Greater Trochanteric Pain Syndrome vs Hip Osteoarthritis vs Lumbar Referral
Lower Limb · 7 min read · 2026-04-11
The Lateral Hip Pain Triangle
"My hip hurts." Three of the most common drivers of this complaint look superficially identical but require entirely different management: greater trochanteric pain syndrome (GTPS), hip osteoarthritis (OA), and referred lumbar pain. A focused exam separates them in under five minutes.
Greater Trochanteric Pain Syndrome (GTPS)
Formerly called "trochanteric bursitis," now recognised as primarily a gluteal tendinopathy of gluteus medius and minimus, often with secondary bursal involvement.
Pain location: directly over the lateral hip, often radiating down the lateral thigh to the knee. Worse lying on the affected side at night.
Key exam findings:
- Point tenderness over the greater trochanter (the most reliable sign)
- Pain reproduced by single-leg stance for 30 seconds
- Pain with resisted hip abduction
- Trendelenburg sign may be positive
- Hip range of motion is normal and pain-free
Hip Osteoarthritis
Degenerative joint disease of the femoroacetabular joint.
Pain location: classically groin pain, often radiating to the anterior thigh or knee (via the obturator nerve). Lateral hip pain alone is unusual for primary hip OA.
Key exam findings:
- Restricted internal rotation of the hip — the earliest and most sensitive finding
- FABER and FADIR tests positive
- Capsular pattern: flexion > abduction > internal rotation loss
- Pain with weight-bearing, stiffness after rest
- Antalgic gait
Lumbar Referred Pain
Lumbar facet joint or L1–L3 nerve root pathology can refer to the lateral hip and thigh, mimicking both GTPS and OA.
Key exam findings:
- Hip examination is essentially normal — full pain-free range
- Lumbar spine extension or rotation reproduces the pain
- Slump test or straight leg raise may be positive
- Tenderness over the lumbar paraspinals or facet joints
- Pain often worse with prolonged sitting or specific spinal movements
The Differentiating Algorithm
The Three-Test Workup
For any lateral hip pain, perform these three tests in order:
- Palpate the greater trochanter — exquisite point tenderness suggests GTPS
- Passive hip internal rotation in flexion — pain or restriction suggests OA
- Lumbar extension and rotation — reproduction suggests spinal origin
A positive finding on any one test, with the other two negative, points to a confident diagnosis.
Common Pitfall
Treating every lateral hip pain as "trochanteric bursitis" with a steroid injection is a known overtreatment. If hip internal rotation is restricted, the patient has OA — the bursa is innocent. If lumbar movements reproduce the pain, the spine is the source.
Clinical Pearl
Hip OA refers pain to the knee in roughly 25% of cases via the obturator nerve, mirroring the paediatric hip-to-knee referral pattern. An adult with isolated knee pain and a normal knee MRI deserves a hip examination.
Summary
Trochanter tenderness with normal hip motion = GTPS. Restricted internal rotation with groin pain = hip OA. Normal hip exam with reproducible spinal pain = lumbar referral. Three tests, three diagnoses, three different treatment paths.