ABSTRACT
Background and Purpose: Lateral hip
pain is of high prevalence in the orthopedic
physical therapy setting. The purpose of this
case study was to determine correct and valid
clinical tests to aid physical therapists in dif-
ferentially diagnosing between trochanteric
bursitis and gluteal tendinosis. Methods: A
detailed literature search was conducted to
determine valid clinical tests that will aid
physical therapists in better differentially
diagnosing lateral hip pain pathologies. Find-
ings: The 5 valid clinical tests found included
single limb stance, hip lag sign, Ober’s test,
resisted abduction, and isometric abduction.
Clinical Relevance: By performing these 5
valid clinical tests, physical therapists can
better narrow down the hip structure of con-
cern; therefore, decreasing pain, increasing
functional ability, and improving quality of
life. Conclusion: There is a need for addi-
tional studies addressing the implementation
of these 5 clinical tests and their effects on
proper diagnosis among patients with lateral
hip pain.
Key Words: clinical testing, muscle strain,
validity
BACKGROUND AND PURPOSE
Lateral hip pain, more commonly referred
to as greater trochanteric pain syndrome
(GTPS), is frequently seen in the orthopedic
physical therapy setting; however, there have
been a plethora of causes identified for lateral
hip pain.1,2 Trochanteric bursitis, iliotibial
band (ITB) friction, gluteal tendinosis, and
gluteal tears are the more common diagnoses
that encompass GTPS, with approximately 2
patients per 1000 each year being affected.3-5
Greater trochanteric pain syndrome is more
prevalent in women than men with a 4:1
ratio, especially between the fourth and sixth
decades of life.1,3,6 Due to the complexity
of the hip joint and surrounding anatomy,
differential diagnosis of lateral hip pain can
often be difficult, specifically between tro-
chanteric bursitis and tendinosis.1,2,6,7
The hip is a ball and socket joint with 3
degrees of freedom.8 The 4 muscle groups
providing motion at the hip include gluteal,
anterior, posterior, and medial. Greater tro-
chanteric pain syndrome typically focuses
on disorders of the gluteal region of the hip
and the structures commonly affected are
gluteus medius and minimus and the ITB.8,9
Due to its shape and location, the gluteus
medius muscle is often the most suscep-
tible to injury.6 It is a fan shaped muscle,
with proximal attachment on the external
surface of the ilium and a distal attachment
on the lateral surface of the greater trochan-
ter8,9 but more specifically to the superior-
posterior and the lateral facets of the greater
trochanter.5 The gluteus medius contributes
to internal rotation and is the prime abduc-
tor of the hip, responsible for keeping the
pelvis level during gait, running, and single
leg activities.4
Other anatomical structures may also
contribute to the lateral hip pain such as
bursae, which are membranous, fluid filled
sacs, located in areas between bony promi-
nences and soft tissues to act as a gliding
interface and provide cushioning during
friction.3-5,9 According to Woodley et al,1
when referring to the trochanteric bursitis,
there are thought to be 8 bursae that could
be the origin of pain in the lateral hip. Of
those 8, the most common bursae involved
in trochanteric bursitis are the subgluteus
medius, the subgluteus maximus (trochan-
teric), and the subgluteus minimus bursae.10
The subgluteus maximus bursa is the larg-
est and located superficially to the posterior
facet of the greater trochanter and the lateral
insertion of the gluteus medius tendon,5,10
whereas the subgluteus medius bursa is
located deep to the gluteus medius tendon,
and the subgluteus minimus bursa is located
over the anterior facet of the greater trochan-
ter, deep to the gluteus minimus tendon.10
Due to the close proximity of numerous ana-
tomical structures, irritation of the bursae is
common.
Trochanteric bursitis has been defined
as inflammation of the bursa, which can be
caused by repetitive action causing friction
over the bursa or acute trauma to the sur-
rounding muscles and tendons.9 Trochan-
teric bursitis is the most common diagnosis
for patients with complaints of lateral hip
pain.1,3,4,6 The common presentation of tro-
chanteric bursitis is a dull, aching pain, with
tenderness around the greater trochanter and
radiation of pain along the lateral thigh.1,5
Conservative treatment and corticosteroid
injections have been shown to be effective in
90% of people diagnosed with trochanteric
bursitis.3 Unfortunately, the pain pattern
and presentation of trochanteric bursitis is
not unique, making it hard to differentiate
between this and other disorders, especially
tendinosis.
Tendons are comprised of 95% Type I
collagen fibers and are responsible for distrib-
uting forces across joints, stabilizing joints,
and aiding in body movement.11 Tendinosis
refers to a degeneration of the tendon’s col-
lagen over time.11,12 Within the lateral hip,
tendinosis and tears most commonly affect
the gluteus medius. Over the last decade,
research has shown an increasing number of
cases of gluteal tendinosis and tears.11 Due
to common misdiagnoses and the umbrella
term GTPS, it is unclear from the litera-
ture exactly what the incidence of gluteus
medius tendinopathies may be. According
to Woodley et al,1 the prevalence of gluteal
tendon pathology is variable, ranging from
25.7% to 83.3%, making it one of the most
common causes of lateral hip pain and the
most common of tendinopathies in the lower
extremity.5
Tendinosis onset is often insidious,
worsening over time; however, it can also
occur following a fall or a forceful contrac-
tion.6 Tendinosis and bursitis share the same
common symptoms of pain and tenderness
along the greater trochanter.3,5,6,9 Tendinosis
does not typically present with inflamma-
tion; therefore, cortisone injections are often
unsuccessful.5,6,11 The most common activity
limitations associated with gluteal tendinosis
are rising to stand or walking after sitting,
sleeping on the involved side, single leg stance
activities, and climbing stairs.5 Patients often
show increased weakness in abduction and
may develop a Trendelenburg gait pattern.5,6
Tendinosis could ultimately result in partial
or even full-thickness tears if untreated or not
detected soon enough, making conservative
therapy an insufficient measure.6,11,12
Differential Diagnosis for
Management of Lateral Hip Pain:
A Case Report
Kristen Simeone, PT, DPT
Jason A. Craig, PT, DPhil
Department of Physical Therapy, Marymount University, Arlington, VA
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