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Greater trochanteric pain syndrome

54 citationsUpdated Oct 2026
Illustration: hip

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Greater trochanteric pain syndrome (GTPS) is a lateral hip pain condition where advances in imaging and sports medicine have refined the understanding of its pathology and management [2]. Accurate diagnosis is critical, as patients without palpable tenderness over the greater trochanter are unlikely to have MRI-detected GTPS [1]. Failure to identify extra-articular sources of hip pain, including pathology from the anterior inferior iliac spine, can lead to poorer outcomes and future revision surgery [4]. Precise diagnosis and appropriate procedures for concurrent GTPS during surgery may improve overall results [6]. Hip abductor tears are increasingly recognized as a cause of lateral hip pain and dysfunction [9]. 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].

The majority of patients with GTPS will improve with non-operative management [24]. However, surgical intervention is indicated for symptomatic patients who have failed a primary nonoperative protocol [51]. There is an identified need for randomized controlled trials to develop a nonoperative strategy for gluteal tendon tears [51]. 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]. 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].

Treatment options include shock wave therapy [7], platelet-rich plasma injections [8], and surgery [8]. 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 GTPS and hamstring pathology [12]. Injections into the greater trochanteric bursa may have longer lasting benefit [15]. A randomized trial found no significant difference in outcomes between low-volume platelet-rich plasma and placebo for the treatment of GTPS up to 6 months following the intervention [26]. Endoscopic techniques, such as trochanteric bursectomy with or without gluteus medius repair, offer advantages including limited soft tissue disruption and diminished blood loss compared with open procedures [57]. 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 full-thickness gluteal tendon tears offers the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair [104]. In a study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, outcomes exceeded the minimum clinically important difference thresholds in the majority of patients at an average of 31.2 months follow-up [104]. Endoscopic iliotibial band release, trochanteric bursectomy, and gluteal tendon repair is a safe and effective treatment for severe recalcitrant cases of GTPS [24]. Hip arthroscopy can effectively improve patient outcomes in atypical hip pain [16].

Anatomy & Pathophysiology

Osseous Structures

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [62]. The pelvic girdle consists of two innominate (coxal) bones that articulate with the sacrum and proximal femora [68]. Each innominate bone comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [62, 68]. The acetabulum features an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [62]. It is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally, with the posterosuperior articular surface thickened to accommodate weight bearing [68]. The inferior surface contains the acetabular (cotyloid) notch, bound by the transverse acetabular ligament [68].

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 [62]. The neck-shaft angle of the femur averages 125° [62] or 127 degrees, beginning at 141 degrees in the fetus [68]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [62]. The femoral neck is normally anteverted approximately 14 degrees in relation to femoral condyles, with a range of 1–40 degrees [68]. The angular projection of the femoral head and neck relative to the obliquely placed acetabulum allows for rotary movements and prevents impingement [62]. At the junction of the neck and shaft are the greater and lesser trochanters, connected by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly [62]. These trochanters serve as important bony landmarks and attachment sites for thigh and pelvic muscles [62].

The iliac crest is a palpable rim of the ilium and an important site for bone graft harvest [68]. The anterior-superior iliac spine (ASIS) is palpable at the lateral edge of the inguinal ligament and serves as the origin of the sartorius muscle and transverse and internal abdominal muscles [68]. The anterior-inferior iliac spine (AIIS) is less prominent and serves as the origin of the direct head of the rectus femoris and iliofemoral ligament [68]. The posterior-superior iliac spine (PSIS) is located 4–5 cm lateral to the S2 spinous process and is an important landmark for posterior iliac crest bone graft harvest [68]. The ischium forms the posterior column of the acetabulum [68]. The ischial tuberosity serves as the origin of the hamstrings [68]. The pubis forms the anterior pelvic ring, with bilateral pubic rami articulating at the pubic symphysis [68]. The iliopectineal eminence is an anterior pelvic rim prominence at the union of the ilium and pubis [68].

