Greater Trochanteric Pain Syndrome Therapy Protocol

[cbest]

PM&R resident here - I'm doing a research project comparing different treatment approaches of greater trochanteric pain syndrome. I'm wondering if anyone knows of a documented PT protocol in the literature for GTPS and/or just greater trochanteric bursitis. Thanks for your help in advance!

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[Fiveoboy11]

I'm not aware of any protocols, but here's some thoughts:

Associated with obesity (wt loss exercise), or high impact activities (relative rest followed by improvement in associated factors followed by gradual return to activity)

In people with low body fat, especially around that area, Graston or ASTYM to ITB glutes and TFL, iontophoresis may help

I notice symptoms as above common in people with single MOI, and LBP with LE weakness induced tendonitis/tendinosis, especially in stenosis (lumbar spinal stenosis protocol - avoid lumbar / end range (especially with overpressure; encourage lumbopelvic PPT, thoracic/thorax extension/expansion, hip / without inducing lumbar / too far, walking program, manual for above as well)

People with large Q-angles and flat feet, maybe arch supports would help

Sometimes I make an artificial IT band for patient's with IT band and/or greater trochanter symptoms with leukotape to take some strain off it temporarily.

Trigger point exercises with a tennis ball on wall (not over greater trochanter, but glutes and TFL

Hip abd/ER strengthening is an obvious one, but I would be cautious as it may flare them up, especially if it is irritable.

I would really like to hear what anyone else thinks too...

 

[facetguy]

I tend to hate these cases. Anymore, because I'm getting crabbier as I get older, I just tell these patients to go get an injection. (Unless they have good insurance, in which case I'll treat them 3x/week for 2 months and THEN refer them for an injection. )

 

[truthseeker]

In general, protocols in PMR are not effective. think of the various possible causes of troch bursitis.

leg length, bad shoes, tight ITB, central hypersensitization, trauma to name a few

all of those things would necessitate different treatment approaches.

Just refer them to PT and let the PT figure out the best treatment.

Maybe you could write your paper about how protocols are an inefficient and ineffective approach to treating NMSK problems.

 

[Fiveoboy11]

In general, protocols in PMR are not effective. think of the various possible causes of troch bursitis.

leg length, bad shoes, tight ITB, central hypersensitization, trauma to name a few

all of those things would necessitate different treatment approaches.

Just refer them to PT and let the PT figure out the best treatment.

Maybe you could write your paper about how protocols are an inefficient and ineffective approach to treating NMSK problems.

True, but a literature review based practice guidelines are a good baseline to begin with.

 

[truthseeker]

True, but a literature review based practice guidelines are a good baseline to begin with.

but any literature that includes a protocol would have to be based upon a faulty premise since there are half a dozen potential causes of hip bursitis that I can think of off of the top of my head.

There are dozens of credible opinions on how an ACL should be rehabilitated. They all have protocols. They all need to be tweaked by the therapist based upon the progression of the patient, their goals, and have tissue healing time superimposed over that as well as the patient's general health, age, do they smoke, how long was it torn before it was repaired, the type of repair, what other tissues were involved etc . . .

Same goes for the hip bursitis.

 

[Fiveoboy11]

but any literature that includes a protocol would have to be based upon a faulty premise since there are half a dozen potential causes of hip bursitis that I can think of off of the top of my head.

There are dozens of credible opinions on how an ACL should be rehabilitated. They all have protocols. They all need to be tweaked by the therapist based upon the progression of the patient, their goals, and have tissue healing time superimposed over that as well as the patient's general health, age, do they smoke, how long was it torn before it was repaired, the type of repair, what other tissues were involved etc . . .

Same goes for the hip bursitis.

I agree 100%. But it is still nice to have guidelines IMO that at least give evidence based treatment grades (made by PT's who know what they're talking about, i.e. the ones being developed by the ortho section of the APTA), and then of course it would get tweaked depending on numerous factors. Physician directed protocols are definitely a joke...if that's what you mean.

 

[truthseeker]

mostly yes. but even PT directed ones are sometimes a joke.

example:

recently I saw an 84 year old gentlemman with severe spinal stenosis and moderage DDD with no radiculopathy. His chief complaint was back pain when standing and limited walking distance.

