Understanding Lateral Hip Pain: Causes, Diagnosis, and Evidence-Based Management

Lateral hip pain is a common complaint in active adults, middle-aged women, and older populations. It can limit walking, running, and even sleeping, often becoming a persistent and frustrating issue if not managed correctly.

While often referred to broadly as “hip bursitis”, research now shows that the majority of cases are actually due to gluteal tendinopathy and related conditions rather than isolated bursitis. Understanding the underlying cause is essential for effective treatment.

Common Causes of Lateral Hip Pain

1. Gluteal Tendinopathy (GT)

What it is: Degenerative or reactive changes in the gluteus medius and/or minimus tendons, often at their attachment to the greater trochanter.

Contributing factors:

• Repetitive overload (e.g., running, stair climbing, long walking)

• Poor pelvic control or biomechanics (hip adduction during stance)

• Female sex (higher prevalence post-menopause due to hormonal changes and pelvic width-to-femur angle)

• Sudden increases in training load

Diagnosis:

• Pain and tenderness over the greater trochanter

• Pain with lying on the affected side, crossing legs, or standing on one leg

• Clinical tests: Single-leg stance test, resisted hip abduction

Management (best evidence):

• Education and activity modification (avoid positions of hip adduction such as crossing legs)

• Progressive gluteal strengthening (side-lying hip abduction, functional single-leg work)

• Shockwave therapy and corticosteroid injections can reduce pain but are less effective long-term compared to exercise

• Manual therapy may assist with pain relief but is not curative

• High-quality evidence: Mellor et al. (2018, BMJ) demonstrated that education and exercise were superior to corticosteroid injection for gluteal tendinopathy at 52 weeks.

2. Greater Trochanteric Pain Syndrome (GTPS)

What it is: An umbrella term encompassing gluteal tendinopathy, bursitis, and iliotibial band (ITB) friction over the greater trochanter.

Contributing factors:

• Similar to gluteal tendinopathy (especially repetitive load and hip adduction)

• ITB tightness and poor lumbopelvic control can contribute

Diagnosis:

• Clinical assessment (pain over greater trochanter, aggravated by lying on the side)

• Imaging (MRI or ultrasound) can confirm tendon or bursal changes but is not always required

Management:

• Similar to gluteal tendinopathy: progressive load, strengthening, and activity modification

• Corticosteroid injection may be considered for short-term relief in recalcitrant cases

3. Trochanteric Bursitis

What it is: Inflammation of the bursae located around the greater trochanter. Often occurs secondary to gluteal tendon pathology rather than in isolation.

Contributing factors:

• Overuse, direct trauma, or friction from the ITB

• Prolonged side-lying or repetitive hip movements

Diagnosis:

• Localised tenderness directly over the greater trochanter

• Pain exacerbated by compression (lying on the side) or repetitive movement

Management:

• Ice and anti-inflammatory strategies in acute cases

• Load management and activity modification

• Corticosteroid injection can be helpful for acute symptom relief

• Long-term management involves addressing gluteal tendon health and biomechanics

4. Referred Pain from the Lumbar Spine or Sacroiliac Joint

What it is: Pain perceived at the lateral hip but originating from lumbar nerve root irritation or sacroiliac dysfunction.

Contributing factors:

• Lumbar spine degenerative changes

• Postural loading or nerve compression

Diagnosis:

• History and physical exam pointing to spinal involvement (neurological symptoms, back pain)

• Imaging if needed

Management:

• Addressing spinal mechanics, strengthening core and gluteal support

• Manual therapy, exercise, and postural correction

Current Best Management Strategies for Lateral Hip Pain

1. Education and Load Management

   
   

   • Avoid aggravating postures (crossing legs, sitting with knees together, lying directly on the affected side).

   • Modify training loads to avoid sudden spikes in running or walking distances.

   
   

2. Exercise Therapy

   
   

   • Progressive strengthening of gluteal muscles is the gold standard.

   • Begin with low-load isometrics for pain relief, progressing to functional single-leg and sport-specific exercises.

   
   

3. Adjunctive Therapies

   
   

   • Shockwave therapy may help in chronic, non-responsive cases.

   • Corticosteroid injections provide short-term pain relief but should be combined with rehabilitation.

   
   

4. Manual Therapy and Soft Tissue Techniques

   
   

   • May provide short-term relief of pain and stiffness, helping facilitate exercise progression.

   
   

5. Surgical Options

   
   

   • Rare, reserved for severe tendon tears or refractory cases that fail conservative management.

   
   

Key Takeaways

• The most common cause of lateral hip pain is gluteal tendinopathy, not isolated bursitis.

• Diagnosis is clinical, supported by imaging when necessary.

• Best evidence supports education + progressive exercise as the cornerstone of management.

• Adjuncts such as shockwave or injections may help but are less effective long-term than strengthening.

• A thorough physiotherapy program addressing biomechanics, load, and strength provides the best outcomes.

References

1. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection versus a wait and see approach on global outcome and pain from gluteal tendinopathy: RCT. BMJ. 2018;361:k1662.

2. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015;45(11):910–922.

3. Woodley SJ, et al. Greater trochanteric pain syndrome: a review of anatomy, diagnosis, and management. J Orthop Sports Phys Ther. 2008;38(6):313–328.