Lateral hip pain is one of the most common musculoskeletal complaints seen in physiotherapy clinics, particularly in women over the age of 40 and in recreational runners. Although many people assume pain over the outside of the hip is caused by "bursitis," research over the past two decades has shown that the condition is often more complex. Most persistent lateral hip pain is now understood to be part of Greater Trochanteric Pain Syndrome (GTPS), which commonly involves tendon pathology of the gluteal muscles, with or without inflammation of the surrounding bursae.
Understanding the underlying pathology is essential because treatment approaches differ depending on the tissues involved and the stage of the condition.
What is Greater Trochanteric Pain Syndrome?
Greater Trochanteric Pain Syndrome (GTPS) is an umbrella term describing pain originating from structures around the greater trochanter of the femur. The syndrome may involve:
Gluteus medius tendinopathy
Gluteus minimus tendinopathy
Partial tears of the gluteal tendons
Trochanteric bursitis
Iliotibial band compression over the greater trochanter
Current evidence suggests that gluteal tendinopathy is the primary pathology in most chronic cases, while bursitis often occurs as a secondary inflammatory response rather than being the main cause of symptoms.
Anatomy
The gluteus medius and gluteus minimus muscles are the primary stabilisers of the pelvis during walking, running and single-leg activities. Their tendons attach onto the greater trochanter of the femur.
Several bursae lie between these tendons and surrounding tissues, helping reduce friction. Repeated compressive loading, excessive tensile forces, or prolonged pressure can overload the gluteal tendons, resulting in pain and reduced function.
Risk Factors
Several factors increase the likelihood of developing lateral hip pain:
Female sex
Age between 40 and 70 years
Hip abductor weakness
Increased body mass index
Lumbar spine dysfunction
Knee osteoarthritis
Sudden increases in walking or running volume
Repetitive stair climbing
Prolonged standing on one leg
Crossing the legs when sitting
Sleeping on the affected side
Biomechanical factors such as poor pelvic control during walking or running may also increase compressive forces on the gluteal tendons.
Clinical Presentation
Patients commonly report:
Pain over the outside of the hip
Tenderness directly over the greater trochanter
Pain when lying on the affected side
Pain climbing stairs or walking uphill
Pain during prolonged walking
Difficulty standing on one leg
Night pain that disturbs sleep
Unlike hip osteoarthritis, groin pain is usually absent, although some patients experience symptoms extending into the lateral thigh.
Diagnosis
Diagnosis is primarily clinical.
Subjective Assessment
As a physiotherapist we will ask about:
Symptom location
Aggravating and easing activities
Night pain
Previous injuries
Changes in activity levels
Functional limitations
The pattern of symptoms often provides valuable diagnostic information.
Physical Examination
Several clinical tests have good diagnostic value when used together.
Common examination findings include:
Tenderness over the greater trochanter
Pain during single-leg stance
Pain on resisted hip abduction
Pain with resisted external rotation
Hip Raange of movement tests
Assessment of hip strength, gait and pelvic control is equally important.
Imaging
Imaging is not routinely required.
Ultrasound and MRI may identify:
Gluteal tendinopathy
Partial tendon tears
Bursal inflammation
Tendon degeneration
However, imaging findings should always be interpreted alongside the clinical picture, as asymptomatic tendon abnormalities are common.
Differential Diagnosis
Lateral hip pain can mimic several other conditions, including:
Hip osteoarthritis
Lumbar referred pain
Lumbar radiculopathy
Femoral neck stress fracture
Sacroiliac joint dysfunction
Meralgia paraesthetica
Gluteal tendon tears
Inflammatory arthropathy
A thorough assessment helps identify these alternative diagnoses.
Physiotherapy Management
Current clinical guidelines strongly support exercise-based rehabilitation as the first-line treatment.
Education
Patient education is one of the most effective interventions.
Patients benefit from understanding how compressive loading affects irritated tendons. Helpful advice includes:
Avoid prolonged standing with weight on one leg
Avoid sitting with crossed legs
Use a pillow between the knees when side sleeping
Reduce aggravating activities temporarily
Modify training loads rather than stopping activity completely
These simple changes reduce compression of the gluteal tendons and create an environment that promotes recovery.
Exercise Therapy
Progressive strengthening remains the cornerstone of treatment this is to build the load tolerance of the tendons. If the load exerted on the structures is greater than the load tolerance PAIN is the outcome.
The rehabilitation programme generally progresses through four stages:
Stage 1
Isometric hip abductor exercises
Pain reduction
Gentle activation
Stage 2
Progressive strengthening
Side-stepping exercises
Bridges
Sit-to-stand progressions
Stage 3
Functional loading
Single-leg control
Step-ups
Balance training
Stage 4
Return to running or sport
Plyometric progression where appropriate
Sport-specific rehabilitation
Exercises should be progressed according to pain response rather than a fixed timeline.
Manual Therapy
Manual therapy may be useful as an adjunct to exercise.
Potential benefits include:
Reduced pain
Improved hip mobility
Reduced muscle guarding
Improved confidence with movement
However, current evidence suggests manual therapy should complement rather than replace an active rehabilitation programme.
Load Management
One of the most important aspects of treatment is appropriate load management.
Complete rest is generally not recommended.
Instead, patients are encouraged to:
Reduce provocative activities
Gradually reload the tendon
Monitor symptoms
Progress activity systematically
This approach reflects current understanding of tendon adaptation.
Other Treatment Options
Corticosteroid Injection
Corticosteroid injections can provide short-term pain relief.
However, research demonstrates that while injections often improve symptoms in the first few weeks, long-term outcomes are generally inferior to structured exercise programmes.
Repeated injections may negatively affect tendon health and should be used judiciously.
Shockwave Therapy
Extracorporeal shockwave therapy (ESWT) has shown moderate evidence of benefit for persistent gluteal tendinopathy, particularly when combined with exercise rehabilitation.
Platelet-Rich Plasma (PRP)
Evidence for PRP remains mixed. Some studies suggest benefit in selected patients with chronic tendinopathy, while others show little advantage over placebo or exercise. At present, PRP cannot be routinely recommended.
Surgery
Surgery is rarely required.
It may be considered for:
Full-thickness gluteal tendon tears
Persistent symptoms despite comprehensive rehabilitation
Significant functional disability
Surgical repair is followed by a prolonged rehabilitation programme.
Prognosis
Most patients improve with conservative treatment.
Recovery often takes:
Mild cases: 6–12 weeks
Moderate cases: 3–6 months
Chronic tendon pathology: 6–12 months
Early diagnosis and appropriate rehabilitation improve outcomes and reduce recurrence.
Key Messages
Most lateral hip pain is caused by gluteal tendinopathy rather than isolated bursitis.
Greater Trochanteric Pain Syndrome is the preferred diagnostic term.
Diagnosis is usually clinical and does not routinely require imaging.
Exercise therapy and education are the most effective long-term treatments.
Corticosteroid injections may provide short-term relief but are less effective than physiotherapy over the long term.
Progressive strengthening and appropriate load management remain the foundation of successful rehabilitation.
If you are suffering with lateral hip pain and would like to start your journey to fitness again call Victoria on 07813 179825 to discuss your options and book an assessment.