Functional Rehabilitation for Greater Trochanteric Pain Syndrome: Thinking Beyond Traditional Isometrics and Isotonics (Physician Update, August 2023)

[Peak PT Administrator 0]

Peak Performance Physical Therapy & Sports Training

 

EVIDENCE-BASED PRACTICE UPDATE

(August 2023)

 

Functional Rehabilitation for Greater Trochanteric Pain Syndrome: Thinking Beyond Traditional Isometrics and Isotonics

by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst

 

Clinical Scenario - What would you do?

Your patient comes into your clinic with complaints of localized hip pain and tenderness at the greater trochanter.  They have an overall reduction in function and ADL ability due to pain with weight bearing activities as well as side lying and certain sitting positions. You’ve assessed the problem and concluded the patient has greater trochanteric pain syndrome (GTPS). 

My clinical thinking is…

A.            Tell them to rest and restrict activity while taking N-SAIDS for pain relief?

B.            Prescribe generic physical therapy for hip strengthening with basic and nonfunctional isometric and isotonic exercises?

C.           Refer them to an orthopedic specialist for possible imaging and cortisone injection?

D.           Order specialized physical therapy with focus on assessing underlying biomechanical pitfalls and treating with indicated functional mobility and strengthening (nwb/wb) and Class IV laser?

 

CURRENT EVIDENCE

Clifford, Christopher, et al. "Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study." BMJ open sport & exercise medicine 5 (1):  1-9, (2019) http://dx.doi.org/10.1136/bmjsem-2019-000558

 

SUMMARY:  

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain affecting up to 24% of females and 9% of males aged 50-79 years of age.  GTPS involves pathology of the gluteus medius and minimus tendons and less frequently the trochanteric bursae.  The authors sought to determine the effectiveness of isotonic and isometric exercises for individuals with GTPS.  Primary care physicians and orthopedists are likely the first contact for diagnosis and treatment recommendations for this condition.  Various treatment options can be utilized for treating this pathology ranging from rest from activity with or without NSAID and traditional physical therapy treatment for strengthening the lateral hip muscles, specifically the gluteus minimus, medius, and maximus.  PCP’s also may consider referral to an orthopedist for further assessment.  Considerations include cortisone injections and possible imaging to determine severity of the condition and how much involvement of the GT bursae vs. possible tendon tears of the medius and minimus.  

Clifford et al examined the effectiveness of isometric and isotonic strengthening of the lateral hip complex as a means of treatment for GTPS.  Although the results of the study do report that reduction of pain and self-reported functional ability increased in the subjects, we must be careful to NOT take this study as “best practice” for conservative treatment of GTPS.  For some, this study may provide low level “evidence” to include these exercises in the treatment plans; however, as professionals we must also appreciate what was not studied.  Simple and traditional strengthening isometric and isotonic exercises, while physiologically stimulating the local involved tissues,  do not specifically treat biomechanical pitfalls that have subsequently resulted in this condition.  We propose an approach that, while including appropriate isometric, isotonic, concentric and/or eccentric emphasized exercise stimuli of the local involved hip muscles, also focuses heavily on finding and identifying potential or likely causative factors.  The fact that lateral hip tissues were overloaded and ultimately “failed” does not in any way mean exclusively that they were at fault or weak/insufficient.  Other factors such as leg length, ipsilateral or contralateral lower extremity asymmetries, including things like asymmetric anteversion or overpronation but also asymmetric ADL/work/sport postures and body mechanics all could be causative of the otherwise normal hip’s overload.  Treating only the “symptom” of the overload may temporarily be effective but misses the mark in the long term.  

 

(We’d love to hear your professional insights on this topic.  Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss)

Background:   GTPS is a common diagnosis of lateral hip pain consisting of possible tendinopathy of the gluteus minimus and/or medius, and less frequently the greater trochanteric bursae.  Limited evidence exists when comparing isometric and isotonic exercises for treatment of GTPS to determine what best practice may be.

