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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 3-5

Is greater trochanteric pain syndrome influenced by pelvic anatomy? A radiological review


1 Department of Trauma and Orthopaedics, Macclesfield Hospital, Macclesfield, UK
2 Department of Trauma and Orthopaedics, Morriston Hospital, Swansea, UK

Date of Submission01-Jun-2020
Date of Acceptance04-May-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Raviprasad Kattimani
Department of Trauma and Orthopaedics, Macclesfield District General Hospital, Macclesfield
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_42_20

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  Abstract 


Introduction: Greater trochanteric pain syndrome (GTPS) is one of the common causes of hip pain, which can be difficult to treat. The incidence of GTPS is highest in the middle aged and the elderly. The iliotibial band (ITB) acts as a tension band over the concave lateral surface of the femur. We postulate that those with wider pelvic morphology have higher tension though the ITB which predisposes to developing GTPS. Aim of the Study: The aim of the study is to evaluate the relationship between pelvic anatomy and GTPS. Methodology: A total of 89 patients underwent steroid injection in a district general hospital for the clinical diagnosis of GTPS between February 2013 and December 2014. We performed a retrospective radiological analysis of their pelvic morphology. We measured intertrochanteric distance and the bispinal distance between both anterosuperior iliac spines on anteroposterior pelvis radiographs. A ratio of intertrochanteric to bispinal distance was calculated. Femoral neck angle and offset were also recorded. Student's t-test was used for statistical analysis. Results: The average intertrochanteric distance and bispinal distance of patients with GTPS and control group were 362 mm and 341 mm, respectively. Intertrochanteric to bi spinal average ratio of 1.06 was found in GTPS group compared to 1.04 in the control group. Patients with GTPS had more varus femoral necks and a larger femoral offset. Intertrochanteric distance, neck-shaft angle, and offset were also statistically significant. Conclusion: We postulate that risk factors for GTPS include female sex, increasing age, and a wider pelvis. To allow for magnification of radiographs, we would suggest the use of the intertrochanteric to bispinal ratio in assessing patients with suspected trochanteric bursitis. We believe a figure of >1.06 would be supportive of the condition.

Keywords: Anatomy, greater trochanteric pain syndrome, pelvis


How to cite this article:
Kattimani R, Bayley M. Is greater trochanteric pain syndrome influenced by pelvic anatomy? A radiological review. J Orthop Traumatol Rehabil 2021;13:3-5

How to cite this URL:
Kattimani R, Bayley M. Is greater trochanteric pain syndrome influenced by pelvic anatomy? A radiological review. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Jul 25];13:3-5. Available from: https://www.jotr.in/text.asp?2021/13/1/3/318412




  Introduction Top


Greater trochanteric pain syndrome (GTPS) is defined as pain over greater trochanter, which can refer down to the lateral aspect of the hip. GTPS is the cause of hip pain in 10%–20% of patients presenting with hip pain to primary care, with an incidence of 1.8 patients per 1000 per year.[1] The incidence peaks between fourth and sixth decades of life.[2],[3] The GTPS was earlier called as “trochanteric bursitis,“ which was first described by Stegeman in 1923 as chronic, intermittent pain in the lateral hip.[4] It was also known as the “great mimicker” because its clinical features overlapped with several other conditions including degenerative joint disease, myofascial pain, and spinal pathology so it has high risk of misdiagnosis.[5]

The term GTPS includes tendinopathies, tendinous tears, bursal inflammation, and effusion.[5],[6] It is common in both sedentary and sporting populations indicating the etiology to be multifactorial.[7],[8] The extrinsic factors may be osteoarthritis of the lumbar spine, hip, or knee; iliotibial band (ITB) tightness or tendonitis; or strain of the hip external rotators may contribute to trochanteric pain by adding stress to the area[9],[10] and the intrinsic factors are female sex and older age[11] and other intrinsic risk factors include peripheral adiposity[7] and pelvic width.[12],[13]

The aim of the study was to evaluate the relationship of pelvic morphology with GTPS.


  Methodology Top


A total of 89 patients underwent steroid injection in a district general hospital for the clinical diagnosis of GTPS between February 2012 and December 2013. We performed a retrospective radiological analysis of their pelvic morphology.

This study was a retrospective review of anteroposterior (AP) pelvis radiographs on picture archiving and communication system. Among the 89 patients with GTPS, 36 were excluded because of inadequate pelvic radiographs (exclusions: 26 – inadequate radiographs, 10 – rotated pelvic radiographs, and 23 – had hip prosthesis). In total, 30 patient pelvis radiographs were analyzed. 81% were female and 19% were male. Mean age was 63 years (range 30–90).

We analyzed AP pelvis radiograph of an age and sex-matched control group (n = 79). 20 patients were excluded (exclusions: 1 – inadequate radiograph, 9 – rotated femurs, 7 – prosthesis, and 3 – osteoarthritis). In total, 59 pelvis radiographs were analyzed.

We measured distance between the outermost edges of greater trochanters (intertrochanteric distance) and the (bispinal distance). It is the distance between anterosuperior iliac spines on either sides of pelvis on AP pelvis radiographs. A ratio of intertrochanteric to bispinal distance was calculated. Femoral neck angle and hip offset were also recorded [Figure 1].
Figure 1: IIllustrates the lines used to measure bispinal distance (a), intertrochanteric distance (b), neck-shaft angle (c), hip offset (d)

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Student's t-test for nonpaired data was used for statistical analysis.


