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Greater trochanteric pain syndrome

67 citationsUpdated Sep 2026

Overview

Greater trochanteric pain syndrome (GTPS) is a lateral hip pain condition increasingly understood through advances in imaging and sports medicine [2]. Accurate diagnosis is critical, as patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected gluteal tendinopathy [1]. Hip abductor tears are a recognized cause of lateral hip pain and dysfunction [9]. Precise diagnosis and proper management of concurrent GTPS during surgery may improve outcomes [6]. Failure to identify extra-articular sources of hip pain, including from the anterior inferior iliac spine, can lead to poorer outcomes and future revision surgery [4]. While the overall prevalence of radiographic findings consistent with femoroacetabular impingement in young patients with hip pain is 60.5% [11], GTPS remains a distinct entity requiring specific evaluation.

Non-operative management includes shock wave therapy, which is an effective treatment for GTPS [7]. Platelet-rich plasma (PRP) injections show mixed results; while all randomized controlled trials found improvements in pain and function with clinically relevant thresholds, and meta-analyses favored PRP for GTPS and hamstring pathology [12], a randomized trial found no significant difference between low-concentration PRP and placebo up to 6 months [26]. Injections into the greater trochanteric bursa may provide longer-lasting benefit [15]. Both PRP injections and surgery result in favorable outcomes, but heterogeneity in treated condition severity and lack of direct comparison make it difficult to declare one method superior [8].

Operative intervention is indicated for symptomatic patients who have failed a primary nonoperative protocol [51]. Surgical repair of torn gluteal tendons in patients with severe symptoms has been effective at relieving symptoms in 95% of reviewed cases [27]. Surgeons should no longer ignore Type I tears if clinically symptomatic, as surgical repairs show improved outcomes, and the bone tunnel technique is recommended for Type II tear repairs [9]. Endoscopic techniques, including iliotibial band release, trochanteric bursectomy, and gluteal tendon repair, are safe and effective for severe recalcitrant cases [24]. These endoscopic approaches offer advantages such as limited soft tissue disruption and diminished blood loss compared with open procedures [56]. Patients experience statistically significant clinical improvement in patient-reported outcomes and pain scores, with high satisfaction after endoscopic trochanteric bursectomy with or without gluteus medius repair [23]. In a study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, excellent outcomes exceeding minimum clinically important difference thresholds were found in the majority of patients at an average of 31.2 months follow-up [102]. Preoperative fatty infiltration was not associated with pertinent parameters of patient outcome after hip abductor tendon repair, including pain, symptoms, functional capacity, perceived improvement, and satisfaction [37]. Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain [5]. The corresponding surgical techniques for peritrochanteric pathology are described as reproducible for surgeons [10].

Anatomy & Pathophysiology

Anatomical Structures

The hip is a multiaxial ball-and-socket diarthrodial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [61, 58]. Stability is based primarily on bony architecture [58]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [61]. The pelvic girdle consists of two innominate bones that articulate with the sacrum and proximal femora, with each innominate bone composed of the ilium, ischium, and pubis converging at the triradiate fusion center [67]. The acetabulum is normally anteverted 15 degrees and obliquely oriented 45 degrees caudally in the coronal plane [67]. It comprises an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [61]. The posterosuperior articular surface is thickened to accommodate weight bearing [67]. The inferior surface contains the acetabular (cotyloid) notch, bound by the transverse acetabular ligament [67].

The acetabular labrum is a fibrocartilaginous ring attached to the rim of the acetabulum that extends the articulating surface area and increases femoral head coverage [61]. It is triangular in cross section, contributing to a pressurized seal of the central compartment during loading [61]. The labrum deepens the acetabulum to enhance stability, with functions including load transmission, maintenance of vacuum seal, regulation of synovial fluid hydrodynamics, and joint lubrication [58]. Only the external one-third of the labrum contains blood vessels, leaving the majority avascular and limiting healing ability following injury [61]. The labrum is highly innervated with mechanoreceptors and nociceptors [61]. It is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as its continuation [61].

The femoral head forms two-thirds of a sphere, with a small central depression from which the ligamentum teres extends to connect to the acetabular notch [61]. The ligamentum teres arises from the apex of the cotyloid notch and attaches to the fovea of the femoral head [58]. It transmits an arterial branch of the posterior division of the obturator artery to the femoral head, which is less significant in adults [58]. The neck-shaft angle of the femur averages 125° [61], or 127 degrees beginning at 141 degrees in the fetus [67]. This angle allows for greater mobility by placing the head and neck more perpendicular to the acetabulum in a neutral position [61]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [61]. The femoral neck is normally anteverted approximately 14 degrees in relation to femoral condyles, with a range of 1–40 degrees [67]. The angular projection of the femoral head and neck in relation to the obliquely placed acetabulum allows for rotary movements and prevents impingement [61].

