. The pain may tend to localise to the anterior or posterior trochanter major. Lying on the affected side is painful, as is abduction against resistance, while passive abduction provides relief from the pressure pain. It is also possible to change the gait pattern due to weakness or to avoid pain. Depending on the severity, the Trendelenburg sign may be positive. When standing on one leg, the pelvis must be examined for tilting to the contralateral side. Gluteal tendon insufficiency is also detected by the Lateral Decubitus Abduction Test LDAT, in which the leg to be examined is extended and abducted as well as endorotated at 50° flexion of the knee joint in the contralateral lateral position. If the leg cannot be actively held in this position, the test is positive and proves gluteal tendon insufficiency. If the test for the
Trendelenburg sign is inconclusive, LDAT provides better information. Sonography can also be used to examine the gluteal tendons dynamically and detect bursitis. Finally, tendon degeneration, partial ruptures and tendon oedema close to the insertion can be seen on MRI, as can changes in the musculotendinous junction. Not all disorders visible in the MRI are symptomatic. Thomas categorises them into three degrees, which also guide treatment. In addition to physical and physiotherapeutic measures and NSAIDs, the main focus is on exercise therapy measures, training of proprioception as well as concentric muscle training. Depending on how these measures are combined, the success rate is between 40 and 83%. Corticosteroid infiltrations are successful in about half to all cases, and still 60% after 6 months. Extracorporeal shock wave therapy also shows good results, especially in the longer term. Corticosteroid therapy appears to be more successful in the short term, but this is reversed in the long term. Treatment-resistant bursitis and tendon disorders after Thomas grade 1 tend to further weaken the tendon towards grade two or three with deterioration up to complete ruptures. Partial and complete ruptures are treated surgically, tendon refixations are possible arthroscopically or openly, which is usually successful. There is still uncertainty about the optimal fixation technique. Movement and sporting behaviour must be adapted so that, ideally, the pain is not triggered in everyday life and sport. If this is the case, the load can be gradually increased during strengthening training. After surgical intervention, partial weight-bearing is started, whereby flexion is initially limited to 90 degrees, active abductions against resistance and passive adductions beyond zero are suspended for six weeks. Sporting activities can then be introduced with further strengthening training, but not contact sports for at least three months.

Cause

  1. Overuse, mostly on the ground of non-optimal structures

Prädisponierend

– posteroperativ

  1. Conditions after hip surgery(TEP: up to 50% develop disorders, arthroscopy, femoral neck fracture)

– Musculoskeletal system

  1. Muscular imbalances, especially weaknesses in the small gluteal muscles; muscular shortening
  2. Leg length differences, malpositions
  3. Weakness of the trunk muscles
  4. Pelvic instability, e.g. due to lack of abductor strength (small glutes)
  5. Sometimes an ITBS and hypertonus of the tensor fasciae latae is favorable

– Dispositional diseases

  1. RA and rheumatoid arthritis

– other factors

  1. female gender
  2. Obesity

Diagnosis

  1. Sono: clarifies degeneration of the tendons
  2. MRI for clarification of DD if necessary
  3. Running and gait analysis, also for non-athletes

Symptoms

  1. Exercise-induced pain
  2. Painful restriction of movement
  3. Pain radiating into the buttocks
  4. Rotational pain of the hip joint
  5. Reduced strength for abduction, limping
  6. Shortened, painful stretching of the glutes
  7. sometimes marked tenderness, especially with bursitis
  8. in an advanced stage: Trendelenburg sign
  9. Snapping hip (coxa saltans, Amon’s snapping hip)
  10. signs of inflammation, if applicable
  11. Painful lying on the affected side

Therapy

  1. PT
  2. Shock wave therapy
  3. ACP injections
  4. Inlays if necessary
  5. NSAIDs if necessary
  6. Relief, load reduction as far as necessary
  7. Stretching training, especially of the hip flexors and gluteal muscles
  8. Elimination of muscular imbalances, in particular one-sided abduction weakness
  9. Flexibility training of the gluteal muscles
  10. Training of the trunk (especially abdominal muscles and autochthonous back muscles) and proprioception
  11. Surgical refixation with debridement (removal of degenerated material from the tendons) in stage 3, prior to this only if indicated, resection of the bursa
  12. Caution with cortisone infiltrations: damages tendons

DD

  1. rheumatoid diseases
  2. DGS / Piriformis syndrome