Methods:   This pilot study consisted of 30 individuals with GTPS separated into 2 groups.  Subjects were separated into 2 groups and prescribed either isometric or isotonic progressive home exercises for 12 weeks with 8 individual physical therapy sessions.  Results were documented primarily using the Victorian Institute of Sports Assessment-Gluteal (VISA-G), the Numerical Pain Scale Rating (0-10), and an 11-point Global Rating of Change Scale.

Inclusion criterion required participants to be >or equal to 18 years old, lateral hip pain >3 months, sx with direct palpation, and one other of 5 provocative pain tests described by Grimaldi et al. Exclusion of participants if they had physical therapy within 6 months of study, cortisone INJ if past 3 months, unable to ABD hip in side lying, Sx with scour testing and XR showing OA, and had previous hip/spine surgery within 12 months.

Treatment of both isometric and isotonic exercise began with no external resistance before progressing to “progressive therapeutic bands” individualized working intp a pain scale up to 5/10 as long as Sx eased after.  

Isometric - non-weight bearing (NWB) sidelying hip ABD to 30 deg then held for 6x30sec with 60s rest between.  WB exercise consisted of moving opposite LE through ABD/ADD 3x10 repetitions with isometric holds of gluteal muscles.  Time under tension (TUT) where time of which tendons were held under load was 6 min daily.  

Isotonic - NWB side lying hip ABD raising to 30 deg then returning to midline.  WB hip ABD slide where the affected leg slid into ABD and returned while holding anteriorly for support with bilat UEs.  Non-affected hip allowed to flex knee to 45 deg during activity.  Both Ex 3x10 with 6 sec duration (3s eccentric and 3s concentric) with TUT 6 min daily.  

Simple analgesia was allowed at home but participants were asked to refrain from other means of sx relief.

Findings:  Out of the 30 participants starting the trial, only 23 completed the 12 week trial.  Outcome measures were taken at baseline, 4 weeks, and 12 weeks. VISA-G was the primary outcome measure with secondary measures of numeric pain rating scale (NPRS), global rating of change (GROC), pain catastrophizing scale, hip disability and OA outcome scale, The Euro QoL, and lastly the International Physical Activity Questionnaire Short Form.

Both groups had similar progress in VISA-G, NPRS, and GROC, although not all participants did not meet MCID.

NPRS- 55% isometric and 58% isotonic reached MCID at 12 weeks

GROC- 64% isometric and 75% reached MCID at 12 weeks

All other questionnaires showed no significant difference between both groups and had minimal changes.

Author's Conclusion:  Compliance of HEP completed 50% or so of daily HEP and 70% isometric and 58% isotonic participants attended 80+% of physical therapy sessions.  MCID was met for both groups for VISA-G, NPRS, and GROC. Both programs show improvement in function and pain however no statistical differences exist.  

 

THE PEAK PERFORMANCE PERSPECTIVE

Although this study claims that there were improvements in pain and “function” when utilizing both isometrics and isotonic exercises for lateral hip strengthening in GTPS, a deeper dive into the evidence would show the multiple limitations of this study that may go unnoticed with an abbreviated glance looking at the results and conclusions reported on the abstract.  For perspective it must be remembered first what was studied and what was not studied.  

There was no control group to compare exercise with which calls to question whether individuals who went on with ADL etc. for the same duration of the study might also show both reduction in pain and improvement in function simply through natural history.  The total number of subjects starting the study was 30, and at the conclusion only 23 remained.  Both isotonic and isometric exercise showed improvement in the NPRS scale and increased function per GROC scale greater than the MCID, however less than 60% of subjects reached the MCID.  Regarding functional improvements, at 4 weeks both groups had less than 50% of subjects statistically improving and at 12 weeks 64% and 75% of subjects had increased function for isotonic and isometric respectively.  Most importantly, the types of exercises studied were limited to a single WB and NWB option for each group, without objective data acquired demonstrating improved strength of the lateral hip musculature which is the point one would perform strengthening exercises.  Although the study sought to define whether isotonic and isometric exercises would help patients with GTPS, no objective data regarding strength was reported, so how can we infer that improved strength would improve symptoms?