The greater and lesser trochanters are connected by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly, serving as important bony landmarks and attachment sites for thigh and pelvic muscles [61]. The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck, enhancing joint stability by preventing translation of the femoral head [61]. The capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [62]. On the femur, it attaches anteriorly along the intertrochanteric crest, while posteriorly it attaches only partially, leaving the basicervical region of the femoral neck and the intertrochanteric region extracapsular [62, 58]. The hip capsule is tight in extension and internal rotation, and relaxed in flexion and external rotation [58].

Ligamentous Anatomy

The iliofemoral ligament, also known as the Y ligament of Bigelow, is Y-shaped and the thickest and strongest of the three main hip ligaments [61, 58]. It is the strongest ligament in the body [58]. The medial portion connects the anterior inferior iliac spine (AIIS) to the anterior intertrochanteric line, while the lateral portion originates slightly superior to the medial arm and attaches to the anterior greater trochanter [61]. It originates at the AIIS and inserts at the intertrochanteric line in an inverted Y manner [58, 62]. The iliofemoral ligament functions to limit external rotation, while in isolation, the lateral arm limits extension of the joint [61]. It becomes taut in full extension, preventing anterior dislocation and hyperextension [62]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [62].

The ischiofemoral ligament extends from the ischial margin of the acetabulum to the greater trochanter of the femur, providing support posteriorly and restricting internal rotation motion [61, 62]. It reinforces the posterior capsule and provides a check to internal rotation [62]. The pubofemoral ligament extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [61]. It attaches to the inferior and medial part of the capsule and may cause a hip adduction contracture [62]. The ischiofemoral and pubofemoral ligaments are weaker but provide additional stability [58]. Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [61].

The sacrospinous and sacrotuberous ligaments create the boundaries of the greater and lesser sciatic foramina [62]. The sacrospinous ligament creates the upper border of the lesser sciatic foramen and the lower border of the greater sciatic foramen [62]. The sacrotuberous ligament creates the inferior border of the lesser sciatic foramen [62]. The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen [62]. The short external rotator muscles exit from the lesser sciatic foramen [62].

Muscular Anatomy

The abductors of the hip are predominantly the gluteus medius and minimus muscles [69]. The gluteus medius has three different components: anterior, middle, and posterior [69]. Its tendon consists of thick posterior and thin anterolateral parts [111]. The gluteus medius and minimus muscles function together to maintain and abduct the femur during the stance phase of gait [69]. A Trendelenburg lurch is an attempt by the body to compensate for abductor weakness by bringing the center of gravity closer to the hip center, forcing the patient to lean toward the affected side [69]. The tensor fasciae latae muscle originates laterally on the anterolateral edge of the iliac crest, with its fibers combining with the fasciae latae to form the iliotibial band [69]. Its action is to flex, abduct, and rotate the hip [69]. The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [69].

Lateral hip anatomy includes three to four bursae surrounding the side of the hips, which allow improved muscle mechanics over the lateral part of the proximal femur [73]. The largest bursa is found between the gluteus maximus muscle and the gluteus medius tendon, located directly lateral to the greater trochanter [73]. The muscular sheaths and tendinous attachments of the gluteus maximus, iliotibial band, tensor fascia lata, gluteus medius, and gluteus minimus contribute to a complex local environment susceptible to overuse injuries, direct trauma, and gait alterations [73].

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [69]. The iliopsoas muscle has a large origin along the iliac crest, iliac fossa, sacra ala, iliolumbar ligaments, and sacroiliac ligaments [69]. It also has origins along the bodies of the T12 through L4 thoracic lumbar vertebra, the transverse process of the first through fifth lumbar vertebra, and the intervertebral disks [69]. The rectus femoris crosses the hip and knee joints [69]. Its straight head originates from the AIIS, while the reflected head originates from the supra-acetabular tubercle at the superior-anterior edge of the acetabulum [69]. The rectus femoris flexes the hip joint and extends the knee joint [69]. The rectus femoris direct and reflected heads originate over a broad area of the anterolateral pelvis and are in close proximity to critical neurovascular structures [100]. The sartorius muscle originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and the pes anserine complex [69].

The gluteus maximus and hamstring muscles are the most important hip joint extensors [69]. The gluteus maximus originates from the sacrum, the coccyx, and the sacrotuberous ligaments [69]. The hamstring muscles originate on the ischial tuberosity [69]. The adductor muscles of the hip include the adductor brevis, adductor longus, adductors magnus, pectineus, and gracilis [69]. The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [69]. The obturator internus muscle originates from the inner component of the obturator foramen and emerges through the lesser sciatic foramen [69]. The piriformis muscle originates from the greater sciatic foramen and inserts onto the greater trochanter [69].

