Which Tests Are Used for Greater Trochanteric Pain Syndrome?

Context

In their 2017 study, Grimaldi et al. investigated the usefulness of six clinical tests and one palpation test for diagnosing gluteal tendinopathy. Following each of these tests, gluteal tendinopathy was confirmed or ruled out by MRI in patients presenting with lateral hip pain.

Video of the Test

Execution

1) The first test is the FADER test (hip "flexion, adduction, and external rotation). The patient is in a supine position. The therapist flexes the patient’s hip to 90°, then brings it into adduction and external rotation to end range. This test is intended to increase both tension and compression of the gluteus minimus and gluteus medius tendons over the greater trochanter through hip positioning and through tension on the iliotibial band.

2) The second test is the FADER-R test, which is the same test as the previous one but with resistance to isometric internal rotation at end range. This test is intended to increase tensile and compressive load on the gluteal tendons through active contraction of the gluteus minimus and gluteus medius, both of which are internal rotators in this position (Delp et al., 1999)

3) The third test is the FABER test (hip flexion, abduction, and external rotation). The therapist places the patient’s lateral malleolus above the patella of the contralateral leg. They then place their cranial hand over the opposite anterior superior iliac spine (ASIS) to stabilize the pelvis and then gently apply downward pressure to the knee of the tested limb toward the table until full range of motion is reached. During this test, the anterior portions of the gluteus minimus and gluteus medius are expected to be under maximal tension, given that they function as internal rotators (Delp et al., 1999).

4) The fourth test is the Passive Hip Adduction Test in side-lying. The patient is positioned diagonally on the table with the bottom hip flexed to 80 to 90°. The therapist supports the top hip and ensures that the patient’s knee remains extended and that the femur is aligned with the trunk (0° of hip extension). With their cranial hand, the therapist keeps both ASIS perpendicular to the examination table. The therapist then passively brings the patient’s hip into adduction to end range while stabilizing the pelvis with the other hand. This test places the lateral insertions of the gluteal tendons under tension and compression.

5) The fifth test is the same as the previous one, but with isometric abduction against resistance at end range. The therapist asks the patient to push the thigh upward against the resistance of the therapist’s hand placed on the lateral side of the knee. This action increases the compression exerted on the gluteal tendons.

6) The sixth test is the Single-Leg Stance (SLS): the patient stands next to a wall with the affected limb farthest from the wall. For stability, the patient places one finger from the unaffected side on the wall at shoulder height. The therapist then asks the patient to lift the foot closest to the wall so that the knee is flexed to 90° and the hip is maintained in a neutral position. This position is then held for 30 seconds. The test is positive if the patient experiences lateral hip pain during this 30-second period.

Finally, once these clinical tests have been completed, the patient is placed in the side-lying position, with the hips flexed to approximately 80-90° and the knees together. The therapist looks for tenderness on palpation over the greater trochanter area. The palpation test is positive if pain is reproduced in this area.

Each clinical test was considered positive if pain was reproduced over the greater trochanter, with a score greater than 2 on the VAS.

Clinical Value

The results show that the overall clinical examination had a sensitivity of 60%, a specificity of 73%, and a negative predictive value of 88%. Palpation over the greater trochanter was the main diagnostic criterion with the highest sensitivity, at 80%, but the lowest specificity, at 47%.

Palpation had the lowest negative LR (LR-), at 0.43, meaning that if palpation was negative, it was the best individual test used in this study to rule out gluteal tendinopathy.

In contrast to palpation, all other tests demonstrated high specificity.

The Single-Leg Stance had a specificity of 100% and a sensitivity of 38%.

The FADER test and the passive hip adduction test both had a high specificity of 86% and a positive predictive value of 88%. It was interesting to note that, when a resisted isometric contraction was added to these latter two tests, their clinical value increased, with a specificity of 93% for both.

The FABER test, for its part, showed a sensitivity of 42% and a specificity of 80%.

In conclusion, it appears that, among all these clinical tests, those involving muscle contraction, such as the FADER-R, the ADD-R test, and the SLS, are more useful than the FADER, FABER, and adduction tests for identifying gluteal tendinopathy on MRI. The most sensitive test is palpation; therefore, if a patient is not tender to palpation over the greater trochanter, it is advisable to consider other hip pathologies (Grimaldi et al., 2017).

Finally, according to the recent literature, trochanteric tenderness alone is not sufficient to establish the diagnosis. However, the combination of positive palpation and positive resisted hip abduction would increase the post-test probability of a diagnosis of GTPS to 96%. Conversely, if both are negative, it would decrease to 16%. The addition of the SLS could also help confirm a positive diagnosis (Kinsella et al., 2024; Grimaldi et al., 2024).