Do you have pain on the outer part of your hip when walking, going up stairs, or lying on your side?
In this blog, I’m going to discuss gluteal tendinopathy (also often referred to as hip bursitis, trochanteric bursitis, or greater trochanteric pain syndrome), dispel the most common myths associated with the diagnosis, and teach you everything you need to know about managing the condition.
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Anatomy & Function
If you put your hand on the side of your hip, you should feel a bony prominence known as the greater trochanter, which is part of your femur, or thigh bone.
The greater trochanter serves as an attachment site for the gluteus medius and gluteus minimus tendons.
In a non-weight bearing position, these two glute muscles act to abduct the hip. More importantly though, they stabilize the pelvis when standing on a single leg, such as when walking, running, and going up stairs.
There is also a trochanteric bursa, which is a fluid-filled sac that serves to cushion and reduce friction in this area. Over the top of these structures lies the Iliotibial (IT) Band.
What’s In A Name?
Hip bursitis, the diagnosis often provided to people experiencing pain in this region, generally refers to inflammation of the trochanteric bursa. However, research spanning across 20 years (Bird et al 2001, Connell et al 2003, Kong et al 2007, Silva et al 2008, Blankenbaker et al 2008, Woodley et al 2008, Fearon et al 2010, Long et al 2013, Lange et al 2022) has determined that bursitis is actually unlikely to be the primary contributing factor to symptoms.
In fact, MRIs often find bursitis in hips that are completely pain-free. For example, a study by Woodley et al in 2008 concluded that “…bursitis was equally prevalent in symptomatic and asymptomatic hips…” It’s common to have bursitis of both hips despite only having symptoms on one side.
Much of the same research found that the tendons of the gluteus medius and minimus are more often involved. Therefore, gluteal tendinopathy, which refers to pain and impaired function associated with the loading of these tendons, has been proposed as the preferred diagnosis.
Having said that, it’s important to point out that tendon changes seen on MRI are also common in people without symptoms. For example, a study by Ganderton et al in 2017 reported that “…88% of asymptomatic participants had pathological gluteal tendon changes on MRI, from mild tendinosis [degeneration] to full-thickness tear.”
Since these “pathological” findings are present in individuals with and without symptoms, imaging is unnecessary in most instances.
In addition to reporting symptoms with sleeping on your side or with activities that load the gluteal tendons, such as walking and climbing up stairs, a study by Grimaldi et al in 2017 concluded that “…a patient who reports lateral hip pain within 30 seconds of single-leg-standing is very likely to have gluteal tendinopathy.”
Alternatively, if you don’t have pain when pressing on your greater trochanter, it’s unlikely that you have gluteal tendinopathy.
It’s also necessary to rule out other causes of lateral hip pain, such as hip osteoarthritis and low back-related issues.
The naming of a diagnosis matters in how it informs management.
Many people associate bursitis with the need for ice, complete rest, and anti-inflammatory medications, and that sometimes creates the idea that management of your symptoms is out of your control.
Gluteal tendinopathy presents more options for self-management, but may oversimplify the problem to a specific set of tissues.
As long as hip osteoarthritis, low back-related issues, and other similar conditions have been ruled out, simply calling it lateral hip pain is another alternative. Although it’s non-specific in nature, it encompasses the potential contributing factors of specific tissues, such as loading of the gluteus medius and minimus tendons, as well as other factors like your metabolic health that I’ll discuss shortly.
Who Gets Gluteal Tendinopathy/Lateral Hip Pain and Why?
Research by Tortolani et al in 2002 and Segal et al in 2007 informs us that it’s more common in women.
One subgroup of women affected is runners. Consider that running consistently loads your gluteal muscles and tendons. If the frequency, volume, and/or intensity of your runs exceeds your capacity to recover and adapt appropriately, gluteal tendinopathy may occur. In this simplified scenario, it’s thought of as a training load error in which you did “too much, too soon.”