Neurovascular Anatomy

The blood supply to the femoral head develops and changes with age [74]. From birth to approximately 4 years of age, the major blood supply comes from the medial and lateral femoral circumflex arteries, with major contributions from the artery of the ligamentum teres [74]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries (from the medial circumflex artery) are the major blood supply [74]. In adulthood, the major blood supply is from the medial femoral circumflex and lateral epiphyseal arteries [74]. The medial femoral circumflex artery is the main blood supply to the femoral head [71]. It terminates in the posterior aspect of the extracapsular arterial ring [71]. The lateral femoral circumflex artery gives rise to the anterior aspect of the arterial ring [71]. The superior and inferior gluteal arteries also contribute branches to the extracapsular arterial ring [71].

The ascending cervical arteries originate from the extracapsular arterial ring and are divided into four distinct groups based on their anatomic relationship to the femoral neck: lateral, medial, posterior, and anterior [71]. The lateral group of ascending branches is the main blood supply to the femoral head [71]. The ascending branches give off multiple perforator vessels to the femoral neck and terminate in the subsynovial arterial ring located at the margin of the articular surface of the femoral head [71]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the femoral head from this system [71]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [71]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery [71]. It does not provide sufficient blood supply to maintain the viability of the femoral head [71].

The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament [74]. It passes anterior and medial to the hip capsule [74]. The common femoral vein is a continuation of the external iliac vein [74]. The common femoral vessels are the most commonly reported extrapelvic vascular structures injured during total hip arthroplasty [74]. The most common mechanism of injury is errant retractor placement anterior to the acetabulum [74]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [74]. It travels between the pectineus and adductor longus muscles [74]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery and has ascending and descending branches [74]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery [74]. It traverses between the pectineus and psoas muscles and appears at the upper border of the quadratus femoris [74].

The superior gluteal vessels are branches of the posterior division of the internal iliac artery [74]. They are closest to the hip as they exit from the sciatic notch [74]. Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [74]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery [74]. They exit the pelvis between the piriformis and coccygeus muscles [74]. The inferior gluteal vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [74].

The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [69]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris all exit the pelvis below the piriformis [69]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [69]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [69].

Pathophysiology & Etiology

Greater trochanteric pain syndrome (GTPS) encompasses greater trochanteric bursitis, gluteus medius and gluteus minimus tears, and external coxa saltans [17]. Two or more of the diagnoses comprising GTPS are often seen concomitantly [17]. Greater trochanteric bursitis has historically been considered the main source of lateral hip pain [17]. A proposed cause of greater trochanteric bursitis is repetitive friction between the greater trochanter and the iliotibial band associated with overuse, trauma, and altered gait patterns [17]. Imaging studies have shown that most patients who receive a diagnosis of bursitis actually have abductor tears, tendinosis, and thickened iliotibial bands with little to no evidence of actual bursitis [17]. Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation, and management of this cohort of patients [2]. Hip abductor tears are increasingly recognized as a cause of lateral hip pain [2].

Classification

Lateral hip pain was historically a poorly defined entity, but advances in imaging and sports medicine interest have improved understanding of its pathology, presentation, and management [2]. Accurate diagnosis of the underlying etiology is the key to successful management of greater trochanteric pain syndrome [17]. The syndrome encompasses greater trochanteric bursitis, gluteus medius and gluteus minimus tears, and external coxa saltans [17]. Two or more diagnoses of greater trochanteric bursitis, gluteal tears, or external coxa saltans are often seen concomitantly [17]. Imaging studies have shown that most patients diagnosed with bursitis actually have abductor tears, tendinosis, and thickened iliotibial bands with little to no evidence of actual bursitis [17].

Intraoperative Classification System: An intraoperative classification system for greater trochanteric pain syndrome includes five types: Type I (trochanteric bursectomy), Type II (trochanteric bursectomy with trochanteric micropuncture), Type IIIA (endoscopic suture staple repair), Type IIIB (endoscopic single row transtendinous repair), Type IV (open or endoscopic double row repair), and Type V (gluteus maximus/tensor fasciae latae transfers) [38]. This system has been validated to improve patient-reported outcome scores [38]. Surgical techniques corresponding to this classification for peritrochanteric pathology are described as reproducible for surgeons [10].

Other Considerations: Surgeons should no longer ignore Type I hip abductor tears if clinically symptomatic, as surgical repairs show improved outcomes [9]. The BT technique is recommended for Type II hip abductor tear repairs [9]. Proximally and distally directed enthesophytes are strong predictors for the presence of a hip abductor tendon tear, specifically a full-thickness tear [13]. Increasing size of pertrochanteric calcifications is associated with more severe tendon injuries [13]. Patients with hip abductor tendon disorders are associated with a high prevalence of underlying lumbar and lumbosacral pathologies [22].

Clinical Presentation

Lateral hip pain has historically been a poorly defined entity, but advances in imaging and sports medicine interest have improved understanding of its pathology, presentation, and management [2]. Greater trochanteric pain syndrome (GTPS) encompasses greater trochanteric bursitis, gluteus medius and gluteus minimus tears, and external coxa saltans [17]. Two or more diagnoses within the GTPS spectrum are often seen concomitantly [17]. Accurate diagnosis of the underlying etiology is the key to successful management of GTPS [17].