He could abolish his symptoms by sitting. I had seen him in the past for more than one course of PT over several years and worked on some iliopsoas and rectus fem flexibility, core stabilization, back sparing techniques, lifting technique, encouraged a graded walking program with a 4 wheeled walker so that he could stoop a little like when pushing a grocery cart (no pain). We also talked about chronic pain concepts quite a bit (not sure how much of that sunk in though).

Each time he was able to improve his walking/standing tolerance but never got more flexible or lifted better. He was able to be compliant with the walking program but did the stretching sparingly.

This last time, he came from a PM and R DO who sent a prescription for traction, MFR, stretching, core stabilization, and bodymechanics education 3x/week for 6 weeks.

I had done all of that except the MFR and the traction. I didn't have any confidence that either of those had any chance to increase his standing tolerance and he wasn't able to do much walking because he was dealing with hypotension with associated dizziness. I was speaking with his primary care doc and through him his cardiologist about the blood pressure but agreed to try the traction for a week to see if it, by itself would change his tolerance for standing. We did it and he couldn't see any difference in his tolerance of standing at all.

I discharged him after talking with him for about 20 minutes about why. He called the DO who had his PA or nurse call me and tell me that they really wanted me to follow their protocol for 6 weeks. She said that the MFR might give him some relief even if it is temporary. I reminded her that he can get all of the relief he wants at anytime by simply sitting down and the only thing that had shown any benefit in the past was the walking program which he couldn't safely do right at the moment because of his low blood pressure AND charge him or someone (medicare, that means you and me) for something that he didn't need.

 

[Fiveoboy11]

mostly yes. but even PT directed ones are sometimes a joke.

example:

recently I saw an 84 year old gentlemman with severe spinal stenosis and moderage DDD with no radiculopathy. His chief complaint was back pain when standing and limited walking distance.

He could abolish his symptoms by sitting. I had seen him in the past for more than one course of PT over several years and worked on some iliopsoas and rectus fem flexibility, core stabilization, back sparing techniques, lifting technique, encouraged a graded walking program with a 4 wheeled walker so that he could stoop a little like when pushing a grocery cart (no pain). We also talked about chronic pain concepts quite a bit (not sure how much of that sunk in though).

Each time he was able to improve his walking/standing tolerance but never got more flexible or lifted better. He was able to be compliant with the walking program but did the stretching sparingly.

This last time, he came from a PM and R DO who sent a prescription for traction, MFR, stretching, core stabilization, and bodymechanics education 3x/week for 6 weeks.

I had done all of that except the MFR and the traction. I didn't have any confidence that either of those had any chance to increase his standing tolerance and he wasn't able to do much walking because he was dealing with hypotension with associated dizziness. I was speaking with his primary care doc and through him his cardiologist about the blood pressure but agreed to try the traction for a week to see if it, by itself would change his tolerance for standing. We did it and he couldn't see any difference in his tolerance of standing at all.

I discharged him after talking with him for about 20 minutes about why. He called the DO who had his PA or nurse call me and tell me that they really wanted me to follow their protocol for 6 weeks. She said that the MFR might give him some relief even if it is temporary. I reminded her that he can get all of the relief he wants at anytime by simply sitting down and the only thing that had shown any benefit in the past was the walking program which he couldn't safely do right at the moment because of his low blood pressure AND charge him or someone (medicare, that means you and me) for something that he didn't need.

Physicians should never be trying to direct physical therapy, even a PM&R physician. They don't know what they're talking about.

There is a well known study for spinal stenosis that discuss the info above

Whitman JM, Flynn TW, Childs JD, et al: A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis. Spine (2006)

Above they recommend a walking program, and that specific manual plus exercise is better than exercise alone. From my interpretation, it would be hip flexor stretching/manual (without fulcruming to lordosis), lumbar PPT/flexion exercises/manual, thoracic/thorax expansion/extension exercises/manual. Sounds like a pretty decent protocol developed by PT's to me. Maybe we just need to be extra careful what guidelines and "experts" we're listening to.

