Story
Lateral Hip Pain
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In one pass Feel the outside of the top of your thigh and you will find a bony bump, the greater trochanter.
Educational content, not medical advice — consult a clinician.
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Chapter 1
Where it hurts, and what hurts
Feel the outside of the top of your thigh and you will find a bony bump, the greater trochanter. Two buttock muscles, the gluteus medius and gluteus minimus, attach their tendons to it; they steady the pelvis when you walk or stand on one leg.
Trouble in these two tendons (gluteal tendinopathy) is now recognized as a primary local source of lateral hip pain. It mostly occurs in mid-life, in both active and inactive people, and more in women than men. It interferes with side-lying sleep and with everyday weight-bearing movements such as walking and climbing stairs. Many people call this pain bursitis; this story is about another source now considered more important: the tendon itself.
Hip pain after a fall with a leg that cannot take your weight, or pain with a fever and a red, swollen, hot joint, is not what this story is about. See a doctor in person promptly.
Trouble in these two tendons (gluteal tendinopathy) is now recognized as a primary local source of lateral hip pain. It mostly occurs in mid-life, in both active and inactive people, and more in women than men. It interferes with side-lying sleep and with everyday weight-bearing movements such as walking and climbing stairs. Many people call this pain bursitis; this story is about another source now considered more important: the tendon itself.
Hip pain after a fall with a leg that cannot take your weight, or pain with a fever and a red, swollen, hot joint, is not what this story is about. See a doctor in person promptly.
Chapter 2
Compression plus pulling hurts tendons most
Tendons depend on load to maintain their structure and their capacity to bear weight; load is what feeds them. But one combination is thought to be the most damaging: excessive compression together with high pulling (tensile) load.
The outside of the hip is prone to exactly that combination. When the thigh moves toward the midline of the body (a movement called adduction), the tendons are pressed against the bony greater trochanter. The available evidence suggests that excessive hip adduction, together with muscle and bone factors, is key to the problem.
That explains the most typical symptom: lying on your side hurts. Lie on the painful side and bone presses straight onto tendon. Lie on the other side and the upper leg drops across the midline, which is adduction again.
Following the mechanism (an inference, not a trial finding), it is reasonable to cut down on positions that hold the thigh across the midline for long periods, such as crossing your legs, standing with one hip pushed out to the side, or lying on your side with nothing between your knees.
The outside of the hip is prone to exactly that combination. When the thigh moves toward the midline of the body (a movement called adduction), the tendons are pressed against the bony greater trochanter. The available evidence suggests that excessive hip adduction, together with muscle and bone factors, is key to the problem.
That explains the most typical symptom: lying on your side hurts. Lie on the painful side and bone presses straight onto tendon. Lie on the other side and the upper leg drops across the midline, which is adduction again.
Following the mechanism (an inference, not a trial finding), it is reasonable to cut down on positions that hold the thigh across the midline for long periods, such as crossing your legs, standing with one hip pushed out to the side, or lying on your side with nothing between your knees.
Chapter 3
Exercise, injection or waiting: one trial's answer
A randomized trial published in the BMJ (the LEAP trial) split people with gluteal tendinopathy into three groups: education plus exercise, a corticosteroid injection, or wait and see. It followed them for a year.
At 8 weeks, both treatments beat waiting, and education plus exercise beat the injection: the most people felt clearly better, and pain was lowest.
At one year, education plus exercise was still ahead of both injection and waiting on global improvement (patients rating themselves clearly better overall). On pain, however, it did not differ from the injection, and both beat waiting.
The authors conclude that education plus exercise is an effective way to manage gluteal tendinopathy.
At 8 weeks, both treatments beat waiting, and education plus exercise beat the injection: the most people felt clearly better, and pain was lowest.
At one year, education plus exercise was still ahead of both injection and waiting on global improvement (patients rating themselves clearly better overall). On pain, however, it did not differ from the injection, and both beat waiting.
The authors conclude that education plus exercise is an effective way to manage gluteal tendinopathy.
