Shockwave therapy for Greater Trochanteric Syndrome

What is Greater Trochanteric Pain Syndrome (GTPS)?

Greater trochanter pain syndrome (GTPS) is an often-overlooked painful overuse sydrome that presents with ongoing pain in the lateral hip region in the region of the trochanteric bursae, of which there are 3.  The condition is commonly referred to as trochanteric bursitis although radiographic images of the region often highlight involvement of other tissues, which are anatomically in proximity to the bursal structures.  The main tissues that are actually affected during this condition appear to be the tendons of the gluteus medius and minimus, which in some cases may be torn or may have undergone degenerative changes.
There is some diagnostic value in obtaining images of the trochanteric bursae region to differentiate the tissues affected and rule out frank tearing of the tendons and peri-tendinous structures.
More commonly GTPS is more frequently found in women than men, and typically occurs during the ages of 40 to 60 years.  This is thought to be related to biomechanical factors affecting the pelvis and lower limb.  Several studies have correlated same side knee, opposite side knee and same side iliotibial band tenderness with the condition, highlighting the biomechanical factors affecting the presentation.
The pain from greater trochanteric pain syndrome may be well localised or may radiate into the posterior/lateral aspect of the thigh/hip and usually increasing with activity.  The pain may increase when laying on the painful side due to direct pressure on the area and therefore the sufferer may complain of night pain resulting from inflammation and compression of the region.
The greater trochanteric region is often tender to touch and will often become more painful once the muscles in that region are activated.  The glute medius and minimus and TFL muscles are highly activated during single leg stance and so this is often used as a method of screening the tendons for pathology.
There are currently several standard treatments which are useful in the management of greater trochanteric pain syndrome.  These include;
  1. Physiotherapy
  2. Ice/Heat
  3. Correction of faulty movement patterns
  4. NSAID’s
  5. Corticosteroid injection
  6. Shockwave therapy
  7. Surgery

How is shockwave therapy applied to the area?

Shockwave therapy for Greater trochanter pain syndrome is applied following a set protocol.  The clinician will carry out a thorough case history taking which isolates the area that is painful and begins to understand the clinical history behind the condition.  It is important to make sure that the condition being treated is actually a Greater trochanter pain syndrome and is therefore treatable with shockwave therapy.
During the examination period a tender point where the pain is maximal will be located, upon which a water-based medium will be applied.  This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your Greater trochanter pain syndrome will begin.  At first the clinician will ensure the discomfort is kept to a minimum.  After a while as the impulses increase little pain is felt.  Although, more often than not there is some pain felt over the area of application.  After treatment you should feel very little pain and this may last for a few days.  After then an aching sensation can occur.  After subsequent treatments there will be a definite improvement in symptoms leading to reduction in the original pain felt.

 

How long will shockwave therapy take to work?

Generally most applications of shockwave for Greater trochanter pain syndrome and most conditions will resolve within 3-4 sessions of 30 minutes (roughly).  This obviously can depend on the exact presentation of the condition.  Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.
It is vital that you continue to work with a physical therapist to maintain the exercise regime you should already be carrying out for Greater trochanter pain syndrome, prior to consulting for shockwave treatment.  This will involve balancing exercises, strength exercises and a good eccentric loading programme depending on your stage of Greater trochanter pain syndrome.

What is the evidence for shockwave therapy and this condition?

Greater trochanteric pain syndrome has been studied in relation to the alternatives to shockwave therapy.  One study (Rompe 2009) focussed on the efficacy of steroid injection vs shockwave therapy for GTPS vs home training regimes.  Results showed that although at 1-month steroid injection was the clear treatment of choice, looking longer term (4 months +) the treatment modality which performed the best was the extracorporeal shockwave therapy.  At 15 months the outcomes showed that radial extracorporeal shockwave therapy and home training were comparable with home training having less reported side effects.
Furia et al (2009) reported clinically significant effects from the use of extracorporeal shockwave therapy for the management of greater trochanteric pain syndrome. Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shockwave therapy than in the control group (P < .001).

Where can I get shockwave therapy for this condition?

 

One is able to get shockwave therapy at a few specialist clinics in the UK.  There are a growing number of clinics providing this specialist form of treatment.  It is beneficial to make certain the type of machine they use is a swiss dolor clast machine as this is the only one that has been tested to high level in research papers.
At Pefect Balance Clinic we often see people with different types of Tendinopathy who have tried other forms of treatment.  Shockwave for us has been the one form of treatment that has consistently delivered results for Tendinopathy.

How long will the treatment last for?

If everything goes to plan with your shockwave therapy for Greater trochanter pain syndrome then the treatment should make a significant contribution to reducing the pain and improving the function of your Greater trochanter pain syndrome.  In most cases the shockwave will get rid of the patellar tendinitis.
With some tendon surgery there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result.  Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.

Conclusion

Greater trochanteric pain syndrome (GTPS) can often be confused with trochanteric bursitis and can be misdiagnosed.  A clear understanding of the pathology of GTPS is important to help in the diagnosis and future management of GTPS.  Once a clear diagnosis is made the treatments are likely to be conservative and biomechanical to address risk factors which have caused the condition to come about in the first instance.
Whilst steroid remains the treatment of choice for short term relief (<1 month) it is clear that addressing the biomechanical factors and using extracorporeal shockwave therapy give much better results in the medium to long term follow up for the condition.  More reach into the area should be carried out to ascertain which particular biomechanical factors cause potential risk factors for GTPS.

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