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Three Part Question

In [GTPS] are [clinical tests and questions] diagnostically valid compared to [radiological investigations]?

Clinical Scenario

A 55 year old female patient presents to the physiotherapy department for assessment of lateral hip pain that came on insidiously 2 years ago. She has been diagnosed with (Greater Trochanteric Pain Syndrome (GTPS) by an orthopaedic consultant, but the patient would like to know what the accuracy/validity of the clinical diagnosis is without also having an MRI scan.

Search Strategy

Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (Trochanteric Bursitis [All Fields] OR GTPS[All Fields] OR Gluteus Medius tendinopathy[All Fields]) AND Diagnosis/broad[filter].

In addition the BestBETS, Cochrane and PEDrO (Physiotherapy best evidence) databases were searched and no further articles were found.

After duplicates were removed, 29 potentially relevant articles were retrieved.

Search Outcome

From these 29 articles, 13 papers were identified that potentially answered the three part search question and the full articles were retrieved. These papers were rated for quality and risk of bias using an appropriate proforma (http://www.bestbets.org/ca/pdf/diagnosis.pdf). 3 papers scored greater than ore equal to 7/10 for quality

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lequesne M, Mathieu P, Vuillemin-Bodaghi V, Bard H, Djian P 2008 France	17 adults with GTPS and matched control population of 20	Diagnostic Test Study with all patients having MRI's	Pain on Trendelenburg stand	All had pain on Tredenlenburg stand	-Reproducibility of tests not assessed. -Chronic condition not acute patients -No other hip pathologies included in the study -Predominately female population study (16) -Small sample size. -No blinding of assessors. -No timeframes provided. -No power calculation. -Lacks generalisability
			-Pain on resisted external de-rotation	Pain in 16 patients
			pain on resisted abduction	Pain on passive external rotation and palpation in all 17 patients
Bird PA, Oakley SP Shnier R Kirkham BW 2001 Australia	24 patients (all women)	Diagnostic Test Study	Tredenlenburg stand	sensitivity 72.7% specificity 76.9%	-No control group. -Only symptomatic hips tested therefore no blinding of the MRI testing. -Intra and inter reliability of MRI not assessed. -Lacks generalisability (all female subjects) -Small sample size
			Pain on resisted abduction	sensitivity 72.7% specificity 46.2%
			Pain on resisted internal rotation	sensitivity 54.5% specificity 69.2%
			All patients had MRI of hip	MRI – 11 patients had Glut Med Tear MRI -15 patients with Glut Med tendinitis (2 had trochanteric bursal distension)
Woodley SJ, Nicholson HD, Livingstone V, Doyle TC, Meikle GR, Macintosh JE, Mercer SR 2008 New Zealand	40 patients with unilateral hip pain (80 hips)	Diagnostic Test Study	Palpation over the greater trochanter	Pain on palpation of greater trochanter (32 patients)	-No control group. -Small sample size. -Order of the tests was not randomised. -Low reliability of clinical measures. -Large ranges of confidence levels with the specificity and sensitivity of tests. -Lacks generalisability -Excludes other hip pathologies.
			Patrick-Faber Test	Patrick-Fabers (16 patients)
			- Ober’s test	-Ober’s Test (11 patients)
			- Resisted flexion, extension, adduction, abduction, internal and external rotation.	- Resisted hip abduction (11 patients)
			- Gait analysis	-No significant findings
			- Trendelenburg stand	-No significant findings
			- Limb length	-No significant findings
			-Flexion/adduction	-No significant findings
			All had MRI of both hips	40% of symptomatic hips had glut med tendon pathology on MRI

Comment(s)

•Difficult to find gold standard. Lack of research to support a specific gold standard. •Many articles quoted subjective findings of GTPS as pain when palpating lateral aspect of affected hip, also pain and weakness of hip abduction. Yet these articles do not compare subjective findings to any radiological test. Therefore how often is the gold standard used in diagnosis, meaning is literature lacking in support of gold standard

Clinical Bottom Line

There is currently only weak evidence to support clinical tests in the diagnosis of Greater Trochanteric Pain Syndrome. Local guidelines should be sought for guidance, and if there are none in place local guidelines should be developed by a specialist MDT team. There is a common misconception that the bursa is the primary structure in causing lateral hip pain whereas evidence has shown that it is actually a dysfunction of the gluteal tendons which could involve the bursa

References

1. Lequesne M, Mathieu P, Vuillemin-Bodaghi V, Bard H, Djian P Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome: Diagnostic Value of Two Clinical Tests American College of Rheumatology Vol. 59, No. 2, February 15, 2008, pp 241–246
2. Bird PA, Oakley SP Shnier R Kirkham BW Prospective Evaluation of Magnetic Resonance Imaging and Physical Examination Findings in Patients With Greater Trochanteric Pain Syndrome American College of Rheumatology Vol. 44, No. 9, September 2001, pp 2138–2145
3. Woodley SJ, Nicholson HD, Livingstone V, Doyle TC, Meikle GR, Macintosh JE, Mercer SR Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination journal of orthopaedic & sports physical therapy 38(6):313-328.