Evidence · why injection is not the first choice
The trial is Mellor 2018: 204 people, mean age 55, most of them women. At 8 weeks, the numbers reporting clear overall improvement were 51/66 with education plus exercise, 38/65 with injection, and 20/68 waiting; pain scores (0-10, higher is worse) were 1.5, 2.7, and 3.8. At 52 weeks, clear improvement was 51/65, 36/63, and 31/60.Injection was not useless in this trial: at 8 weeks it clearly beat waiting, and at 52 weeks its pain scores also beat waiting and matched the exercise group. So why not start with an injection? Because at both time points, education plus exercise gave about 20 percentage points more global improvement. And education and exercise target the mechanism from the chapter on compression plus pulling: less compression, and loading the tendon back to its full capacity.
What a steroid injection means for a tendon, and why tendons need load, get their own chapter in Tendon Recovery. The trade-off here: an injection can bring the pain down first, while education plus exercise brings more overall improvement across a year. Decide the specifics with a doctor or physical therapist.
Chapter 4
Load it, rather than resting it
Resting when it hurts is the natural reaction. Tendons work the other way: mechanical load drives the biological processes inside a tendon and determines its structure and how much force it can bear. Left unused, the force it can take only shrinks.
So the question is not rest or exercise but how to exercise. Following the compression-plus-pulling mechanism, give the tendon tensile (pulling) load while avoiding the large adduction, the thigh crossing the body's midline, that presses it onto bone. That is why the LEAP trial group combined education (knowing which positions compress the tendon) with exercise (loading it back to capacity).
The general principle of gradual progression is the same one used for knee and shoulder tendons, and Tendon Recovery explains it in full.
So the question is not rest or exercise but how to exercise. Following the compression-plus-pulling mechanism, give the tendon tensile (pulling) load while avoiding the large adduction, the thigh crossing the body's midline, that presses it onto bone. That is why the LEAP trial group combined education (knowing which positions compress the tendon) with exercise (loading it back to capacity).
The general principle of gradual progression is the same one used for knee and shoulder tendons, and Tendon Recovery explains it in full.
Chapter 5
When to see a doctor
Hip pain has more than one source, and there is currently no consensus on which clinical tests best diagnose gluteal tendinopathy. So this story describes one common condition; it is not for diagnosing yourself.
See a doctor in person promptly, rather than treating it at home as ordinary lateral hip pain, if:
hip pain after a fall with inability to bear weight, especially in older people or those with osteoporosis — a fracture needs ruling outpain with fever, or a joint that is red, swollen and hotpain in the groin (front of the hip) rather than the side, or clearly restricted hip rotationpain running from the lower back down the leg with numbness or weaknesspain that wakes you at night and does not ease with rest, with unexplained weight loss
This site provides general education and advice. It does not replace a physician's diagnosis and treatment.
See a doctor in person promptly, rather than treating it at home as ordinary lateral hip pain, if:
hip pain after a fall with inability to bear weight, especially in older people or those with osteoporosis — a fracture needs ruling outpain with fever, or a joint that is red, swollen and hotpain in the groin (front of the hip) rather than the side, or clearly restricted hip rotationpain running from the lower back down the leg with numbness or weaknesspain that wakes you at night and does not ease with rest, with unexplained weight loss
This site provides general education and advice. It does not replace a physician's diagnosis and treatment.
References · 2
- Grimaldi, A., Mellor, R., Hodges, P., Bennell, K., Wajswelner, H., & Vicenzino, B. (2015). Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine, 45(8), 1107-1119. Gluteus medius and minimus tendinopathy is a primary local source of lateral hip pain; mostly mid-life, in athletes and non-exercisers, more in women; interferes with side-lying sleep and weight-bearing. Mechanical loading drives tendon biology and determines structure and load capacity; combined excessive compression and high tensile load is thought most damaging; excessive hip adduction with muscle and bone factors is key. No consensus on which clinical tests have the best diagnostic utility. 10.1007/s40279-015-0336-5
- Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ, 361, k1662. 204 participants (167 women, mean age 54.8). Global success at 8 weeks: education+exercise 51/66, injection 38/65, wait-and-see 20/68; pain (0-10) 1.5, 2.7, 3.8. At 52 weeks: 51/65, 36/63, 31/60; education+exercise better than injection on global improvement (risk difference 20.4%) but no difference in pain; both better than wait-and-see on pain. 10.1136/bmj.k1662