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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 19-22

Dry needling: A promising treatment modality for greater trochanteric pain syndrome


1 Department of Pain Medicine, Daradia Pain Clinic, Kolkata, West Bengal, India
2 Department of Anaesthesia and Pain Clinic, Dr. D. Y. Patil, Medical College, Hospital and Research Center, Pune, Maharashtra, India

Date of Submission28-Jul-2020
Date of Acceptance27-Oct-2020
Date of Web Publication08-Mar-2021

Correspondence Address:
Archana Y Nankar
Department of Pain Medicine, Daradia Pain Clinic, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrap.jrap_6_20

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  Abstract 


Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain, seen more commonly in females between the ages of 40 and 60 years. GTPS is presently attributed to tendinopathy of the gluteus medius and/or minimus with or without coexisting trochanteric bursitis. Conventionally, cortisone injection into the lateral hip, with the intention of injecting the bursa, was accepted treatment for this condition in cases not responding to conservative treatment. But since the etiology of GTPS is not necessarily the bursa, injecting it with steroid is not as logical. As trigger points and myofascial pain of the affected hip and thigh musculature are being implicated as sources of pain, dry needling (DN), that has shown potential in treating a variety of soft-tissue injury and neuromyofascial pain, and which requires the insertion of thin monofilament needles into sensitive loci (trigger points) in the muscles and soft tissue could be an effective option. Hereby, we present a case of a 52-year-old woman, who came to us with chronic lateral lower limb pain since 1 year. The pain was dull aching in quality, extended from the right buttock region to the lateral aspect of thigh and was specially felt on abduction of thigh while sitting in cross-legged position on the ground. The patient had tenderness along proximal lateral thigh around the greater trochanteric region. One-week course of nonsteroidal anti-inflammatory drugs had minimal effect. We decided to treat her with DN in her pain area. The patient reported more than 75% pain relief after the session.

Keywords: Dry needling, greater trochanteric pain syndrome, trochanteric bursitis


How to cite this article:
Nankar AY, Nankar YL. Dry needling: A promising treatment modality for greater trochanteric pain syndrome. J Recent Adv Pain 2020;6:19-22

How to cite this URL:
Nankar AY, Nankar YL. Dry needling: A promising treatment modality for greater trochanteric pain syndrome. J Recent Adv Pain [serial online] 2020 [cited 2021 Aug 4];6:19-22. Available from: http://www.jorapain.com/text.asp?2020/6/2/19/310955




  Introduction Top


Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain, seen more commonly in females between the ages of 40 and 60 years.[1],[2],[3] It is also common in patients with coexisting low back pain, osteoarthritis, iliotibial band (ITB) tenderness, and obesity.[4],[5] GTPS is the etiology in 10%–20% of patients presenting with hip pain to primary care, with an incidence of 1.8 patients per 1000 per year.[3],[4] It is characterized by chronic, intermittent pain accompanied by tenderness to palpation overlying the lateral aspect of the hip.[5]

GTPS is the current terminology for what used to be called greater trochanteric or subgluteal bursitis. The change in nomenclature was due to findings that, in most cases, contractile tissues, not the bursa, are injured, and that inflammation is often not involved.[5] Surgical, histological, and imaging studies have shown that GTPS is attributable to tendinopathy of the gluteus medius and/or minimus due to abnormal hip biomechanics. Compressive forces cause impingement of the gluteal tendons and bursa onto the greater trochanter by the ITB as the hip moves into adduction.[3] GTPS may also involve trigger points in contractile tissue crossing the hip.[4],[5]

GTPS carries significant morbidity; pain on side lying and subsequent reduction in physical activity levels carry negative implications for general health, employment, and wellbeing. It is important to accurately diagnose GTPS early, as delay and mismanagement can worsen prognosis due to progression to recalcitrant symptoms.[3] The condition is also known as “great mimicker” as its often mistaken for diseases such as osteoarthritis of the hip, lumbar spine referred pain, and pelvic pathology.[3],[4]

Cortisone injection into the lateral hip, with the intention of injecting the bursa, has been a traditionally accepted treatment for this condition. Because the cause of GTPS is not necessarily the bursa around the greater trochanter, injecting it with a steroid is not as logical.[5]

Dry needling (DN) uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and impairment in movement. The advantages of DN are increasingly documented and include an immediate reduction in local, referred, and widespread pain, restoration of range of motion and muscle activation patterns, and a normalization of the immediate chemical environment of active myofascial trigger points.[6]

The purpose of this case report is to emphasize the efficacy of DN technique in the management of GTPS as myofascial pain and trigger points in the affected hip and thigh musculature are possible sources of pain.[4],[7]


  Case Report Top


A 52-year-old woman presented to us with complaints of chronic low back pain since 6 years and right lower limb pain since 1 year. In the past 6–7 years, she had been evaluated and conservatively treated by multiple specialists but her pain had persisted. In past 2 months, her lower limb pain had aggravated causing her lot of discomfort, restricting her daily activity.

Her back pain was located in midline, aching in quality, aggravated on prolonged sitting, prolonged standing and on activities requiring flexion of back. It got relieved on lying down. Her lower limb pain was felt from the right buttock region to the lateral proximal thigh. It was specially felt on abduction of thigh while sitting in cross legged position on the ground. Hence, she mainly complained that she cannot sit in that position. She could not lie down on ipsilateral side. She also said that pain was more in morning when she got up from sleep. Pain severity was 7–8 on numerical rating scale. There was no associated tingling numbness. Pain did not aggravate on walking.