The clinical presentation of GTPS includes tenderness over the lateral aspect of the hip and weakness in abduction [17]. Increasing size of peritrochanteric enthesophytes is associated with more severe tendon injuries [13]. Patients with GTPS were the least likely to be in full-time work compared to an asymptomatic group [33]. Participants with GTPS had lower quality of life scores and Harris Hip Scores compared to the asymptomatic group [33]. Participants with GTPS had higher Oswestry Disability Index scores compared to the asymptomatic group [33].

Increased symptoms with provocative impingement or instability testing indicate the presence of intra-articular abnormalities that may require adjunctive hip arthroscopy [40]. Ultrasound-guided analgesic injection testing can aid in the diagnosis of mixed-pathology cases involving GTPS and intra-articular abnormalities [40].

Investigations

A comprehensive clinical examination is required to establish a differential diagnosis, as many hip conditions present with similar symptoms [45]. Clinical examination tests and imaging findings must be used to confirm a suspected clinical diagnosis [45]. In patients with greater trochanteric pain syndrome, increased symptoms during provocative impingement or instability testing indicate adjunctive hip arthroscopy to address intra-articular abnormalities [40]. Ultrasound-guided analgesic injection testing can aid in diagnosis for mixed-pathology cases [40]; however, intra-articular findings in patients who did not respond to a diagnostic injection did not differ from those who responded, implying that false-negative results render the technique not 100% reliable [105]. Research studies are needed to determine how well diagnostic injection predicts outcome after arthroscopic hip surgery in those with nonarthritic intra-articular hip pain [44].

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip and can diagnose fractures, developmental dysplasia of the hip, femoroacetabular impingement, and osteoarthritis [46]. A complete hip series usually consists of an anterior-posterior pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [46]. The femoral head-neck junction morphology is often assessed using the alpha angle on radiographs [46]. Some studies have shown that radiographs, in particular the Dunn 45° view, may be more accurate for determining the alpha angle measurement than CT or MRI [46].

MRI: For patients suspected of soft tissue or intra-articular pathology, MRI is the modality of choice given its superior sensitivity and specificity [78]. Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [78]. Magnetic resonance arthrography is more appropriate to determine injuries to the labrochondral structures and the ligamentum teres and to identify the presence of loose bodies and synovial chondromatosis [78]. However, in the accurate detection and staging of articular cartilage lesions, the utility of magnetic resonance arthrography is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [78]. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair of abductor avulsion [109].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [78].

Bone scan: Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis [32].

Other Considerations: Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [78]. It is also being increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip [78]. Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear [13]. Increasing size of peritrochanteric calcifications was associated with more severe tendon injuries [13]. Patients with hip abductor tendon disorders were associated with a high prevalence of underlying lumbar and lumbosacral pathologies [22]. Patients with unilateral femoroacetabular impingement syndrome have a significantly decreased muscle cross-sectional area in the symptomatic hip compared with the asymptomatic hip [28]. Preoperative widths and cross-sectional areas of the gluteus medius/minimus, gluteus maximus, and iliopsoas muscles may be associated with, and to a limited extent help predict, the clinical outcomes at two years postoperatively in patients with femoroacetabular impingement syndrome [54]. The increased muscle cross-sectional area of the gluteus maximus and the gluteus minimus was significantly correlated with improvement in modified Harris Hip Score and pain Visual Analog Scale, respectively [42]. An unusual cause of hip pain, ischiofemoral impingement syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle [21]. All patients with increased femoral version greater than 35° had limited external rotation less than 40°, and most had limited extension less than 20° due to posterior intra- or extra-articular hip impingement [36].

Treatment

Non-Operative

Conservative management remains the primary initial strategy for greater trochanteric pain syndrome (GTPS). While most patients improve with non-operative care, more than one-third fail best-practice management, warranting consideration of early surgical intervention in these refractory cases [106]. Corticosteroid injections are effective for postoperative trochanteric bursitis, though nonoperative management is more likely to fail in young patients and those with leg-length discrepancy [107]. In the post-arthroplasty population, first-line treatments are distributed nearly equally among physiotherapy, corticosteroid injections, and oral anti-inflammatories [92]. More than 60% of surgeons utilize corticosteroids as either first- or second-line therapy for GTPS after total hip arthroplasty [92]. Platelet-rich plasma (PRP) use is infrequent in this setting, with no surgeons employing it as a first-line treatment due to uncertainty regarding its benefits [92]. A randomized trial found no significant difference in outcomes between low-volume PRP and placebo for GTPS up to 6 months post-intervention [26]. Structured exercise programs, such as the Gluteal Loading Exercise (GLoBE) intervention, yield significantly better VISA-G, HOOS, OHS, and lateral hip pain questionnaire scores in responders compared to sham controls [31]. For degenerative hip abductor lesions, particularly partial tears, nonoperative treatment is a valid long-term option, demonstrating a low risk of clinically relevant progression or muscle fatty infiltration and clinical outcomes similar to operatively treated lesions [35].