More commonly however, gluteal tendinopathy affects older, less active perimenopausal women. Although loading of the gluteal tendons is still a component of the diagnosis, it’s been well-documented that other lifestyle and metabolic factors influence the health of tendons, such as diabetes, hypercholesterolemia, adiposity, and certain medication usage like statins and antibiotics.
Gluteal tendinopathy is complex and multifactorial. It’s useful to acknowledge the role of tendon loading and unloading in its presentation, but the importance of your overall health and well-being cannot be overlooked.
Thankfully, either way, there are a lot of management options!
Load Management & Activity Modifications (Recommended)
Many of the recommendations come from one of the leading researchers, Alison Grimaldi, and co-authors. I’ll list out possible aggravating activities and self-management options. In most cases, the goal is to temporarily modify or minimize painful activities to aid with long-term recovery.
If you have pain sleeping on your affected side, there are 3 easy things to try:
1. Sleep on your back with or without a pillow under your knees
2. Sleep on your unaffected side with 2 pillows between your legs
3. Purchase a mattress topper for added comfort
If you have pain while sitting, you can try to determine if symptoms are worse when your legs are crossed, when you sit in a low or deep seat, or when you sit for a prolonged period of time.
If needed, modify your sitting position, raise the height of your seat, or take periodic standing breaks.
If you have pain while walking, the most important thing to do is track your steps, figure out your maximum tolerable distance on a day-to-day basis, and then gradually increase your steps over time as symptoms improve. You can also trial walking faster or taking shorter steps as both require less time spent in single limb stance per step.
If you have pain with stairs, make sure to always use the railing on the opposite side of your painful hip when available. If even that is too much, go up one step at a time, leading with your non-painful side.
With regards to stretching, many people believe that it’s required to get better, especially as it relates to the IT band or piriformis. If performing a seated figure 4 stretch or standing hip stretch feels good, you can certainly do it, but neither is absolutely necessary. Gluteal tendinopathy isn’t the result of the IT band or piriformis being “too tight”.
If you have pain with running, it’s essential to modify the frequency, volume, and/or intensity of your runs to find a tolerable starting point. You can also test out increasing your cadence, which is the number of steps you take per minute, by 5-10% with the intention of decreasing the load on the glutes.
There are a lot of options, but you only need to address the activities relevant to you.
What About Exercise?
To date, there are three randomized controlled trials assessing the effectiveness of exercise as it relates to gluteal tendinopathy. Without going into the details of each study, I want to highlight that some people will get better without having to do specific exercises – perhaps due to the passage of time. We don’t know exactly who those individuals are, but if you’re watching this, you get to decide what information from this blog that you want to apply to your own life.
My bias is to include at least some exercise for several reasons:
- To improve function. Although it’s a chicken or egg scenario, individuals with gluteal tendinopathy demonstrate muscle weakness, which may affect single limb stance. If specific exercises have the potential to improve your function so you can walk further or go upstairs with less difficulty, I think they’re worth a shot.
- To improve your overall health and well-being. People with severe gluteal tendinopathy tend to be less physically active, have a poorer quality of life, and have greater BMIs. General physical activity may address some of these factors, as well as the metabolic factors I mentioned earlier. Whether it’s walking, swimming in a pool, riding a stationary bicycle, or something else, any amount of physical activity is beneficial.
- To improve your confidence. An exploratory analysis of the most recent exercise trial found that “Education plus exercise improves a patient’s overall perception of improvement through mechanisms associated with improving pain self-efficacy and patient-reported hip function and reducing the proportion of time in pain, not through gains in isometric hip abductor muscle strength.” This paper essentially showed that you don’t necessarily have to get stronger or move differently to get better, but believing in your ability to manage your symptoms and accomplish tasks might be an important component of rehab.
I’m going to present 3 categories of exercises and explain my rationale for each. Remember that you get to decide what exercises you choose to do, if you choose to do exercises at all. I’m trying to provide options to accommodate different goals and needs.
Exercise Category #1: “Functional” Movements (Recommended)
Exercise category #1 relates to movements that mimic day-to-day activities, such as getting up and down from a chair, climbing stairs, and standing on a single leg. I think knowing you can accomplish these movements is beneficial for everyday life, regardless if you have gluteal tendinopathy or not.