I agree that mechanical traction is a lame idea for this patient, isn't that only supposed to be used in cases where symptoms do not centralize with repeated or sustained positions?

MFR is synonymous with "massage" if you ask me, and from what I know about it, that is gargabe for LBP or stenosis LE pain.

 

[fozzy40]

Physicians should never be trying to direct physical therapy, even a PM&R physician. They don't know what they're talking about.

Many but not all of us

I agree with how you treated and educated this patient not that you need validation from this physician that doesn't know anything

Just out of curiosity, what did they want you to MFR specifically? What was their protocol?

 

[Fiveoboy11]

Many but not all of us

I agree with how you treated and educated this patient not that you need validation from this physician that doesn't know anything

Just out of curiosity, what did they want you to MFR specifically? What was their protocol?

You probably think you know what is best for a patient in terms of physical therapy, but you do not and neither does the rest of your cohort. No physician is qualified to direct or practice physical therapy, unless they are a licensed and actively practicing PT as well.

 

[facetguy]

You probably think you know what is best for a patient in terms of physical therapy, but you do not and neither does the rest of your cohort. No physician is qualified to direct or practice physical therapy, unless they are a licensed and actively practicing PT as well.

TEAMWORK!!

 

[Fiveoboy11]

TEAMWORK!!

people who embrace the team concept can stuff it as far as I'm concerned. Everyone and their mother is using that terminology, how's that working out? Is there actually teamwork?

I'm in favor of everyone knowing their role and doing their own job. The team is the patient and the respective clinician.

 

[facetguy]

people who embrace the team concept can stuff it as far as I'm concerned. Everyone and their mother is using that terminology, how's that working out? Is there actually teamwork?

I'm in favor of everyone knowing their role and doing their own job. The team is the patient and the respective clinician.

The team is everyone trying to help that patient. Being an isolationist doesn't serve the patient well.

 

[Fiveoboy11]

The team is everyone trying to help that patient. Being an isolationist doesn't serve the patient well.

Tell that to your entire profession...

I didn't mean isolating oneself from other professionals is the way to go. I was trying to say that everyone doing their own job in reality will yield the best patient outcomes. Pretending to be a "team" blurs lines, is uncoordinated, and ineffective.

Communication is very important, just do your own damn job and let other clinicians do theirs.

 

[facetguy]

Tell that to your entire profession...

I didn't mean isolating oneself from other professionals is the way to go. I was trying to say that everyone doing their own job in reality will yield the best patient outcomes. Pretending to be a "team" blurs lines, is uncoordinated, and ineffective.

Communication is very important, just do your own damn job and let other clinicians do theirs.

Is there ever a time when another clinician can be of assistance to you in managing a patient? I'm not clear on what you are saying.

 

[Azimuthal]

the team is everyone trying to help that patient. Being an isolationist doesn't serve the patient well.

+1

 

[Fiveoboy11]

Is there ever a time when another clinician can be of assistance to you in managing a patient? I'm not clear on what you are saying.

Absolutely. But do you think >98% of patients need collaborated care other than a physical therapist for common MSK problems, i.e. RC tendonitis, lateral ankle sprain, cervical radiculopathy, LBP?? I don't! Sometimes patient's just need one session of education and it's done, etc. there doesn't necessarily need to be a garbage truckload of time and money wasting or teamwork. What there needs to be is high quality care, NOW.

I'm saying the "team" concept as it is, is garbage. I'm in favor of highly communicated care but with respective disciplines doing their own jobs.

Let me put it to you like this, if your profession relied on referrals from physicians and you constantly got referrals for lets say acute LBP that says "massage, HP, US", what would you think of that? That's a physician's idea of communicating. Ordering.

How about this, a physician does their job, promptly referrs to physical therapy or chiropractic if appropriate based on evidence WITH the physicians report, not some lame brain waste of ink statement. Then the PT/DC performs the eval, initiates Rx if approrpiate, and sends the evaluation to the physician. Don't you think that is a little more intelligent? Good communication, quality care. Not ordering (communicating) and providing garbage care. I guess I've been missing the "teamwork" component that's so prevalent in today's MD/DO and PT interaction.

