Runners and jumpers are prone to trochanteric hip pain, a syndrome that is caused by inflammation of tendons. Physiotherapist Peter Jackson looks into the causes and treatment

Pain on the outer area of the hip is a common problem experienced by many athletes. It is not usually caused by the hip at all, rather by a group of tissues that are based on the outside of the hip and is a problem known as trochanteric pain syndrome.

The syndrome is often related to pain arising from inflammation of some small fluid-filled sacs known as bursitis or a tendon pain from the gluteal tendons.

What is it?

The name trochanteric pain syndrome comes from the medical terminology of the bony surface on the outside of the hip. That hard, bony prominence you can feel is called the “greater trochanter of the femur”. This is the outermost aspect of the leg bone; it is not your hip joint, although it is often mistaken for being so. This bony prominence is an important attachment for many of the gluteal muscles which arise in your buttock and are responsible for extending and rotating your hip along with taking it out to the side.

They work very hard during the running process. Anybody can develop this pain syndrome but it usually occurs in runners or athletes who are placing large loading forces through their legs such as triple jumpers and high jumpers, particularly if they struggle to fully control the load forces during running. It also often occurs in people aged between 30 and 50 years and is more prevalent in women than men.

How do you know you have it?

The pain is characterised by an ache on the outer part of the thigh which feels tender to touch. Often people with the condition have difficulty lying on their affected side due to the pain. The pain is specific to the bony prominence on the outside of the hip but can refer down the outer part of the thigh. It should not radiate beyond the knee or travel into the groin – if this is the case it most likely is not greater trochanteric pain. A snapping sensation can sometimes be felt over the outside of the hip, which is often related to the soft tissues overlying the bony prominence.

What causes it?

Historically the condition was thought to be related to the fluid-filled sac overlying the bony prominence on the outside of the hip. These sacs, called bursa, are designed to reduce the friction between the tendons and the bone.

Due to repeated overloading, the bursa can become inflamed, leading to a condition known as bursitis. They can also become inflamed secondary to a trauma, for instance a fall on to your side. We now believe these episodes of bursitis usually happen in conjunction with other associated problems.

The muscles that make up the buttock are predominantly known as the gluteal muscles. These are a group of muscle that stabilise your pelvis and create forward propulsion in walking and running. Anecdotally one of the findings is that the gluteal muscles in a chunk of the population are not working as effectively as hoped. This means that, although you may be able to run okay, the control around the pelvis is somewhat haphazard.

Typically, this causes the knee to drop inward on the stance phase of running, which leads to increased stress to the trochanteric bursa and excessive loading through the gluteal tendons. Tendonitis or tendinosis where the tendons become swollen, thickened and painful can sometimes be the result. Given they attach on to the greater trochanter, the pain would be in the same area as the bursitis and impossible to differentiate without radiological imaging.

Another contributing factor to trochanteric pain is tightness to a fibrous tissue that runs directly over the bony area around the hip. This is a structure commonly known to runners called the Iliotibial band, or ITB. This band of tissue  runs all the way down the outside of the thigh and if it is excessively tight (often the case in runners), can cause increased friction either over the greater trochanter or over the outside of the knee.

Treatment

The main treatment for this condition is to improve the control around the hip and pelvis. This includes strengthening the gluteal muscles to control the pelvis, particularly during the stance phase of running.

The following gluteal strengthening exercises are a good place to start:

Side lying leg lifts: Lie on your side with your legs out straight. Lift your uppermost leg upwards without your pelvis rotating forwards or backwards.

Squats: Stand up tall and initially start with small squats before you go lower. Ensure alignment with your thighs staying straight, your knee not rotating inwards and do not go on to your tip-toes. Instead imagine you are almost trying to sit down to activate your gluteal muscles. Do not go below halfway and to make the exercise harder you can add weights.

Lunges: These are an essential exercise to master for runners because they almost replicate the functional aspect of running with one leg in front of the other.

It is also important to lengthen the ITB. This is done most effectively through a massage technique by a trained professional or by using a foam roller at home. The ITB is not a muscle and consequently has no stretch receptors; hence the best way to lengthen it is to get hands on. My only warning is it can be very painful but will have good outcomes.

A more invasive treatment is a corticosteroid injection into the trochanteric bursa. This works as an anti-inflammatory to reduce the inflammation within the bursa and can often be extremely effective. However, it will not cure the problem if the symptoms are secondary to gluteal weakness or ITB tightness as the irritation will continue to develop.

Prognosis

This condition is usually thought to be self-limiting; therefore it should improve over time. However, this can take months or even years. If the pain is related to poor pelvic control and stability during the running cycle, realistically if this is not improved the condition is likely to persist. Get those gluteal muscles firing and keep your ITB nice and mobile to keep this condition at bay.

» Peter Jackson is a clinical specialist physiotherapist in sports medicine based in Northern Ireland