The first exercise is a bridge. Lie on your back, squeeze your butt muscles, and lift your hips up toward the ceiling. If you want to progress, you can stagger your legs so that one side is working harder than the other. You would do that on both sides. If you want to progress even more, you can perform single leg bridges on each leg. You can set a goal of working up to 3 sets of 20 repetitions, but it’s fine to start with as few repetitions as you need.
The second exercise is a sit-to-stand. You’ll scoot to the front of a stable chair, lean forward, stand up, slowly sit back down, and repeat. If you need to make it easier, you can use your hands for assistance. If you want to make it harder, hold a weight in your hands. Once again, you can have a goal of working up to 3 sets of 20 repetitions, but it’s fine to start with as few repetitions as you need.
The third exercise is a step up, assuming the sit-to-stands are manageable. You can use actual stairs or stack up sturdy objects available to you. If you need to make it easier, use your hands for assistance, decrease the height of the step, or do both. A typical flight of stairs might have around 15 steps, so you can set a goal of being able to perform at least 3 sets of 10 repetitions per leg.
The last exercise is single leg balance. Squeeze the glutes of your standing leg and use your hands for assistance as needed. Build up to 3 sets of 60 seconds.
Whether you choose to do 1 exercise or all 4, they can be done every other day.
Exercise Category #2: Gluteus Medius Specific Strengthening (Optional)
Exercise category #2 relates to movements that focus on directly challenging the hip abduction action of the gluteus medius and minimus muscles. I’ll present 3 options of varying difficulty.
For the first option, place a band or belt above your knees and then lie on your back with a pillow under your knees. Gradually push out into the band or belt for 30 to 45 seconds.
For the second option, stand with your heels hip-width apart or greater, imagine spreading the floor with your feet, and hold this position for 30-45 seconds.
For the final option, lie on your unaffected side with your bottom hip and knee bent. Your top leg should be resting on 2 pillows. While keeping your knee straight, slightly lift the top leg off the pillows and hold for 30-45 seconds. You can add a band or weight to make this exercise harder.
For any of the exercises, you can put your hand on the side of your hip to feel your glutes contracting. You can choose to do 1 movement, as often as daily, for 3 sets of 30-45 second holds.
Exercise Category #3: Advanced Exercises (Optional)
Exercise category #3 includes advanced exercises, which may be most suitable for the runners who want to try to ward off future occurrences of gluteal tendinopathy. Incorporating single leg hip thrusts, split squats, single leg deadlifts, side planks, and banded side steps into your training routine 2 days per week will improve the conditioning of your hip musculature, as well as the rest of your lower leg and trunk.
Understanding and Monitoring Pain
How much pain is acceptable during exercise and other forms of physical activity? Just make sure you can answer “yes” to these 3 questions:
- Are your symptoms tolerable during exercise?
- Are your symptoms tolerable immediately after exercise?
- Are your symptoms tolerable the day after exercise?
If you’re experiencing significant pain during or immediately after exercise, or you have a flare-up in symptoms the following day that you believe to be related to exercise, then it’s worthwhile reevaluating your approach.
Pain during exercise doesn’t necessarily mean that you’re damaging structures or worsening your condition. However, if it’s at a level that’s hindering progress with the exercises, daily activities, or your short and long-term goals, then it’s appropriate to scale back.
The art of rehab is about finding that fine line between doing too much and doing too little. You rarely need to completely rest and avoid all symptoms, but you also shouldn’t approach rehab with a “no pain, no gain” mentality.
And although tracking your pain intensity can be useful in certain situations, don’t only tie your successes or failures to its fluctuations. Consider answering other questions throughout the rehab process to reflect on your progress. For example:
- Do you have more control over your symptoms?
- Are you exercising more regularly?
- Has your function improved?
- Are you sleeping better or walking more?
- Are you doing more of the things you enjoy?
Let me put all of this information together by presenting 2 case examples.