 

[fozzy40]

You probably think you know what is best for a patient in terms of physical therapy, but you do not and neither does the rest of your cohort. No physician is qualified to direct or practice physical therapy, unless they are a licensed and actively practicing PT as well.

Don't put words in my mouth. If you look at all of my posts, I NEVER claim to know how to practice physical therapy. However, I do read the current PT literature because I want to understand what my patient is doing in therapy. In previous posts, you constantly talk about physicians lack of knowledge of the musculoskeletal system and physical rehabilitation disciplines/technique which I agree with. Here I am reading the literature and trying to understand what it is that you do and I'm always met with a "stay in your lane" mentality. I talk with therapists all of the time so please don't put me and "some of my cohort" in the box of being closed minded, know-it-all physicians. I would hope that PTs and other providers alike would seek us out since we are likely to be good team players.

Lastly, I don't think that a single physician would claim to know how to practice physical therapy. However, we are in a system where patients have to go through physicians. Is it perfect? Nope. Is anything perfect? Nope. Don't hate this educated player. Hate the game. FYI...physicians have games to play too...as does everyone else.

 

[cbest]

So no PT protocols available for review to anyone's knowledge. Just wanted to make sure I wasn't missing something in my own search.

 

[fozzy40]

So no PT protocols available for review to anyone's knowledge. Just wanted to make sure I wasn't missing something in my own search.

Oh yeah! The original question...It doesn't sound like it bud Are you trying to create a protocol for your research project?

 

[truthseeker]

Many but not all of us

I agree with how you treated and educated this patient not that you need validation from this physician that doesn't know anything

Just out of curiosity, what did they want you to MFR specifically? What was their protocol?

They didn't specify. Their hearts were in the right place but I think they just wanted to give the guy something. I think they wanted me to rub his back.

BTW, I didn't say that I didn't want input from the physicians, that was someone else. Physicians certainly know many, many things that we PTs don't. However, some don't realize that PTs are really specialists. What I want from them is to tell me what not to do. I don't read many journal articles on the different ways to manage, for example, liver disease. What is important for any professional to realize what they don't know and get the client to the person that does. That applies to every profession, from healthcare to plumbers, landscapers, and demolition companies.

 

[truthseeker]

So no PT protocols available for review to anyone's knowledge. Just wanted to make sure I wasn't missing something in my own search.

Sorry to kidnap your thread. I guess my point is that I don't know of one, and if there is one, it probably isn't any good.

What might be interesting is a decision algorithm to direct the caregivers toward making the best decision about how to treat troch bursitis rather than relying on protocols. That is how I would like our professions to evolve.

If blank, then blank. If not blank, then blank. Or something like that with a bunch of boxes with arrows.

 

[fozzy40]

They didn't specify. Their hearts were in the right place but I think they just wanted to give the guy something. I think they wanted me to rub his back.

BTW, I didn't say that I didn't want input from the physicians, that was someone else. Physicians certainly know many, many things that we PTs don't. However, some don't realize that PTs are really specialists. What I want from them is to tell me what not to do. I don't read many journal articles on the different ways to manage, for example, liver disease. What is important for any professional to realize what they don't know and get the client to the person that does. That applies to every profession, from healthcare to plumbers, landscapers, and demolition companies.

Oh, I know you didn't say or imply that. It was a directed at other posters on the thread.

 

[Fiveoboy11]

Oh, I know you didn't say or imply that. It was a directed at other posters on the thread.

So fozzy...

What is your input with regard to greater trochanter bursitis? Is there anything you would like to educate us on? Particular interventions provided by someone such as yourself or any thoughts in general?

 

[fozzy40]

Well, I doubt that I will educate physical therapists on greater troch bursitis. But, I can give you my perspective/approach.