Operative

Indications: Surgical intervention is indicated for severe, recalcitrant cases that have failed a primary nonoperative protocol [51]. Accurate diagnosis of the underlying etiology is the key to successful management, as GTPS encompasses greater trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans, often occurring concomitantly [17]. Imaging studies indicate that most patients diagnosed with bursitis actually have abductor tears, tendinosis, and thickened iliotibial bands (ITBs) with little evidence of true bursitis [17]. Proximally and distally directed enthesophytes are strong predictors for hip abductor tendon tears, specifically full-thickness tears, with increasing size associated with more severe injuries [13].

Surgical Approach / Technique: Endoscopic iliotibial band release, trochanteric bursectomy, and gluteal tendon repair constitute a safe and effective treatment for severe recalcitrant cases [24]. Arthroscopic trochanteric bursectomy with concomitant ITB release is a minimally invasive technique allowing patients to return to full activities within a few weeks [103]. This endoscopic approach offers advantages over open procedures, including limited soft tissue disruption and diminished blood loss [56]. For gluteal tendon repairs, both open and endoscopic techniques lead to functional improvement with similar failure rates [39]. Endoscopic gluteus medius repair results in significant improvement in patient-reported outcomes and pain scores at two-year follow-up [43]. The bone trough technique is recommended for Type II tear repairs, and surgeons should no longer ignore clinically symptomatic Type I tears, as surgical repairs show improved outcomes [9]. Corresponding surgical techniques for peritrochanteric pathology are described as reproducible for surgeons treating this condition [10].

Other Considerations: In the context of femoroacetabular impingement syndrome, failure to identify extra-articular sources of hip pain, including those from the anterior inferior iliac spine, can lead to poorer outcomes and future revision surgery [4]. Hip arthroscopy demonstrates a preventive effect on the development and progression of osteoarthritis in young patients with femoroacetabular impingement at mid- to long-term follow-up [41]. For iliopsoas impingement after total hip arthroplasty, endoscopic iliopsoas tenotomy is effective, resolving groin pain in 93.3% of patients while avoiding acetabular revision and resulting in a low rate of complications [99].

Complications

Other Considerations: When postoperative hip pain increases or plateaus, further investigation and treatment is warranted between 6 and 12 months [3]. Reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain [3]. One patient reported poor satisfaction following endoscopic gluteus medius repair due to noncompliance with postoperative weightbearing restrictions, continued tobacco use against medical advice, and undergoing a spinal fusion 6 months after the repair [96].

The occurrence of trochanteric bursitis following primary total hip arthroplasty is not influenced by the surgical approach (posterior or direct anterior) [25]. Furthermore, the occurrence of trochanteric bursitis following primary total hip arthroplasty could not be predicted by specific comorbidities or radiographic measurements [25].

Recovery

Non-Operative Management: All randomized controlled trials found improvements in pain and function following platelet-rich plasma injection with clinically relevant outcome thresholds [12]. Meta-analyses favored platelet-rich plasma when treating greater trochanteric pain syndrome and hamstring pathology [12]. Both platelet-rich plasma injections and surgery result in favorable outcomes in patients with greater trochanteric pain syndrome [8]. However, heterogeneity of the treated condition, severity, treatment, and lack of direct comparison make it difficult to say one method is better than the other regarding platelet-rich plasma versus surgery [8]. Nonoperative treatment might be a valid long-term option for degenerative hip abductor lesions, especially for partial tears [35]. Partial tears demonstrated a low risk of clinically relevant progression or muscle fatty infiltration [35]. Partial tears demonstrated similar clinical outcomes to those reported in the literature for operatively treated hip abductor tendon lesions [35].

Operative Management: Patients experienced a statistically significant clinical improvement in patient-reported outcomes and pain scores after endoscopic trochanteric bursectomy with or without gluteus medius repair [23]. Patients reported high satisfaction after endoscopic trochanteric bursectomy with or without gluteus medius repair [23]. Endoscopic repair of gluteus medius tears is a safe procedure with favorable and durable long-term outcomes at minimum 10-year follow-up [52]. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively for endoscopic repair of gluteal tendon tears [53]. Patients experienced good pain relief and improved function after arthroscopic bursectomy for recalcitrant trochanteric bursitis [55]. Improvements in pain and function after arthroscopic bursectomy were evident by 1 to 3 months and lasted throughout the follow-up period [55]. Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years [5]. Gluteus maximus tendon transfer for abductor insufficiency resulted in improvement in hip function and pain at 3 years [5].

