Greater Trochanteric Pain Syndrome vs Hip Osteoarthritis vs Lumbar Referral

Lower Limb · 7 min read · Published 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:

1. Palpate the greater trochanter - exquisite point tenderness suggests GTPS
2. Passive hip internal rotation in flexion - pain or restriction suggests OA
3. 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.

Try free hip pain differential cases

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