Greater trochanter bursitis (in my opinion) is usually often the "victim" not the "perpetrator." Determining the "perpetrator" is the key. I typically look up and down the kinetic chain and focus most often on a couple things: a flexed hip/spine, foot arches, and leg length discrepancies. The main treatments I recommend patients are PT and education. Things I've found effective in terms of treatment include aggressive ITB release (I typically tell the patient it should hurt), hip ABDuctor neuromuscular re-training, and proprioceptive exercises. I think education is a big piece of the puzzle. As we all know, greater troch pain is tough to treat and often comes back. I'm very upfront with my patients and tell them that any treatment is management and not a cure. I explain to them that like most MSK things, they get better but they do come back. So I expect them to approach it that way. It's my way of managing their expectations.

From a medical perspective, treatment is usually driven by how severe their symptoms. If they are in excruciating pain, not able to sleep, etc, I will lean towards doing a cortisone injection targeting the bursa. Otherwise, it's a trial of oral NSAIDs or topical if they can't tolerate orals. I've seen some people get imaging and the radiologist comments on glut med tendinosis. I'm not typically impressed by that radiological finding unless they actually have tenderness at glut med. People are doing prolotherapy, platelet rich plasma therapy, cortisone injections at the glut med origin. I would consider this but it's typically low on my treatment plan. I have seen lateral femoral cutnaneous neuropathies and L5 radiculopathies masquerade as greater trochanter bursitis as well.

I'm tend to be pretty conservative and will inject a patient maybe 10% of the time. I find that the right therapist alone will achieve good results 85% of the time. The other 5% need NSAIDs plus therapy.

 

[Fiveoboy11]

That actually was educational...

But I have a follow up question. I mentioned above that in my opinion greater trochanteric bursitis is associated with obesity. Why aren't many of these people set up on a medically supervised weight loss program? Are they not interested? Is it often contraindicated? Are there not many options as far as this goes? I thought there were FDA approved Rx for weight loss but maybe I'm wrong.

You mention that we're looking for the perpetrator and I definitely agree with that. Seems to me that that the perpetrator is obesity often times, resulting in functional weakness, resulting in tendonitis/tendonosis of ITB/glute med/min/TFL and/or bursitis. So, shouldn't we focus on wt loss?

 

[fozzy40]

Weight loss is I think a key factor in everything: musculoskeletal, emotional, psychological, cardiovascular, etc.

The 2 problems I run into in the clinic when it comes to weight loss are 1) it's a tough subject to bring up and 2) people don't often want to hear it. Even when I do, patient's will often say "how can I lose weight when I can't exercise because of XYZ pain." It's true, how can I expect them to get their heart rate up when it hurts to stand? I usually tell them that I want to get them physically active first, decrease their pain symptoms, focus on sleep, and then re-evaluate. Because weight loss is loss process, I usually don't set that as a primary goal for symptom control initially for the patient. Maybe as a long term goal that can help prevent recurrence. I take this approach again to help manage the patient's expectations. I don't want them set a unrealistic short term goal and then get discouraged.

But absolutely, I agree that weight loss is a big issue that should be addressed. It's tough though. I continue to struggle with pitching it to a patient and having them listen to my reasons. I'll keep trying though!

 

[facetguy]

That actually was educational...

But I have a follow up question. I mentioned above that in my opinion greater trochanteric bursitis is associated with obesity. Why aren't many of these people set up on a medically supervised weight loss program? Are they not interested? Is it often contraindicated? Are there not many options as far as this goes? I thought there were FDA approved Rx for weight loss but maybe I'm wrong.

You mention that we're looking for the perpetrator and I definitely agree with that. Seems to me that that the perpetrator is obesity often times, resulting in functional weakness, resulting in tendonitis/tendonosis of ITB/glute med/min/TFL and/or bursitis. So, shouldn't we focus on wt loss?

How deeply into weight loss matters do PTs generally go? Many of your patient's are in your office for a short time, so I'm thinking you don't get much chance to get into weight loss with them.

 

[Fiveoboy11]

Weight loss is I think a key factor in everything: musculoskeletal, emotional, psychological, cardiovascular, etc.