  Results Top


Our results are listed in [Table 1], [Table 2], [Table 3], [Table 4]. We found statistically significant differences in pelvic anatomy of patients with GTPS and control group. The average intertrochanteric distance and bispinal distances were more in females in both control and GTPS group.
Table 1: Inter trochanteric distance (Distance between lateral most tips of greater trochanters)

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Table 2: Bi-spinal distance (Distance between anterior superior iliac spines)

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Table 3: Neck shaft angle (degrees)

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Table 4: Hip offset (mm)

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Patients with GTPS had lower neck-shaft angle 129.1 degrees compared to control 133.1 degrees (P = 0.004) and higher hip offset of GTPS group 48.3 mm compared to control group 43.55 (P = 0.004).

Patients with GTPS had more varus femoral necks and a larger femoral offset and increased intertrochanteric and bispinal distance. Females had more varus necks in GTPS group, and hip offsets were more in males in GTPS group compared to females.

Discussion

GTPS is one of the common causes of hip pain in elderly female population. This study was undertaken to evaluate whether there is a relationship between the pelvic anatomy and the GTPS. We found that patients with GTPS had lower neck-shaft angle and a larger femoral offset and increased intertrochanteric distance and higher hip offset.

Fearon et al. found that women with lower neck-shaft angles had persistent and more severe form of GTPS.[7] The ITB applies more medial pressure over the greater trochanter in femurs with lower neck-shaft angles than in those with higher neck-shaft angles as shown by finite element modeling.[13] The gluteus medius tendon has pressure from medial side by greater trochanter and on the lateral side by ITB which may likely result in tendinopathy and eventual tendon rupture.[14],[15],[16]

Our study supports the findings of Viradia et al. who were the first to study anatomical relationship of pelvis and their possible link to GTPS. They found that trochanteric widths and iliac wing widths were significantly more in patients with GTPS than control group.[17] This study also supports the previous study that GTPS is more common in females and in elderly population.[6]

The limitations of this study were, it was retrospective study; the study population was small and limited to small geographic location. The randomly selected patients who presented to radiology department with pelvic pain in the control group assumed not to have GTPS but may actually have had GTPS.


  Conclusion Top


We postulate that risk factors for GTPS include female sex, increasing age, and a wider pelvis. Our results suggest that lateralization of the greater trochanters may predispose to GTPS. To allow for magnification of radiographs, we would suggest the use of the intertrochanteric to bi spinal ratio in assessing patients with suspected GTPS. We believe that a figure of >1.06 would be supportive of the condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: A systematic review. Br J Sports Med 2017;51:97-104.  Back to cited text no. 1
    
2.
Speers CJ, Bhogal GS. Greater trochanteric pain syndrome: A review of diagnosis and management in general practice. Br J Gen Pract 2017;67:479-80.  Back to cited text no. 2
    
3.
Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc 1996;71:565-9.  Back to cited text no. 3
    
4.
Board TN, Hughes SJ, and Freemont AJ. Trochanteric bursitis: the last great misnomer. Hip international: 2014;24:6.  Back to cited text no. 4
    
5.
Williams BS, Cohen SP. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg 2009;108:1662-70.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
Fearon A, Stephens S, Cook J, Smith P, Neeman T, Cormick W, et al. The relationship of femoral neck shaft angle and adiposity to greater trochanteric pain syndrome in women. A case control morphology and anthropometric study. Br J Sports Med 2012;46:888-92.  Back to cited text no. 7
    
8.
Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001;29:521-33.  Back to cited text no. 8
    
9.
Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: Trochanteric bursitis. J Clin Rheumatol 2004;10:123-4.  Back to cited text no. 9
    
10.
Swezey RL. Pseudo-radiculopathy in subacute trochanteric bursitis of the subgluteus maximus bursa. Arch Phys Med Rehabil 1976;57:387-90.  Back to cited text no. 10
    
11.
Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med 2009;37:1981-90.  Back to cited text no. 11
    
12.
Sim FH, Scott SG. Injuries of the pelvis and hip in athletes: Anatomy and function. In: Nicholson JA, Hershman EB, editors. The Lower Extremity and Spine in Sports Medicine. St Louis: Mosby; 1986. p. 1119-69.  Back to cited text no. 12
    
13.
Birnbaum K, Pandorf T. Finite element model of the proximal femur under consideration of the hip centralizing forces of the iliotibial tract. Clin Biomech (Bristol, Avon) 2011;26:58-64.  Back to cited text no. 13
    
14.
Slack C, Bradley G, Beaumont B, Poole A, Flint M. Changes in the morphology and synthetic activity of cultured rat tail tendon. Cell Tissue Res 1986;245:359-68.  Back to cited text no. 14
    
15.
Gillard GC, Merrilees MJ, Bell-Booth PG, Reilly HC, Flint MH. The proteoglycan content and the axial periodicity of collagen in tendon. Biochem J 1977;163:145-51.  Back to cited text no. 15
    
16.
Samiric T, Parkinson J, Ilic MZ, Cook J, Feller JA, Handley CJ. Changes in the composition of the extracellular matrix in patellar tendinopathy. Matrix Biol 2009;28:230-6.  Back to cited text no. 16
    
17.
Viradia NK, Berger AA, Dahners LE. Relationship between width of greater trochanters and width of iliac wings in tronchanteric bursitis. Am J Orthop (Belle Mead NJ) 2011;40:E159-62.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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