The femoral head is usually not present at birth but appears as one large physis that includes both trochanters at about the age of 11 months and fuses at age 18 years [68]. Slipped capital femoral epiphysis occurs through the femoral head physis in the zone of hypertrophy [68]. The distal femoral epiphysis is present at birth and fuses at age 19 years, responsible for the highest percentage of growth in the lower extremity [68].

Ligamentous Structures

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [62]. The capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [62]. The hip capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [63]. Inferiorly, the hip capsule is attached to the acetabular labrum [63]. The capsule is attached to the femur anteriorly along the intertrochanteric crest; on the posterior side, it attaches only partially, such that the basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [63].

The Y-shaped iliofemoral ligament is the thickest and strongest of the three main ligaments supporting the hip [62]. The medial portion connects the anterior inferior iliac spine to the anterior intertrochanteric line, while the lateral portion originates slightly superior to the medial arm and attaches to the anterior greater trochanter [62]. The iliofemoral ligament functions to limit external rotation, while, in isolation, the lateral arm limits extension of the joint [62]. The iliofemoral ligament becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [63]. 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 [62]. The ischiofemoral ligament reinforces the posterior capsule and provides a check to internal rotation of the hip [63]. The pubofemoral ligament extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [62]. Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [62]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [63].

The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [63]. The sacrospinous and sacrotuberous ligaments create the boundaries of the greater and lesser sciatic foramina [63]. The sacrospinous ligament creates the upper border of the lesser sciatic foramen and the lower border of the greater sciatic foramen [63]. The sacrotuberous ligament creates the inferior border of the lesser sciatic foramen [63]. The iliac spine separates the greater and lesser sciatic notch, and the sacrospinous ligament separates the greater and lesser sciatic foramina [68]. The greater sciatic notch is located posterior and superior to the acetabulum [68].

Meniscal Structures

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 [62]. The labrum is triangular in cross section, which contributes to its ability to create a pressurized seal of the central compartment of the hip during loading [62]. Only the external one-third of the labrum contains blood vessels, leaving the majority of the structure avascular and limiting its healing ability following injury [62]. The labrum is highly innervated, with the presence of both mechanoreceptors and nociceptors [62]. The labrum is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as the continuation of the labrum [62].

Vascular & Neural Structures

The blood supply to the femoral head develops and changes with age [75]. 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 [75]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries (from the medial circumflex artery) are the major blood supply, with minimal supply from the lateral circumflex and ligamentum teres arteries [75]. In adulthood, the major blood supply is from the medial femoral circumflex and lateral epiphyseal arteries [75]. The medial femoral circumflex artery is the main blood supply to the femoral head, terminating in the posterior aspect of the extracapsular arterial ring [72]. The lateral femoral circumflex artery gives rise to the anterior aspect of the arterial ring [72]. The superior and inferior gluteal arteries also contribute branches to the extracapsular arterial ring [72].

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 [72]. The lateral group of ascending branches is the main blood supply to the femoral head [72]. 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 [72]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the [72].

The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament [75]. The common femoral artery passes anterior and medial to the hip capsule [75]. The common femoral vein is a continuation of the external iliac vein [75]. The common femoral vessels are the most commonly reported extrapelvic vascular structures injured during total hip arthroplasty [75]. The most common mechanism of injury to the common femoral vessels is errant retractor placement anterior to the acetabulum [75]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [75]. The profundus femoral artery travels between the pectineus and adductor longus muscles [75]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery and has ascending and descending branches [75]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery [75]. The medial circumflex artery traverses between the pectineus and psoas muscles and appears at the upper border of the quadratus femoris [75].

The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [75]. Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [75]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery and exit the pelvis between the piriformis and coccygeus muscles [75]. The inferior gluteal vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [75].

The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen [63]. The short external rotator muscles exit from the lesser sciatic foramen [63]. The piriformis forms the reference structure for the posterior part of the hip, with structures identified by whether they originate above or below it [70]. The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [70]. 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 exit the pelvis below the piriformis [70]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [70]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [70].

