Introduction

Human hips do a lot of work. Even the most sedentary among us take millions of steps a year, mostly on very hard surfaces like concrete and tarmac. The opportunity for strains and pains to build up in the tissues is substantial, to say the very least. When our gait (human wheel alignment) is working well, we tend not to get trochanter pain. But when we have underlying issues with our gait, this can significantly predispose us to trochanteric pain syndrome. The underlying mechanism behind trochanteric pain syndrome in each case is ‘repetitive strain’.

Greater Trochanteric Pain Syndrome Caused by Gluteal Tendinopathy

Tendinopathy, characterised by pain and dysfunction in the tendon, is defined as a flawed tendon healing process. This involves irregular proliferation of tenocytes, abnormalities within tenocytes at the cellular level, disruption of collagen fibres, and a subsequent rise in non-collagenous matrix. Greater trochanteric pain syndrome is a prevalent source of lateral hip discomfort, often observed in females aged 40 to 60. It accounts for hip pain in about 10-20% of individuals seeking primary care for hip-related issues, with an occurrence rate of approximately 1.8 patients per 1000 annually. 

Traditionally, trochanteric bursitis was believed to be the root cause of greater trochanteric pain syndrome. However, surgical investigations, histological examinations, and imaging studies have revealed that greater trochanter pain syndrome primarily stems from tendinopathy affecting the gluteus medius and/or minimus muscles, sometimes alongside concurrent issues in the bursa. 

Greater Trochanteric Pain Syndrome Caused by Abnormal Hip Biomechanics

Greater trochanteric pain syndrome frequently stems from irregular hip biomechanics, characterised by imbalanced movements or irregularities that strain the tendons near the femur’s greater trochanter. Muscle weakness or tightness, joint instability, and improper movement patterns are common factors contributing to this condition. These biomechanical irregularities gradually lead to overuse injuries and inflammation of the tendons, culminating in the onset of greater trochanter pain syndrome. Over time, the persistent strain on the affected tendons exacerbates the condition, causing discomfort and limiting mobility in the lateral hip region. If left unaddressed, the tendons can become scar-like in appearance, causing significant hip and greater trochanter pain.  

Greater Trochanteric Pain Syndrome Caused by Gender

Women typically have a wider pelvic width compared to their overall body width, resulting in a more prominent appearance of the trochanters. This prominence and increased tension of the iliotibial band (ITB) over the trochanter predispose females to greater trochanteric pain syndrome. Additionally, a lower femoral neck-shaft angle in females may contribute to this condition by intensifying compression of the gluteus medius tendon on the greater trochanter. Furthermore, increased acetabular anteversion could also play a role in predisposing individuals to greater trochanteric pain syndrome. The primary mechanism behind greater trochanteric pain syndrome involves repetitive friction between the greater trochanter and ITB, leading to microtrauma in the gluteal tendons attached to the greater trochanter. This repetitive trauma results in local inflammation, tendon degeneration, trochanter pain and heightened tension of the ITB.

Greater Trochanteric Pain Syndrome Caused by Increased Adiposity

Increased Adiposity is a significant factor in the development of greater trochanteric pain syndrome. The excess weight places added strain on the hip joints and surrounding structures, including the tendons and muscles near the greater trochanter of the femur. This increased load can disrupt standard hip mechanics, leading to biomechanical imbalances and altered gait patterns, which are vital contributors to greater trochanter pain syndrome. Moreover, obesity is often linked to systemic inflammation and metabolic changes, which can worsen existing tendon problems and contribute to persistent hip pain. Additionally, individuals who are overweight or obese may lead a less active lifestyle, resulting in muscle atrophy and reduced flexibility, further increasing their susceptibility to greater trochanter pain syndrome.

Greater Trochanteric Pain Syndrome Caused by Flat Feet

One of the most significant contributing factors to abnormal hip biomechanics is overpronation of the foot. When the foot pronates, it causes the leg to rotate inward, disrupting its alignment with the hips. This misalignment results in uneven weight distribution on the hips, termed “improper load transfer.” Consequently, excessive stress is placed on the hip joints, muscles, and ligaments, leading to discomfort and pain. Additionally, the overpronation-induced rolling motion can extend up the leg, affecting the muscles and ligaments where the leg meets the hip, further intensifying the discomfort. 

If left unaddressed, this misalignment and subsequent strain on the hip region can impair mobility and lead to chronic hip issues like greater trochanteric pain syndrome.

Greater Trochanteric Pain Syndrome Caused by Leg Length Discrepancy 

Leg length discrepancy (LLD) can contribute to greater trochanter pain syndrome by causing altered biomechanics and asymmetrical loading of the hips. When one leg is shorter than the other, it can lead to pelvic tilt, spinal curvature, and compensatory changes in gait patterns to maintain balance and stability while walking or running. These compensatory mechanisms can place excessive stress on the tendons and muscles around the greater trochanter of the femur, leading to inflammation and greater trochanter pain. 

A recent study found that individuals with a leg length discrepancy (LLD) exceeding 5 mm often report more trochanteric symptoms (29.2%) than those with a more minor deviation. This disparity highlights the potential link between greater trochanteric pain syndrome and LLD. When the combined parameters deviate significantly, it can disrupt biomechanical balance and increase stress on the affected hip. As a result, individuals with more significant deviations may experience more frequent and pronounced trochanteric symptoms than those with more minor leg length differences.

Greater Trochanteric Pain Syndrome Caused by Scoliosis

Scoliosis is the chronic presence of substantial lateral curvature in a given region of the spine. It is usually accompanied by rotation of the vertebrae within the curve. Hip pain and greater trochanter pain may arise from the stretching of ligaments caused by the abnormal curvature of the spine in scoliosis. When the spine’s curvature leads to pelvic tilt, one hip may bear more weight than the other, resulting in uneven strain on tendons and supporting muscles, ultimately causing discomfort. Scoliosis-related hip pain often results from the uneven strain on the iliolumbar and sacroiliac ligaments. It stabilises the lumbosacral spine where it meets the pelvis, leading to sacroiliac joint pain (SIJ pain).

Pelvic dysfunction due to altered gait patterns in scoliosis can also contribute to hip pain. Irregular movement patterns result in uneven wear and tear on the spine, pelvis, and hips.

Furthermore, muscular and fascial involvement plays a role in scoliosis-related hip pain. Fascial restrictions can cause tightness and rigidity, exacerbating tension and discomfort in the hip region due to the abnormal stresses imposed by scoliosis on the spine and pelvis.

Greater Trochanteric Pain Syndrome Caused By Old Injuries

Believe it or not, a significant number of people with trochanteric pain syndrome ultimately find it was caused by a sprained ankle. And not only that, but a sprained ankle that they had years ago.

When we injure our ankles and knees, we are often left with persistent weakness and instability around the joint. This weakness is easily avoided with consistent long-term strengthening (a minimum of 12 months for a moderate to mild ankle sprain), yet how many of us can say that we did 12 months of strength and balance work after we sprained our ankle?

If you have a history of ankle sprains, knee injuries or perhaps even some more significant injury to your lower limb like a fracture, it is entirely possible that a pattern of weakness left in the wake of the injury is the underlying cause of your trochanteric pain syndrome.