Gluteal Tendinopathy (Lateral Hip Pain)

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

Gluteal tendinopathy is the most common cause of pain over the outer (lateral) side of the hip, at the bony point called the greater trochanter. The gluteus medius and minimus muscles attach here by their tendons, and act as the main stabilisers of the pelvis – they stop the pelvis dropping when you stand on one leg and when you walk. Gluteal tendinopathy is a degenerative and load-related problem of these tendons, and is the true cause of most pain that used to be labelled “trochanteric bursitis”. The bursa (a fluid-filled cushion overlying the tendons) may be inflamed as well, but the tendon is usually the primary problem.

It is most common in women between 40 and 65, and in runners and walkers. It affects roughly one in four women over 50 at some point, and although benign, it can be surprisingly disabling and slow to settle.

Why it happens

Two forces combine to irritate the tendon. The first is tensile overload – simply asking the tendon to do more than it is conditioned for (a rapid increase in walking or running, or weakness of the hip muscles). The second, and often more important, is compression – when the thigh moves across the midline of the body, the tendon is squeezed against the bone. Everyday positions that compress the tendon include standing “hanging” on one hip, sitting with the knees crossed or knees together and feet apart, and lying on your side with the top knee dropped forward. Over time the tendon becomes degenerate (tendinopathy) and, in some people, develops partial or full-thickness tears, sometimes with wasting (fatty atrophy) of the muscle.

Symptoms

Typical features are pain and tenderness over the point of the hip, often spreading down the outer thigh, that is:

●      Worse when lying on the affected side at night (and sometimes on the opposite side, when the painful hip drops into compression)

●      Worse going up stairs or hills, standing on one leg, and after prolonged sitting or walking

●      Sometimes associated with a limp or a feeling of weakness in more severe or torn cases

Diagnosis

The diagnosis is usually clear from the history and examination. Key findings include tenderness directly over the greater trochanter and pain reproduced by standing on the affected leg (a single-leg stance test) or by resisted hip abduction. An important part of the assessment is distinguishing gluteal tendinopathy from other causes of hip and buttock pain – particularly hip joint arthritis, referred pain from the lower back, and femoroacetabular impingement – because these are treated very differently.

Where the diagnosis is unclear, or a tendon tear is suspected (persistent weakness, a limp, or failure to improve), ultrasound or MRI can confirm tendinopathy, show whether there is a partial or full-thickness tear, and grade any muscle wasting – information that influences whether surgery is likely to help.

Non-operative treatment

The great majority of people improve without surgery, and this is always the starting point. It has two parts:

Load management and unloading the tendon

Learning to avoid the compressive positions listed above is often the single most helpful step – for example not sitting with the legs crossed, keeping the knees apart, not standing hung on one hip, and placing a pillow between the knees when sleeping on the side. Painful activities are modified (not stopped) to keep the tendon below its irritable threshold.

A structured exercise programme

A progressive, physiotherapist-guided programme, typically starting with gentle isometric (static) holds and building to strengthening of the hip abductors and control of the pelvis, is the most effective treatment. It takes time – usually several months – and consistency is more important than intensity.

The role of injections

A corticosteroid injection can reduce pain in the short term but does not improve the longer-term outcome, and repeated injections can weaken the tendon, so it is used sparingly. Other injections (such as platelet-rich plasma) and shockwave therapy are used in some resistant cases, but the evidence for them is still developing.

Surgery — for tendon tears

Surgery is not needed for most people. It is considered where there is a significant tendon tear, or where a good non-operative programme has failed, particularly if there is weakness and a limp. The operation reattaches the torn abductor tendon to the bone (usually with suture anchors), and any troublesome bursa is removed. It can be performed through a small open incision or endoscopically (keyhole).

What the evidence shows

The LEAP randomised controlled trial compared education plus exercise, a corticosteroid injection, and a “wait and see” approach. Education and exercise produced significantly greater improvement in pain and global rating of change at both 8 weeks and 52 weeks than either other option, and by 12 months a corticosteroid injection was no better than doing nothing – strong evidence for prioritising a structured exercise programme.

For tendon tears that require surgery, a systematic review found that both open and endoscopic repair reliably improve pain and function, with a low overall re-tear rate (around 4%) and a lower complication rate for endoscopic repair (about 0.7% versus 7.8% for open), while large, retracted tears with significant muscle wasting have a less predictable result and are usually best repaired open.

Complications

This is a benign condition and complications are uncommon, but points to understand include:

●      Corticosteroid injections can weaken the tendon, thin the fat under the skin and lighten the skin, and give only short-term benefit.

●      The condition is often slow to settle and can flare with overload; recurrence is common if load is not managed.

●      Where surgery is performed, risks include failure of the repair to heal (re-tear), wound problems and infection (more common with open repair), blood clots, and a period of protected weight-bearing and restricted activity during recovery; large, wasted tears may not fully restore strength.

Summary

Lateral hip pain is usually gluteal tendinopathy, driven by compression and overload of the hip abductor tendons. The best first treatment is unloading the tendon and a progressive exercise programme, not injection. Surgery is reserved for genuine tendon tears or resistant cases. Dr Spelman will confirm the diagnosis, exclude other causes such as hip arthritis or spinal referral, and guide the right programme for you.