Primary care more often and orthopedic physicians are often the first line of providers assessing patients for GTPS to make appropriate treatment recommendations including the referral to skilled physical therapy.  Given the choice between standard abductor exercises and a biomechanical functional treatment plan, the former may be the most common choice, however, the latter biomechanical approach at least attempts to  both identify root causes rather than symptoms only and also considers authentic biomechanical demands with strengthening progression drills.  The intention would be to create the smallest “leap of faith” from the body’s exercise stimulus in PT to the real-world demands of ambulation, ADL, work, and sport/recreation possible.

Why strengthen someone’s hip primarily with static isometric NWB exercises when that individual needs to improve their ability of locomotion?  It would be prudent to not accept the article above as “best practice” for treating lateral hip pain when the study does not provide its subjects with any functional exercises despite measuring function as one of its primary outcomes assessed.  Subjects were asked to perform both NWB and WB “strength” exercises however the thoroughness (ie compliance) of completing the exercises on to the level prescribed and progressions of loading (self-determined but the subject via band color) were primarily on the individual and their home exercise program with minimal assistance from a therapist 8 sessions in total.  

Specific parameters were advised by the therapist in terms of side lying leg raises to approx 30⁰ and completed for a total time under tension (TUT) of 6 minutes.  Isotonic exercises included 3x10 reps with timed concentric and eccentric directives.  Left to their own devices, individual subjects were asked to complete exercises without professional assistance for form and technique reported both compliance and noncompliance.  100% of those who completed their exercise diaries and completed more than 50% of daily exercise.  Only 70% of the isometric group completed 80% of in person sessions compared to only 58% of isotonic subjects limiting the ability to provide appropriate feedback to exercise technique. 

The authors may have failed to isolate the glute medius and minimus during WB isotonic slides as the affected LE was asked to slide laterally with load as the stationary unaffected leg bent to 45⁰ deg flexion at the knee.  Despite the claims of this to emphasize lateral hip stimulus, assessing where center of mass is and joint positioning during activity creates an abductor moment controlled primarily with pelvic adductors and not the abductors for both eccentric and concentric return.  Understandings like this are paramount in accelerating return to functional capacity as it acts to more effectively stimulate the muscles needed to increase strength and load accepting forces through locomotion.  The lack of assessment of other potential biomechanical pitfalls that have contributed to the onset of GTPS should be addressed when designing an individualized rehabilitation program.  The “simple” exercises studied by Clifford et al. may be hurting the PT population if prescribed by a provider advising to rest and do common leg raises or single leg stance drills.

The incidence of GTPS can increase due to overloading the demand or stress of the lateral hip as it functions to accept load bearing forces.  Hip Abductors and external rotators have to eccentrically decelerate hip adduction and internal rotation upon impact of the lower limb.  The control of dynamic valgus at the knee can be addressed through strategic exercise planning to attack the problem from the adjacent hip and ankle.  Weakness of the glute med/min may not decelerate the femur effectively through loading of the limb; however the foot may exhibit overpronation either from biomechanical faults of the joint unlocking the midfoot excessively in WB without poor deceleration by the posterior tibialis.  If the foot/ankle complex fails to control dynamic valgus at the knee, the lateral hip must take up larger stress demands than necessary contributing to the onset of GTPS.  Leg length discrepancy is another possible contributor to strain on the glute medius and minimus as a larger hip adduction moment is necessary to drop the contralateral pelvis down so that the shorter leg may accept body weight during functional mobility.  A tight IT band can also provide increased stress and friction to the greater trochanter and bursae commonly seen with individuals with GTPS.  

Skilled functional rehabilitation can identify these underlying factors that can increase the stress on the lateral hip tendons and bursae.  Simply completing NWB abduction leg raises and single leg stance or lateral slides may improve pain in a limited studied population but effectively identifying kinetic chain factors resulting in hip Adduction and/or IR overload as well as 3D methods of authentically loading/strengthening not only the affected hip but also those contributory segments is key to both a successful short term and long term recovery.

THE PEAK PERFORMANCE EXPERIENCE

Jacqueline said: “I ran this morning and it felt totally fine!”

History: Pt is a 51 y.o. female who is an avid runner with 4 workouts a week up to 4 miles at a time.  She presents with L hip trochanteric bursitis and dual small labral tear, contributing to deep anterior hip pain, but which the orthopedist does not think there is any alarm for concern.