Prognosis and Natural History: Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear [13]. Proximally and distally directed enthesophytes were strong predictors for the presence of a full-thickness hip abductor tendon tear [13]. Increasing size of radiographic findings was associated with more severe tendon injuries [13]. Participants with greater trochanteric pain syndrome were the least likely to be in fulltime work compared to the asymptomatic group [33]. Participants with greater trochanteric pain syndrome had lower quality of life scores compared to the asymptomatic group [33]. Participants with greater trochanteric pain syndrome had lower Harris Hip Scores compared to the asymptomatic group [33]. Participants with greater trochanteric pain syndrome had higher Oswestry Disability Index scores compared to the asymptomatic group [33].

Key Evidence

  • [L4] Patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected GT. [1] (10.1136/bjsports-2016-096175)
  • [L4] Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. [2] (10.1007/s00167-020-06354-1)
  • [L5] In cases in which postoperative hip pain increased/plateaued, further investigation and treatment is warranted between 6 and 12 months, and a reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain. [3] (10.1016/j.arthro.2022.11.023)
  • [L4] Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the AIIS, could lead to poorer outcomes and future revision surgery. [4] (10.1177/03635465211062903)
  • [L4] Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. [5] (10.1016/j.arth.2023.10.036)
  • [L5] Precise diagnosis and proper procedures for concurrent greater trochanteric pain syndrome (GTPS) during surgery may improve outcomes. [6] (10.1016/j.arthro.2022.02.014)
  • [L3] Shock wave therapy is an effective treatment for greater trochanteric pain syndrome. [7] (10.1177/0363546509333014)
  • [L5] Both platelet-rich plasma injections and surgery result in favorable outcomes in patients with greater trochanteric pain syndrome, but heterogeneity of the treated condition, severity, treatment, and lack of direct comparison make it difficult to say one method is better than the other. [8] (10.1016/j.arthro.2019.12.019)
  • [L5] Hip abductor tears are increasingly recognized as a cause of lateral hip pain and dysfunction; surgeons should no longer ignore Type I tears if clinically symptomatic as surgical repairs show improved outcomes, and the BT technique is recommended for Type II tear repairs. [9] (10.5435/jaaos-d-23-00224)
  • [Paper] The corresponding surgical techniques are described as reproducible for surgeons treating peritrochanteric pathology. [10] (10.1016/j.eats.2019.04.004)
  • [L3] The overall prevalence of radiographic findings consistent with FAI in young patients presenting with hip pain was 60.5%. [11] (10.1177/0363546519896355)
  • [L1] All RCTs found improvements in pain and function following PRP injection with clinically relevant outcome thresholds, and meta-analyses favored PRP when treating greater trochanteric pain syndrome and hamstring pathology. [12] (10.1002/arj.70024)
  • [L3] Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear, and increasing size of the findings was associated with more severe tendon injuries. [13] (10.1177/03635465211008104)
  • [L4] Endoscopic resection of the lesser trochanter via posterior approach provides satisfactory outcomes with symptom relief and good functional results in patients with Ischiofemoral impingement. [14] (10.1007/s00167-020-06309-6)
  • [L1] Injections into the Greater Trochanteric Bursa may have longer lasting benefit. [15] (10.1186/s12891-024-07217-3)
  • [L2] Hip arthroscopy can effectively improve patient outcomes in atypical hip pain. [16] (10.1177/0363546519887733)
  • [L5] [17] (10.5435/jaaos-d-14-00406)
  • [L3] Cup revision is effective in resolving the pain due to ilio-psoas impingement in selected patients, with 85% of patients satisfied at last follow-up. [19] (10.1016/j.otsr.2017.07.021)
  • [Case_report] An unusual cause of hip pain, IFI syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle. [21] (10.1186/s13018-022-03287-y)
  • [L4] Patients with hip abductor tendon disorders were associated with a high prevalence of underlying lumbar and lumbosacral pathologies. [22] (10.1016/j.arthro.2021.09.026)
  • [L4] Patients experienced a statistically significant clinical improvement in PROs, and pain scores, and reported high satisfaction after endoscopic trochanteric bursectomy with or without gluteus medius repair. [23] (10.1177/2325967114s00012)
  • [L4] While the majority of patients with GTPS will improve with non-operative management, endoscopic iliotibial band release, trochanteric bursectomy and gluteal tendon repair is a safe and effective treatment for severe recalcitrant cases. [24] (10.1007/s00402-016-2511-z)
  • [L3] The occurrence of trochanteric bursitis is not influenced by the surgical approach (posterior or direct anterior) and could not be predicted by specific comorbidities or radiographic measurements. [25] (10.1016/j.arth.2017.11.016)
  • [L1] This randomized trial found no significant difference in outcomes between LR-PRP and placebo for the treatment of greater trochanteric pain up to 6 months following the intervention. [26] (10.2106/jbjs.24.00763)
  • [L4] Surgical repair of torn gluteal tendons in patients with severe symptoms has been effective at relieving symptoms in 95% of the cases that were reviewed. [27] (10.1016/j.arth.2011.03.004)
  • [L4] Patients with unilateral FAIS have a significantly decreased muscle CSA in the symptomatic hip compared with the asymptomatic hip. [28] (10.1016/j.arthro.2018.11.053)
  • [L1] Responders to the GLoBE intervention had significantly better VISA-G, HOOS, OHS, and lateral hip pain questionnaire scores compared to responders in the sham group. [31] (10.1089/jwh.2017.6729)