Muscular Structures

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [70]. The iliopsoas muscle has a large origin along the iliac crest, iliac fossa, sacra ala, iliolumbar ligaments, and sacroiliac ligaments, as well as origins along the bodies of T12 through L4 vertebrae, transverse processes of L1–L5, and intervertebral disks [70]. The iliacus muscle originates from the iliac fossa and inserts on the lesser trochanter, innervated by the femoral nerve (L2–L4) [70]. The psoas muscle originates from the transverse processes of L1 through L5 and inserts on the lesser trochanter, innervated by the femoral nerve (L2–L4) [70]. The rectus femoris crosses the hip and knee joints, with the straight head originating from the AIIS and the reflected head from the supra-acetabular tubercle [70]. The rectus femoris originates from the AIIS and acetabular rim, inserting on the patella and tibial tubercle, innervated by the femoral nerve (L2–L4) [70]. The sartorius muscle originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and pes anserine complex [70]. The sartorius originates from the ASIS and inserts on the proximal medial tibia, innervated by the femoral nerve (L2–L4) [70]. The pectineus muscle originates from the pectineal line of the pubis and inserts on the pectineal line of the femur, innervated by the femoral nerve (L2–L4) [70]. The iliopsoas muscle/tendon traverses a groove between the iliopectineal eminence and AIIS [68].

The tensor fasciae latae muscle originates laterally on the anterolateral edge of the iliac crest, with fibers combining with the fasciae latae to form the iliotibial band [70]. The action of the tensor fasciae latae is to flex, abduct, and rotate the hip [70]. The gluteus maximus and hamstring muscles are the most important hip joint extensors [70]. The gluteus maximus originates from the sacrum, coccyx, and sacrotuberous ligaments, inserting into the lateral intramuscular septum [70]. The hamstring muscles originate on the ischial tuberosity [70].

The abductors of the hip are predominantly the gluteus medius and minimus muscles [70]. The gluteus medius has three different components: anterior, middle, and posterior [70]. The gluteus medius and minimus muscles function together to maintain and abduct the femur during the stance phase of gait [70]. 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 [70]. Damage and/or weakness to the abductor muscles can occur during surgical approaches to the hip, affecting hip stability and potentially necessitating constrained hip implants [70].

The adductor muscles of the hip include the adductor brevis, adductor longus, adductors magnus, pectineus, and gracilis [70]. The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [70]. The obturator internus muscle originates from the inner component of the obturator foramen and emerges through the lesser sciatic foramen [70]. The piriformis muscle originates from the greater sciatic foramen and inserts onto the greater trochanter [70]. The internal rotation of the hip is performed by muscles that have primary functions other than internal rotation, making it a secondary function of those muscle groups [70]. The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [70].

Kinematics

The average range of motion of a normal hip is approximately 120° of flexion, 30° of extension, 45° of abduction, 20° to 30° of adduction, 35° of internal rotation, and 45° of external rotation [70]. Normal gait function requires hip flexion of 30°, hyperextension of 10°, abduction and adduction of 5°, and internal and external rotation of 5° [70].

Classification

Historical Context and Diagnostic Criteria: 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]. Patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected gluteal tendinopathy [1]. Accurate diagnosis of the underlying etiology is the key to successful management of greater trochanteric pain syndrome [17].

Greater Trochanteric Pain Syndrome Spectrum: Greater trochanteric pain syndrome encompasses greater trochanteric bursitis, gluteus medius and gluteus minimus tears, and external coxa saltans [17]. Two or more diagnoses within the greater trochanteric pain syndrome spectrum 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 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]. The corresponding surgical techniques for the intraoperative classification of greater trochanteric pain syndrome are described as reproducible for surgeons treating peritrochanteric pathology [10]. The bursectomy technique is recommended for Type II hip abductor tear repairs [9].