Subjective: Pain reports unable to run along with severe discomfort while sitting with pain at worst rated a 6/10 at lateral hip with self-functional rating of 60% out of 100% baseline.  Lower extremity functional questionnaire (LEFS) scored 58% functional.

Objective:   

(*=pain)	Initial Eval	Re-Eval
Pelvis and leg length	L LE long leg (high trochanter)  with posterior rotated innominate	Corrected with small lift under RLE and SIJ muscle energy techniques with reduction of anterior hip pain
Hip flexion PROM	115/130 (88%)	123/134 (92%)
Isometric hip flexion	22.4kg/25.7  (87%)	22.3/22.3 (100%)
WB DF (STJn)	11/16 (69%)	20/18 (111%)
SL Squat (knee flexion deg.)	60/69 (87%)	65/70 (93%)
SLB rotation	Minimal INCR pronation	INCR control pronation into supination
Anterior hop 2x	INCR femur IR (dynamic valgus)	Reduction but still present dynamic valgus
Isometric Abduction Supine	14.0/11.5 kg	26.1/21.2

Key Findings: Upon evaluation, pt presented with a  longer left leg length discrepancy contributing to INCR stress and demand of the lateral hip complex to control WB hip ADD upon impact when running -  this was corrected with a heel lift.  ITB tightness was greater on LLE than RLE.  SIJ dysfunction was also present and anterior hip pain subsided following osteopathic muscle energy techniques to correct for her asymmetrically.  Reduced DF can produce compensatory overpronation leading to INCR dynamic valgus that mutually produces excessive hip ADD/IR, increasing strain on gluteal muscles to decelerate impact on the left LE.  Weakness noted in the LLE via SL squat testing for depth.

Treatment: Correction of the LLD with heel lift and corresponding pelvic “correction” via manual then self-muscle energy techniques.  Ankle DF ROM improved with functional manual reaction (FMR) to improve talocrural joint mobility in a STJn position and reinforced with self gastroc and soleus stretching.  IT Band flexibility promoted in WB to reduce lateral hip tension.  Hip flexion PROM improved with self stretching NWB.  Left hip abductors (minimus and medius) strengthened initially with NWB lateral leg raises due to pain with WB before transitioning to WB anterior slides with the nondominant  moving anterior.  This promotes the LLE transitioning from initial impact in hip flexion progressing to extension before take off with focus on maintaining L hip position controlling hip ADD.  Increased lateral hip strengthening in SL stance with anterior/posterior RLE marches to stimulate running stress of LLE.  Care taken with all WB hip drills to improve dynamic valgus control as pt had poor tolerance to resisted ECC hip external rotator stimulation secondary to Sx.  SL squatting improved via single leg squatting with glute emphasis via hip flexion moments to aid in control of dynamic valgus with INCR external rotators in the sagittal plane.  SLB resupination/pronation control addressed with toe tapping with RLE with LLE IR/ER movements with modifications initially maintain a neutral to supinated position before advancing to controlling pronation to supination experienced at initial contact/impact on landing and progression of gait cycle to a rigid and supinated and locked on midfoot. 

Outcome: Upon reevaluation, the patient's lateral hip pain had dropped from 6/10 to 2/10 and was deemed more tightness than sharp.  Pt was able to resume running from 1.5 to 3 miles without Sx whereas before she had to cease running altogether.  Self FNXL rating improved from 60% to 70% and LEFS questionnaire from 58% to 86%. Anterior hip pain had improved much, reducing Sx while sitting and was attributed to correction of leg length discrepancy and pelvic asymmetry in the sagittal plane.  Pt did undergo a cortisone injection after reevaluation due to concern she had of improvement however not eliminated Sx and reported to PT further reduction of pain to negligible afterwards.

 

 

You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals.

Call us at 218-0240 to discuss your patient's specific needs.  

Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester.  

We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients.  No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. 

No surprises. No hassles. Confident your patient is in the right place. 

 

COME VISIT US AT

161 E Commercial St

Just 1 mile off 490 exit

(585) 218-0240

 

www.PeakPTRochester.com