On examination, point tenderness was elicited in the right greater trochanteric region. Flexion, abduction, external rotation of hip joint (Patrick test) caused pain in the lateral proximal thigh region. Restricted active abduction test was positive. Neurological examination was normal.

Laboratory examination including complete blood count, erythrocyte sedimentation rate, and C-reactive protein was normal. X-rays of lumbosacral spine showed mild scoliosis toward right [Figure 1]. X-ray of bilateral sacroiliac joints and bilateral hip joints was normal [Figure 2]. Magnetic resonance imaging revealed multiple lumbar degenerated discs without any significant neural compromise [Figure 3] and [Figure 4].
Figure 1: X-ray: Lumbosacral spine

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Figure 2: X-ray sacroiliac and hip joints

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Figure 3: Magnetic resonance imaging lumbosacral spine: Sagital section

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Figure 4: Magnetic resonance imaging lumbosacral spine:Transverse section

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A diagnosis of discogenic pain was made for her back pain and she was treated with Duloxetine 20 mg BD, which gave her significant relief.

For her thigh pain, ultrasonography of the right trochanteric region was done which revealed trochanteric bursitis and mild enthesopathic changes [Figure 5] and [Figure 6]. A diagnosis of GTPS was made. She was initially treated with 1 week course of non-steroidal anti-inflammatory drugs with minimal pain relief. There after she was offered the option of DN.
Figure 5: Ultrasonography - Trochanteric bursitis

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Figure 6: Ultrasonography – Enthesopathy

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Her points of maximum tenderness were marked along the proximal lateral aspect of thigh over the greater trochanteric region. Thin monofilament needles were inserted along the points marked [Figure 7]. They were kept in situ for 45 min, rotated every 15 min. The patient reported immediate pain relief of about 75% which persisted at 1 week follow-up, following which the patient was referred to physiotherapist for further rehabilitative measures.
Figure 7: Dry needling: Greater trochanteric region

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  Discussion Top


GTPS is a fairly common condition that encompasses a number of potential etiologies. More recent evidence has indicated pathology/dysfunction of structures of the posterolateral hip/pelvis other than the trochanteric bursa as the cause.[5] Myofascial pain and trigger points associated with these structures have been implicated as possible pain generators.[4],[7]

DN is typically used to treat muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for the management of a variety of neuro-musculoskeletal pain syndromes.[8] Researchers have discovered biochemical, neurologic, vascular, and clinical changes effected through this technique.[5] Hence, it could be a viable option to resolve this pain.

Muscle trigger points (MTrPs) are discrete painful loci in the muscles due to altered motor end-plate activity, leading to tonic fiber contraction, local ischemia, myofiber injury, and biochemical imbalance.[5] In our patient, these painful loci were identified and marked, and then were targeted with DN. The patient reported significant improvement of the trochanteric region pain. She subjectively reported being able to sit in the cross-legged position with less discomfort than before. She was also able to lie down on her right side after the treatment.

Possible mechanism by which DN caused pain relief is by destroying the motor end plates and causing distal axon denervation when the needle hit an MTrP. The literature claims that it changes the end plate cholinesterase and Ach receptors as part of the normal muscle regeneration process. Needling destroys the existing MTrPs and allows the loci to regenerate in a normal manner which in one way relieves the pain.[6]

Also following DN, active trigger points are said to have significantly lower levels of substance P and calcitonin gene-related peptide, both of which are chemicals associated with pain. Vasodilation in the region of referred pain has also been reported.[5]

DN is cost-effective, easy to learn with appropriate training, carrying lower risk and minimally invasive treatment modality. It also has segmental anti-nociceptive effects and also causes immediate reduction in pain through its effect on descending inhibitory system.[6]


  Declaration of patient consent Top


The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Conclusion Top


DN of the greater trochanteric region significantly improved GTPS symptoms and function in the patient without any adverse effects. Hence, the use of DN for GTPS shows promise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: A systematic review. Br J Sports Med 2017;51:97-104.  Back to cited text no. 1
    
2.
Chowdhury R, Naaseri S, Lee J, Rajeswaran G. Imaging and management of greater trochanteric pain syndrome. Postgrad Med J 2014;90:576-81.  Back to cited text no. 2
    
3.
Speers JB, Bhogal GS. Greater trochanteric pain syndrome: A review of diagnosis and management in general practice. Br J Gen Pract 2017;67:479-80.  Back to cited text no. 3
    
4.
Williams BS, Cohen SP. Greater trochanteric pain syndrome: A review of anatomy, diagnosis and treatment. Anesth Analg 2009;108:1662-70.  Back to cited text no. 4
    
5.
Brennan KL, Allen BC, Maldonado YM. Dry needling versus cortisone injection in the treatment of greater trochanteric pain syndrome: A noninferiority randomized clinical trial. J Orthop Sports Phys Ther 2017;47:232-9.  Back to cited text no. 5
    
6.
Asha V, Kannan R, Jacob TR. A novel case of orofacial pain treated by dry needling technique – A case report. Dentistry 2015;5:319.  Back to cited text no. 6
    
7.
Pavkovich R. The use of dry needling for a subject with chronic lateral hip and thigh pain: A case report. Int J Sports Phys Ther 2015;10:246-55.  Back to cited text no. 7
    
8.
Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T, et al. Dry needling: A literature review with implications for clinical practice guidelines. Phys Ther Rev 2014;19:252-65.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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