The 2 problems I run into in the clinic when it comes to weight loss are 1) it's a tough subject to bring up and 2) people don't often want to hear it. Even when I do, patient's will often say "how can I lose weight when I can't exercise because of XYZ pain." It's true, how can I expect them to get their heart rate up when it hurts to stand? I usually tell them that I want to get them physically active first, decrease their pain symptoms, focus on sleep, and then re-evaluate. Because weight loss is loss process, I usually don't set that as a primary goal for symptom control initially for the patient. Maybe as a long term goal that can help prevent recurrence. I take this approach again to help manage the patient's expectations. I don't want them set a unrealistic short term goal and then get discouraged.

But absolutely, I agree that weight loss is a big issue that should be addressed. It's tough though. I continue to struggle with pitching it to a patient and having them listen to my reasons. I'll keep trying though!

Good points, it definitely is a sensitive issue. I don't exactly state it bluntly to people when I feel it is a good component to the POC (wt loss exercise). I usually will encourage low grade, low impact cardiovascular exercise, i.e. recumbent bike, pool exercise. Perhaps explanation to patient's about functional weakness and joint forces would allow them to put it together on their own, I'm not sure. Sometimes the patient will even initiate the fact by noting recent wt gain or how they know they need to lose weight. At that point I'll usually ask if they have a weight loss goal and how much they would like to lose. Then I will definitely correlate it to their presenting complaints if it is related.

 

[Fiveoboy11]

How deeply into weight loss matters do PTs generally go? Many of your patient's are in your office for a short time, so I'm thinking you don't get much chance to get into weight loss with them.

Most not very deep, including myself. The guidelines for knee OA strongly suggest considering wt loss exercise if obesity is a factor (level A evidence), and it seems to be quite common in LBP, hip OA, posterior tibial dysfunction..

I do not think it is typical for a PT to get involved with wt loss exercise in terms of the psychological impact and/or direct cardiovascular risk factors. But we should get a lot better at that. There are obvious benefits of the mood elevating effects of exercise, which I always educate patients on if they have comorbid anxiety/depression/chronic stress.

I'm fairly sure there are PT's who work in nearly exclusive bariatric clinics, and I know of a few who have wt loss programs.

 

[cbest]

Oh yeah! The original question...It doesn't sound like it bud Are you trying to create a protocol for your research project?

A sports med doc at my hospital and I are trying to create a research project comparing a couple different approaches to GTPS. She finds that some pts with chronically inflamed GT bursitis and/or hip abductor tendinopathy seem to respond better with more passive vs active approaches and we want to try and tease out which approach is better (if there's any difference at all).

All the articles I read mentioned PT under the conservative treatment portion but none dove into the specifics.

 

[fozzy40]

A sports med doc at my hospital and I are trying to create a research project comparing a couple different approaches to GTPS. She finds that some pts with chronically inflamed GT bursitis and/or hip abductor tendinopathy seem to respond better with more passive vs active approaches and we want to try and tease out which approach is better (if there's any difference at all).

All the articles I read mentioned PT under the conservative treatment portion but none dove into the specifics.

Cool! How are you validating bursitis and/or tendinopathy? US? MRI? Share if you feel comfortable

 

[cbest]

Likely going to use previously documented diagnostic criteria for GTPS (forget the authors of article off the top of my head)

 

[truthseeker]

A sports med doc at my hospital and I are trying to create a research project comparing a couple different approaches to GTPS. She finds that some pts with chronically inflamed GT bursitis and/or hip abductor tendinopathy seem to respond better with more passive vs active approaches and we want to try and tease out which approach is better (if there's any difference at all).

All the articles I read mentioned PT under the conservative treatment portion but none dove into the specifics.

It comes down to the concept of relative rest. Its tough, but you have to find the level of activity that is just a bit less than the level that provokes an inflammatory response. then you gradually increase it from there. Passive treatments to reduce inflammation are helpful but the patient needs to reduce the excessive loads, and learn to keep them reduced. Sometimes its weight loss, sometimes it is improved motor control, sometimes it is strength, sometimes it is LLD, sometimes it is their bed, sometimes its actually referral pain from the spine, sometimes they have horrible feet that tilt their hips into adduction, sometimes its crappy shoes or too many miles, sometimes its tight ITB, but usually it is a combination of some or all of the above.

Tough one to crack with a protocol. Same with patello-femoral syndrome, similar potential mechanical causes.