Greater trochanteric pain syndrome: pathology, assessment and management

Submission note: A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy to the Department of Rehabilitation, Nutrition and Sport, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora.

This thesis presents a series of research projects that underpin the method used in the final clinical trial featured, a randomised controlled trial (RCT) investigating the effects of exercise and education in post-menopausal women with greater trochanteric pain syndrome (GTPS). Initially a systematic review was completed to identify the effects of hormone therapy on molecular, morphologic and mechanical elements of tendon. As there were no clear conclusions, it was deemed appropriate to trial menopausal hormone therapy in a clinical trial. Following this, assessment procedures for diagnosing GTPS were established. A gluteal tendon specific questionnaire (VISA-G) was formulated and assessed as being a reliable and valid score for measuring the severity of disability associated with GTPS. Thus, the VISA-G was chosen as a primary outcome measure for the final RCT. Furthermore, a diagnostic test study was completed to identify appropriate tests to use in the clinical assessment of this condition. Findings of this study guided a more efficient approach to clinical assessment of participants for inclusion in the RCT. Participants were required to have positive reproduction of their greater trochanteric pain in at least three out of the five following tests: palpation of the greater trochanter, FABER test, Trendelenburg/single leg stance test, standard external de-rotation test and modified external de-rotation test. Subsequent studies evaluated segmental gluteal muscle activity during gait, and a series of hip rehabilitation exercises, in both a control and GTPS population. It was identified that isometric exercises elicited higher levels of segmental muscle activity compared to dynamic 2 exercises, and standing isometric hip abduction elicited the highest amount of gluteal muscle activity for the least amount of discomfort in the GTPS group. Consequently, these were used to guide the prescription of exercises in the final RCT. The final sections of the thesis involve a published protocol paper and results of a single arm randomised controlled trial. Recruitment for the RCT investigating the effects of menopausal hormone therapy in combination with education and exercise for the management of GTPS is still underway. The RCT presented in this study evaluates exercise and education interventions only, and found significant within-group improvements in both the targeted intervention group (GLoBE: Gluteal La Trobe exercise program) and the sham group in response to combined education and exercise, however, no between-group differences were identified. Responders to the targeted intervention, defined as greater than or equal to ‘+5 (quite a bit better)’ on the global rating of change questionnaire, had significantly better Victorian institute of sport assessment – gluteal tendon (VISA-G), hip dysfunction and osteoarthritis outcome score (HOOS), Oxford hip score (OHS) and lateral hip pain questionnaire (LHPQ) scores, when compared to responders in the sham group. This thesis found that education on postural strategies and functional activities could be the most important element in the management of GTPS in post-menopausal women, and subgrouping of GTPS participants may assist with the individualisation of GTPS rehabilitation programs.