Case Example #1 (Runner)
Let’s say you’re a 35 year-old marathon runner who developed gluteal tendinopathy 3 weeks ago as you were preparing for an upcoming race. Assuming the onset of symptoms was associated with a significant increase in training mileage in a short amount of time, the first difficult decision you have to make is whether or not it’s feasible for you to continue with the race.
For example, if the marathon is in 3 weeks, but you currently can’t run more than 3 miles before starting to limp, you probably have to make the sacrifice of losing this battle so you win the war of getting healthy and back to your normal training.
Otherwise, step 1 is easy – reduce the mileage and intensity of your weekly runs to a tolerable level.
Step 2 is also easy, but requires more patience – gradually increase the mileage and intensity of your weekly runs while minimizing occurrences of flare-ups.
That’s the gist of it. If you intervene early enough and you’re disciplined with your approach, you can reduce the likelihood of gluteal tendinopathy becoming a long-term issue.
As I mentioned earlier, you can try a 5-10% increase in your cadence, but this shouldn’t overshadow proper programming.
Aside from changes in training, ask yourself if anything has changed as it relates to your sleep, nutrition, or stress levels. If so, try to address any possible contributing factors.
Finally, you can incorporate other forms of exercise. For instance, if you’re unable to run as much as you normally like, you can replace 1 or 2 of your normal runs with a different aerobic activity like cycling to maintain your cardiorespiratory fitness.
As you begin to resume normal activity, consider adding in resistance training 1-2 days per week for 3 sets of 8-12 reps per exercise.
Case Example #2 (Older, Less Active Individual)
Now let’s say you’re a less active, 59 year-old who feels like you’ve been suffering with hip pain for 2 years. You don’t remember when your symptoms started, but your health has declined and you don’t get to do many of the things you enjoy anymore.
Step 1 is going to look much different. What can you do to find some relief with daily activities? Perhaps you haven’t tried some of the tips I mentioned earlier like sleeping with 2 pillows between your knees or purchasing a mattress topper to reduce the discomfort of lying on that side.
Step 2 is harder to overcome than the previous example because it requires accepting that there is no quick fix. You’ll have to take it day-by-day while being in it for the long haul and acknowledging that there are inevitably going to be ups and downs along the way.
So what do you do?
Whatever you can to improve your overall health and well-being.
Find a reasonable amount of physical activity that you can do on a regular basis. It doesn’t have to be perfect.
As an example, maybe you start walking or riding a recumbent bike for 10 minutes, 3 times per week. Over the course of 12 months, you might turn that into 30 minutes every single day. Keep track of your successes with a journal.
If you’re feeling up to it, you can start the exercise with a band around your thighs while lying on your back each morning.
At some point, you can throw in the bridges, sit-to-stands, step-ups, and single leg balance.
To make all of this more achievable, find support from a friend, family member, healthcare provider, or a combination of all three.
Summary
In summary, gluteal tendinopathy has been proposed as the preferred term for pain presenting on the side of the hip because research spanning across 20 years has determined that bursitis is unlikely to be the primary contributing factor to symptoms.
It is characterized by pain with activities that load the gluteus medius and minimus, such as standing on a single leg, walking, running, and going up stairs, as well as sleeping on the affected side.
The diagnosis is most common in older, less active women, but it can also occur in runners.
Although some individuals will get better with time, a primary focus of management should include modifying any aggravating activities.
Specific exercises can be performed to improve the conditioning and function of the glute muscles.
Since gluteal tendinopathy may be associated with other health-related issues such as diabetes and hypercholesterolemia, any lifestyle interventions to improve overall health (like regular physical activity) should be considered.
Regardless of what you decide to do, it’s important to tailor the plan to your individual goals and needs. There is no quick fix for gluteal tendinopathy, so it’s helpful to set realistic expectations and plan for the process to take a minimum of 3 months.
Don’t forget to check out our Hip Resilience Program!
Want to learn more? Check out some of our other similar blogs:
Hip Osteoarthritis, Proximal Hamstring Tendinopathy, Gluteus Medius Training
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