  • [L2] Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis. [32] (10.1097/blo.0b013e31802f9f9a)
  • [L3] Participants with GTPS were the least likely to be in fulltime work and had lower quality of life scores, Harris Hip Scores, and higher Oswestry Disability Index scores compared to the asymptomatic group. [33] (10.1016/j.arth.2012.10.016)
  • [L4] Nonoperative treatment might be a valid long-term option for degenerative hip abductor lesions, especially for partial tears, which demonstrated a low risk of clinically relevant progression or muscle fatty infiltration and similar clinical outcomes to those reported in the literature for operatively treated hip abductor tendon lesions. [35] (10.1177/03635465221135759)
  • [L3] All patients with increased femoral version >35° had limited external rotation <40°, and most had limited extension <20° due to posterior intra- or extra-articular hip impingement. [36] (10.1177/03635465231153624)
  • [L4] Preoperative fatty infiltration was not associated with pertinent parameters of patient outcome after hip abductor tendon repair, including pain, symptoms, functional capacity, perceived improvement, and satisfaction. [37] (10.1177/0363546519873672)
  • [L3] [38] (10.1016/j.arthro.2021.01.058)
  • [L4] [39] (10.1136/jisakos-2020-000474)
  • [L5] Increased symptoms with provocative impingement or instability testing indicate adjunctive hip arthroscopy to address intra-articular abnormalities, and ultrasound-guided analgesic injection testing can aid in diagnosis for mixed-pathology cases. [40] (10.1016/j.arthro.2022.08.014)
  • [L3] The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up. [41] (10.1177/03635465231188114)
  • [L4] The increased muscle CSA of the gluteus maximus and the gluteus minimus was significantly correlated with improvement in modified Harris Hip Score and pain Visual Analog Scale, respectively. [42] (10.1016/j.arthro.2020.10.049)
  • [L4] Endoscopic gluteus medius repair resulted in significant improvement in all four patient-reported outcomes and pain scores at two-year follow-up. [43] (10.2106/jbjs.n.01229)
  • [L5] Research studies are needed to see how well diagnostic injection predicts outcome after arthroscopic hip surgery in those with nonarthritic intra-articular hip pain. [44] (10.1016/j.arthro.2013.11.024)
  • [L5] The article highlights the importance of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol, and identifies the need for randomized controlled trials to develop a nonoperative strategy. [51] (10.1016/j.arthro.2017.08.238)
  • [L4] Endoscopic repair of gluteus medius tears is a safe procedure with favorable and durable long-term outcomes at minimum 10-year follow-up. [52] (10.1016/j.arthro.2023.10.049)
  • [L1] Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively. [53] (10.1016/j.arthro.2022.06.031)
  • [L3] Preoperative widths and cross-sectional areas of the gluteus medius/minimus, gluteus maximus, and iliopsoas muscles may be associated with, and to a limited extent help predict, the clinical outcomes at two years postoperatively in patients with FAIS. [54] (10.1186/s12891-026-10096-5)
  • [L3] Patients experienced good pain relief and improved function after surgery, with improvements evident by 1 to 3 months and lasting throughout the follow-up period. [55] (10.1016/j.arthro.2007.03.031)
  • [Paper] The manuscript presents a preferred method for the treatment of trochanteric bursitis using a minimally invasive endoscopic procedure, noting advantages such as limited soft tissue disruption and diminished blood loss compared with open procedures. [56] (10.1016/j.eats.2016.07.005)
  • [L4] [92] (10.5435/jaaosglobal-d-23-00085)
  • [L4] [96] (10.1177/0363546513481575)
  • [L4] Endoscopic iliopsoas tenotomy after THA is effective for treating iliopsoas impingement with resolution of groin pain in 93.3% of patients, avoiding acetabular revision and resulting in only a low rate of complications. [99] (10.1016/j.arth.2019.03.030)
  • [L5] The rectus femoris direct and reflected heads originate over a broad area of the anterolateral pelvis and are in close proximity to critical neurovascular structures, and care must be taken to avoid them during hip arthroscopy. [100] (10.1016/j.arthro.2014.03.003)
  • [L4] In this study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average of 31.2 months follow-up, while offering the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair. [102] (10.1016/j.arthro.2020.04.025)
  • [L4] Arthroscopic trochanteric bursectomy with concomitant iliotibial band release is a new, safe, minimally invasive technique that allows patients to return to full activities within a few weeks. [103] (10.1016/j.arthro.2006.10.021)
  • [L4] Intra-articular findings in patients who did not respond to the diagnostic injection did not differ from those who responded, implying false-negative results render the technique not 100% reliable. [105] (10.1016/j.arthro.2013.11.023)
  • [L4] More than one-third of patients will fail even best-practice nonoperative management, and in these patients early surgical intervention should be considered. [106] (10.1177/03635465221148744)
  • [L3] Corticosteroid injection(s) for postoperative trochanteric bursitis is effective, but nonoperative management may be more likely to fail in young patients and those with leg-length discrepancy. [107] (10.1016/j.arth.2009.02.008)
  • [L4] Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair. [109] (10.1016/j.arth.2008.12.010)
  • [L5] The gluteus medius tendon consists of thick posterior and thin anterolateral parts, which were identified by the facet or aspect of the bone structures and thinness of their border region. [111] (10.2106/jbjs.18.00602)