Other Considerations: Proximally and distally directed enthesophytes are strong predictors for the presence of a hip abductor tendon tear [13]. Proximally and distally directed enthesophytes are specifically strong predictors for the presence of a full-thickness hip abductor tendon tear [13]. Increasing size of pertrochanteric calcifications is associated with more severe hip abductor 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 the 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]. Accurate diagnosis of the underlying etiology is the key to successful management of GTPS [17]. Two or more diagnoses within the GTPS spectrum are often seen concomitantly [17]. Imaging studies indicate that most patients diagnosed with bursitis actually have abductor tears, tendinosis, and thickened iliotibial bands with little to no evidence of actual bursitis [17].

The clinical presentation of GTPS includes tenderness over the lateral aspect of the hip and weakness in abduction [17]. 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 peritrochanteric calcifications is associated with more severe tendon injuries [13]. Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis [32].

Patients with GTPS are the least likely to be in full-time work compared to asymptomatic individuals [33]. Patients with GTPS have lower quality of life scores and Harris Hip Scores compared to asymptomatic individuals [33]. Patients with GTPS have higher Oswestry Disability Index scores compared to asymptomatic individuals [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

Clinical Examination and Diagnostic Testing: A thorough clinical examination is required to establish a differential diagnosis, as many hip conditions present with similar symptoms [45]. Clinical examination tests and imaging findings should be used to confirm a suspected clinical diagnosis [45]. Increased symptoms with provocative impingement or instability testing indicate adjunctive hip arthroscopy to address intra-articular abnormalities in patients with greater trochanteric pain syndrome [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 false-negative results render the technique not 100% reliable [107]. 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 [46]. A complete hip series usually consists of an anterior-posterior (AP) 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]. 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].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [79]. Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [79]. Magnetic resonance arthrography (MRA) is more appropriate to determine injuries to the labrochondral structures and the ligamentum teres and identify the presence of loose bodies and synovial chondromatosis [79]. The utility of MRA in the accurate detection and staging of articular cartilage lesions is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [79]. Recent advances in MRI imaging techniques, such as delayed gadolinium-enhanced MR imaging and T2* mapping, allow for a more in-depth analysis of the structure of articular cartilage [79]. Imaging studies have shown that most patients who receive a diagnosis of bursitis actually have abductor tears, tendinosis, and thickened ITBs with little to no evidence of actual bursitis [17]. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair [111]. Patients with hip abductor tendon disorders were associated with a high prevalence of underlying lumbar and lumbosacral pathologies [22].

Ultrasonography: Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [64]. It is particularly useful in providing real-time guidance during diagnostic and therapeutic procedures [64]. Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [79]. It is increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip [79]. Ultrasonography provides dynamic assessment of structures such as tendon and nerve subluxation [83]. However, ultrasonography cannot image inside bone because bone cortex reflects almost all sound waves [83].

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 [79]. Measurements of femoral head coverage and acetabular and femoral impingement can also be performed reliably using CT images [79]. CT overcomes the limitations of radiography by providing three-dimensional assessment of bony morphology and, to some degree, assessment of soft-tissue abnormalities [64]. Combined with arthrography, CT can evaluate chondrolabral abnormalities, specifically in patients with contraindications to MRI [64].

Other Considerations: Findings from imaging studies should complement clinical examination findings to provide the most accurate diagnosis [45]. The complexity of the hip and pelvic region can make accurate diagnosis of painful conditions difficult [45]. A thorough understanding of normal anatomy and biomechanics is necessary to identify pathology and determine the appropriate course of treatment [45].

Treatment

Non-Operative

Conservative management remains a primary treatment pathway for greater trochanteric pain syndrome. All randomized controlled trials demonstrated improvements in pain and function following platelet-rich plasma injection, meeting clinically relevant outcome thresholds, with meta-analyses favoring this intervention for greater trochanteric pain syndrome and hamstring pathology [12]. Gluteal loading exercise interventions also yield significant benefits; responders exhibited significantly better VISA-G, HOOS, OHS, and lateral hip pain questionnaire scores compared to responders in the sham group [31]. For degenerative hip abductor lesions, particularly partial tears, nonoperative treatment is a valid long-term option, as these patients demonstrate a low risk of clinically relevant progression or muscle fatty infiltration and achieve clinical outcomes similar to those reported for operatively treated lesions [35]. 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 [109]. While both platelet-rich plasma injections and surgery result in favorable outcomes, heterogeneity in the treated condition, severity, and treatment protocols makes it difficult to definitively state that one method is superior to the other [8]. More than one-third of patients fail even best-practice nonoperative management, warranting consideration of early surgical intervention in these cases [108].

