Gluteal Tendinopathy: Outer Hip Pain and Treatment

The gluteal muscles sit at the side and back of the hip. Two of them — gluteus medius and gluteus minimus — attach by tendons to the greater trochanter, the bony bump you can feel on the outside of the hip. Their main job is to keep the pelvis level and steady the hip when you are on one leg.

That happens far more often than people realise: every step of walking, every stair, getting up out of a chair, and standing on one leg to put on trousers or socks. When the demand on those tendons rises faster than they can adapt, or the tendon is repeatedly squashed against the bone, the tissue becomes irritated and painful.

Most people feel pain and tenderness over the outside of the hip, right on or around the bony point. Pressing the area often reproduces it.

The pain can also spread down the outer thigh, sometimes as far as the knee. People describe it in different ways — a deep ache, a burning feeling, or a sharper catch with certain movements. It does not usually travel below the knee or into the foot; pain that does may be coming from elsewhere, such as the lower back.

• pain when lying on the affected side
• pain lying on either side, because of the way the top hip drops across the body
• tenderness when you touch or press the outer hip
• pain climbing stairs or walking uphill
• pain getting out of a chair, or during the first few steps
• pain standing on one leg while dressing
• pain after longer walks or a spell of increased activity
• disturbed sleep, often waking when you roll over
• occasional weakness, or a feeling that the hip might give way

There is not always one clear cause, and often several things add up. Things that may play a part include:

• gradual overload of the tendon over months or years
• a sudden increase in walking, running or exercise
• repeated stairs, steep hills or uneven ground
• a fall or knock directly onto the outside of the hip
• weakness in the hip and pelvic muscles
• a long period of inactivity, illness or reduced walking
• positions that repeatedly compress the tendon — sitting with the legs crossed, standing with the weight slumped through one hip, or sleeping curled tightly on one side

Increased risk has also been associated with age, hormonal changes around the menopause, diabetes, higher body weight, high cholesterol, and some existing hip or lower-back problems. None of these on its own causes gluteal tendinopathy, and plenty of people with them never develop it.

Outer hip pain is sometimes something else, or a mix of problems. It can be confused with:

• hip osteoarthritis
• pain referred from the lower back
• sciatica
• a hip fracture after an injury, particularly in older people
• inflammatory conditions, or an infection
• other tendon, muscle or bursa problems around the hip and pelvis

Because the treatment differs, pain that persists, keeps returning, or that you are unsure about should be assessed rather than self-diagnosed.

A GP, physiotherapist or other qualified clinician will usually listen to how the pain behaves — where it is, what sets it off, how you sleep — and then examine the hip. That normally includes looking at how you walk, testing strength around the hip, checking movements of the hip and lower back, and pressing over the outside of the hip.

Scans are not always needed. An ultrasound, X-ray or MRI may occasionally be arranged, for example if the picture is unclear, if another problem is suspected, or before considering an injection or specialist treatment.

Small changes through the day often settle things more than any single treatment:

• avoid standing for long periods with all your weight hanging through one hip
• avoid crossing your legs, or sitting for long spells with the knees pressed tightly together
• use a supportive chair at a reasonable height rather than a very low, soft seat
• temporarily cut back long walks, steep hills or repeated stairs if they cause a substantial flare-up
• keep gently active within limits you can tolerate — complete bed rest is not helpful and tends to make things stiffer and weaker
• change position regularly rather than holding one position for a long time

This is not a list of things to avoid forever. The aim is simply to reduce repeated squashing of the tendon while symptoms settle, so that strengthening work can get going.

• where possible, avoid sleeping directly on the painful side
• when lying on the other side, place a firm pillow between the knees and ankles so the top leg stays supported and does not drop across the body
• some people are more comfortable on their back, with pillows supporting the legs
• a softer mattress topper sometimes helps if the side you sleep on feels pressed

Sleep often improves as the tendon settles. If pain keeps preventing sleep, get professional advice rather than putting up with it.

Progressive strengthening of the muscles around the hip and pelvis is normally the main treatment for gluteal tendinopathy. Tendons respond to load that is gradually built up over time, so exercises are usually chosen and progressed to suit the individual — their symptoms, their strength and what they need to get back to.

There is no single exercise that suits everyone, and a fixed programme copied from elsewhere can easily be too much or too little. NHS inform publishes general exercise guidance, which can be a helpful starting point.

Please get a professional assessment first if you have severe pain, poor balance, a recent injury or fall, or you are not sure what is causing the pain.

One practical point: strong stretching across the outside of the hip — for example pulling the knee firmly across the body — can increase compression on the tendon and makes symptoms worse for some people, even though it feels like it should help.

It helps to tell the difference between manageable discomfort — some soreness during or after activity that settles within a day and does not build up — and a significant reaction, where pain is clearly worse for longer, sleep is disturbed, or walking becomes harder.

After a significant reaction, reduce the amount or intensity of whatever aggravated it for a short while, then build it back up gradually. That might mean shorter walks, flatter routes, fewer stairs, or less weight on a particular exercise for a week or two.

"No pain, no gain" is not a useful rule for tendons. Neither is stopping everything: long periods of avoiding activity weaken the muscles that support the hip and tend to slow recovery down.

Simple pain relief can make it easier to sleep and to get on with exercises, but it treats the pain rather than the tendon itself. Which option is suitable depends on your health and any other medicines you take.

Ask a pharmacist or GP before starting pain relief, particularly if you have or have had stomach ulcers or indigestion, kidney, liver or heart problems, or asthma; if you take blood-thinning medicine or other regular medicines; or if you are pregnant or breastfeeding.

We do not give doses or recommend specific medicines. A pharmacist can advise free of charge, without an appointment.

A corticosteroid injection is sometimes offered and may give short-term pain relief for some people. It does not rebuild or repair the tendon, and pain can return once the effect wears off. If it is being considered, discuss the likely benefit, the limitations and the risks with an appropriate clinician, and treat it as something that may create a window to get strengthening work started rather than a cure on its own.

Surgery is rarely needed. It would normally only be considered after specialist assessment where substantial symptoms continue despite a proper trial of non-surgical treatment.

Be cautious about anything promising a quick fix for tendon pain. If you are unsure whether a treatment is worthwhile, ask your GP or physiotherapist.

Tendon recovery is normally gradual. Progress is best judged by what you can do — walking further, managing stairs more comfortably, sleeping through the night, feeling steadier on one leg — rather than by waiting for every last twinge to disappear.

Some people improve within several weeks. Longer-standing problems often need several months of progressive rehabilitation, and there may be ups and downs along the way. A flare-up does not undo the work you have already done.

Once things have settled, keeping up some hip strengthening usually helps reduce the chance of it coming back.

Arrange an assessment if:

• the pain is persistent, getting worse, or keeps coming back
• sleep or normal walking is substantially affected
• you are not sure whether the pain is coming from your hip or your back
• there is weakness, or the hip repeatedly feels as though it gives way
• looking after it yourself has not brought any improvement
• the pain started after an injury or a fall
• you have unexplained weight loss, a history of cancer, or you feel generally unwell