See Also

References

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[2] Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06354-1

[3] Clinical and Radiographic Criteria Define “Acceptable” Surgical Correction of Hip Femoroacetabular Impingement Syndrome as Well as Postoperative Complications: An International Modified Delphi Study. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.11.023

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[5] Gluteus Maximus Transfer for Irreparable Hip Abductor Deficiency: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2023.10.036

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[8] Editorial Commentary: Platelet‐Rich Plasma Versus Surgery for Hip Greater Trochanteric Pain Syndrome—Systematic Reviews Made Difficult by the Use of Vague Terms. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2019.12.019

[9] Management of Hip Abductor Tears and Recalcitrant Trochanteric Bursitis in Native Hips. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00224

[10] Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2019.04.004

[11] The Prevalence of Radiographic Findings of Structural Hip Deformities for Femoroacetabular Impingement in Patients With Hip Pain. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546519896355

[12] Improved Outcomes With Platelet‐Rich Plasma for Treating Extra‐articular Hip Pathology Especially Greater Trochanteric Pain Syndrome and Hamstring Injury: A Systematic Review of Randomized Controlled Trials. Arthroscopy. 2026. DOI: 10.1002/arj.70024

[13] Pertrochanteric Calcifications in Patients With Greater Trochanteric Pain Syndrome: Description, Prevalence, and Correlation With Intraoperatively Diagnosed Hip Abductor Tendon Injuries. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211008104

[14] Pain relief and good functional outcomes after hip endoscopy via posterior approach in patients with ischiofemoral impingement. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06309-6

[15] What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07217-3

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[17] Greater Trochanteric Pain Syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-14-00406

[19] Outcomes of cup revision for ilio-psoas impingement after total hip arthroplasty: Retrospective study of 46 patients. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.07.021

[21] Ischiofemoral impingement syndrome: a case report and review of literature. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03287-y

[22] High Prevalence of Lumbosacral Pathology in Patients with Greater Trochanteric Pain Syndrome. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.09.026

[23] Outcomes of Endoscopic Treatment for Greater Trochanteric Pain Syndrome: Minimum of Two-Year Follow-Up. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00012

[24] The outcome of endoscopy for recalcitrant greater trochanteric pain syndrome. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2511-z

[25] Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.11.016

[26] Efficacy of Platelet-Rich Plasma Versus Placebo for the Treatment of Greater Trochanteric Pain Syndrome. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00763

[27] Surgical Repair of the Gluteal Tendons. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2011.03.004

[28] Patients With Unilateral Femoroacetabular Impingement Syndrome Have Asymmetrical Hip Muscle Cross‐Sectional Area and Compensatory Muscle Changes Associated With Preoperative Pain Level. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.11.053

[31] Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial. Journal of Women's Health. 2018. DOI: 10.1089/jwh.2017.6729

[32] Lateral Hip Pain. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e31802f9f9a

[33] Greater Trochanteric Pain Syndrome Negatively Affects Work, Physical Activity and Quality of Life: A Case Control Study. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2012.10.016

[35] Natural History of Degenerative Hip Abductor Tendon Lesions. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221135759

[36] Limited External Rotation and Hip Extension Due to Posterior Extra-articular Ischiofemoral Hip Impingement in Female Patients With Increased Femoral Anteversion: Implications for Sports, Sexual, and Daily Activities. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231153624

[37] Association of Preoperative Gluteal Muscle Fatty Infiltration With Patient Outcomes in Women After Hip Abductor Tendon Repair Augmented With LARS. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519873672

[38] Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.01.058

[39] Both open and endoscopic gluteal tendon repairs lead to functional improvement with similar failure rates: a systematic review. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000474

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[41] Progression of Osteoarthritis at Long-term Follow-up in Patients Treated for Symptomatic Femoroacetabular Impingement With Hip Arthroscopy Compared With Nonsurgically Treated Patients. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231188114

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Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.