Operative

Indications: Surgical intervention is indicated when nonoperative management fails, which occurs in more than one-third of patients [108]. 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 [9].

Surgical Approach / Technique: Endoscopic gluteus medius repair results in significant improvement in all four patient-reported outcomes and pain scores at two-year follow-up [43]. Patients report high satisfaction and statistically significant clinical improvement in patient-reported outcomes and pain scores after endoscopic trochanteric bursectomy, with or without gluteus medius repair [23]. Arthroscopic trochanteric bursectomy with concomitant iliotibial band release is a safe, minimally invasive technique that allows patients to return to full activities within a few weeks [105]. The corresponding surgical techniques for peritrochanteric pathology are described as reproducible for surgeons treating greater trochanteric pain syndrome [10]. A preferred method for treating trochanteric bursitis using a minimally invasive endoscopic procedure offers advantages such as limited soft tissue disruption and diminished blood loss compared with open procedures [57]. For Type II tear repairs, the bone tunnel technique is recommended [9]. Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain [5].

Other Considerations: In cases where postoperative hip pain increases or plateaus, further investigation and treatment are warranted between 6 and 12 months. A reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain [3].

Complications

Diagnostic and Etiologic Considerations

Diagnostic Overlap: 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 who receive a diagnosis of bursitis actually have abductor tears, tendinosis, and thickened iliotibial bands with little to no evidence of actual bursitis [17].

Systemic Associations: There is an association between systemic hormonal contraception and hip pathology 5 years after initiation among female patients aged 13 to 50 years old [18].

Missed Extra-articular Pathology: Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the anterior inferior iliac spine, could lead to poorer outcomes and future revision surgery [4].

Postoperative Complications and Management

Timing of Re-intervention: In cases in which postoperative hip pain increased or plateaued, further investigation and treatment is warranted between 6 and 12 months [3]. A reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain [3].

Post-THA Bursitis: The occurrence of trochanteric bursitis following primary total hip arthroplasty is not influenced by the surgical approach (posterior or direct anterior) [25]. 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: Meta-analyses of randomized controlled trials favor platelet-rich plasma (PRP) for treating greater trochanteric pain syndrome and hamstring pathology [12]. All randomized controlled trials identified clinically relevant improvements in pain and function following PRP injection [12]. However, a specific randomized trial found no significant difference in outcomes between low-volume PRP and placebo for greater trochanteric pain up to 6 months post-intervention [26]. Heterogeneity in treated condition, severity, and treatment, combined with a lack of direct comparison, makes it difficult to determine if PRP or surgery is superior [8]. Nonoperative treatment remains a valid long-term option for degenerative hip abductor lesions, especially partial tears [35]. Partial tears demonstrate a low risk of clinically relevant progression or muscle fatty infiltration [35] and achieve clinical outcomes similar to those reported for operatively treated hip abductor tendon lesions [35].

Operative Management: Endoscopic repair of gluteus medius tears is a safe procedure with favorable and durable long-term outcomes at minimum 10-year follow-up [53]. Patient-reported functional outcomes improve at follow-up at least 1 year postoperatively for endoscopic repair of gluteal tendon tears [54]. For recalcitrant trochanteric bursitis, arthroscopic bursectomy provides good pain relief and improved function [56], with improvements evident by 1 to 3 months and lasting throughout the follow-up period [56]. Gluteus maximus tendon transfer for abductor insufficiency demonstrates reliable outcomes at 3 years [5], resulting in improved hip function and pain at that interval [5].

Prognosis and Natural History: Participants with greater trochanteric pain syndrome are the least likely to be in fulltime work compared to the asymptomatic group [33]. This population reports lower quality of life scores [33] and lower Harris Hip Scores [33] compared to asymptomatic individuals. Additionally, participants with greater trochanteric pain syndrome exhibit 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)
  • [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] There is an association between systemic hormonal contraception and hip pathology 5 years after initiation among female patients aged 13 to 50 years old. [18] (10.1016/j.arthro.2025.07.017)
  • [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)
  • [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)
  • [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)
  • [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)
  • [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. [53] (10.1016/j.arthro.2023.10.049)
  • [L1] Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively. [54] (10.1016/j.arthro.2022.06.031)
  • [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. [56] (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. [57] (10.1016/j.eats.2016.07.005)
  • [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. [104] (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. [105] (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. [107] (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. [108] (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. [109] (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. [111] (10.1016/j.arth.2008.12.010)

See Also

References

[1] Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine. 2016. DOI: 10.1136/bjsports-2016-096175

[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

[4] Outcomes of Arthroscopic Decompression of the Anterior Inferior Iliac Spine: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465211062903

[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

[6] Editorial Commentary: The Indication and Technique of Iliotibial Band Release for External Snapping Hip During Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.02.014

[7] Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Greater Trochanteric Pain Syndrome. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509333014

[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

[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

[16] Atypical Hip Pain in Femoroacetabular Impingement: A Comparison of Outcomes Based on Primary Hip Pain Location. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519887733

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

[18] Systemic Hormonal Contraception Is Associated With a Greater Rate of Greater Trochanteric Pain Syndrome, Labral Tear, and Femoroacetabular Impingement Syndrome in Female Patients. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2025.07.017

[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

[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

[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

[40] Editorial Commentary: Treatment of Concomitant Intra‐Articular Pathology in Patients With Greater Trochanteric Pain Syndrome Is Indicated by Provocative Impingement or Instability Physical Examination and Ultrasound‐Guided Analgesic Injection Testing. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.08.014

[43] Outcomes of Endoscopic Gluteus Medius Repair. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.01229

[44] Authors' Reply. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.11.024

[45] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Summary.

[46] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[51] Editorial Commentary: Pioneering the Gluteal Interval: Understanding and Treating Undersurface and Full‐Thickness Gluteus Medius Tears of the Hip. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.238

[53] Favorable and Durable Outcomes at 10‐Year Follow‐Up After Endoscopic Gluteus Medius Repair With Concomitant Hip Arthroscopy. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.10.049

[54] Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.06.031

[56] Arthroscopic Bursectomy for Recalcitrant Trochanteric Bursitis (SS‐18). Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.031

[57] Endoscopic Trochanteric Bursectomy and Iliotibial Band Release for Persistent Trochanteric Bursitis. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.07.005

[62] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[63] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[64] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Introduction.

[68] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > LOWER EXTREMITY.

[70] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[72] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Hip > I. General Considerations.

[75] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

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[83] Aaos Comprehensive Orthopaedic Review 3. Musculoskeletal Imaging* > IV. Ultrasonography.

[104] Endoscopic Repair of Full‐Thickness Gluteus Medius and Minimus Tears—Prospective Study With a Minimum 2‐Year Follow‐Up. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.04.025

[105] Arthroscopic Bursectomy With Concomitant Iliotibial Band Release for the Treatment of Recalcitrant Trochanteric Bursitis. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.10.021

[107] The Role of Fluoroscopically Guided Intra‐Articular Hip Injections in Potential Candidates for Hip Arthroscopy: Experience at a UK Tertiary Referral Center Over 34 Months. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.11.023

[108] The Effect of a Formal Nonoperative Management Program Combining a Hip Injection With Structured Adjunctive Exercise Rehabilitation in Patients With Symptomatic Femoroacetabular Impingement Syndrome. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221148744

[109] Trochanteric Bursitis After Total Hip Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.02.008

[111] Late Repair of Abductor Avulsion After the Transgluteal Approach for Hip Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.12.010

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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.