Lateral Hip Pain (Hip Bursitis)

Download PDF of below Clinicians Tips for Lateral Hip Pain

Tips for Diagnosing Lateral Hip Pain

Lateral hip pain was traditionally known as ‘trochanteric bursitis’. This term implies underlying bursal inflammation, which can result in a focus on passive treatment strategies such as rest, NSAIDs and corticosteroid injections. The gluteal tendon is now considered the primary pain driver. We’ve used the terms ‘lateral hip pain’ and ‘gluteal tendinopathy’ interchangeably. This condition is also known as ‘greater trochanteric pain syndrome’.

risk factors

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  • Prevalence is highest in post-menopausal females. One in 4 women over 50 years old will experience lateral hip pain. It can however also affect males (estimated prevalence <10%).
  • Younger active individuals who have increased their running volume (particularly on inclines or uneven ground) can develop symptoms, or women returning to sport post-partum.
  • Obesity may play a role both systemically and mechanically, and body mass index (BMI) is reportedly higher in people with gluteal tendinopathy compared to asymptomatic control.
  • Mixed presentations are common. People with low back pain are more at risk. Gluteal tendinopathy is found in 20 to 25% of patients undergoing total hip arthroplasty.

Clinical Features

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  • Patients with gluteal tendinopathy can report pain levels similar to those with end stage hip osteoarthritis. Impact on quality of life can be significant as it affects people's ability to be active, as well to rest (sitting, lying and sleeping).

  • Clinical features include lateral hip pain while walking upstairs, pain standing on one leg (dressing). Pain sitting in lower seats or with legs crossed or a few seconds of 'start up pain' after sitting.

  • Pain is typically well localised. Patients often put their hand directly over the greater trochanter to indicate the area of pain. Pain can sometimes radiate down the lateral thigh and very occasionally extend beyond the knee (usually indicates involvement of the iliotibial band)

  • Night pain can be a significant issue. Lying on the affected side can cause pain due to tendon compression . Sleeping on the unaffected side can also be painful, if the upper leg falls into adduction, and exerts a compressive and tensile tendon load.

  • It is important to consider the role of psychological and emotional factors. People with more severe symptoms are characterised by higher pain catastrophizing and depression scores, and lower pain self-efficacy.

Differential Diagnosis

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  • Two common conditions that can need to be excluded as sources of lateral hip pain are (i) hip osteoarthritis and (ii) lumbar radicular pain
  • Suspect hip osteoarthritis when a patient reports (i) joint stiffness, especially in the morning or after prolonged sitting, (ii) a deeper more global joint ache, (iii) night pain in the groin and/or buttock, rather than localised to the greater trochanter (iv) restricted hip range of motion.
  • Suspect lumbar spine involvement when pain emanates from the buttock or lumbar spine and radiates to the lateral thigh or are accompanied by paraesthesia.

Physical Examination and Diagnostic Tests

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  • Useful clinical outcome measures can include pain at night (0-10 Numerical Rating Scale), time to pain onset with single limb stance, pain with stair walking, pain self-efficacy and hip abduction strength.
  • Whilst palpation for trochanteric tenderness plays a role, it is not sufficiently reliable alone to diagnose or exclude gluteal tendinopathy. However, combining it with resisted hip abduction in a side lying position, can represent a useful cluster of tests.
  • To Rule Out gluteal tendinopathy, a negative gluteal tendon palpation test followed by a negative resisted hip abduction test significantly reduces the probability from 59% to 14%.
  • To Rule In gluteal tendinopathy, a positive gluteal tendon palpation test followed by a positive resisted hip abduction test significantly increase the probability from 59% to 96%.
  • Another useful test is the 30-second single leg stance test. This involves a single leg stand (with fingertip support) on the affected leg. A positive result is reproduction of the patient’s familiar lateral hip pain. Milder presentation should manage close to 30 seconds on the affected leg.
  • A useful clinical test for gluteal tendinopathy in a runner or active individual is tendon pain reported during a hop or repeated hopping.
  • Generally early imaging does not have a role. Abnormalities on MRI are present in a high percentage of people who do not report lateral hip pain. For patients with pain syndrome not responding to conservative therapy, ultrasonography or MRI should be considered to evaluate for a gluteus medius tendon tear.
  • The presence of partial and full thickness tendon tears still merit conservative management as these patients demonstrate successful outcomes with non-surgical management.

Tips for Managing Lateral Hip Pain

Education

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Patient education is a cornerstone of early management. Patients need to be actively involved in understanding (i) how to interpret their pain (ii) how to manage tendon load and (iii) modify any aggravating activities/postures.

  • A lack of information about the meaning of symptoms in relation to activity and potential tissue damage can affect people’s confidence to be active.
    1. Invest time in helping patients understand that hurt does not equal harm to the tendons.
    2. Teach patients to interpret the pain response in a way that gives them confidence to be active and engage with an exercise programme.
    3. Choose your language carefully, refer to a 'grumpy ' or ‘irritated’ tendon rather than tendon ‘damage’.
  • Load management is a key principle in managing tendon-related pain. Tendons adapt and respond positively to load, when it is built up slow and consistently. Avoid rapid increases in activity levels.
    1. Help patients gauge the amount of activity their hip tendons will currently tolerate and identify gradual changes to progress them towards their goals.
    2. Teach patients about monitoring their response to exercise or activity. An increase in pain that night and/or the next morning is an indication that loads may need to be adjusted. See “Tips for managing hip pain during activity”’ in the patient section of the website https://jointpain.ie/for-patients/hip-pain/lateral-hip-pain/
  • Set realistic patient expectations. Depending on how long the patient has had symptoms, this tendinopathy can take 6-12 months for symptoms to resolve.

Modifying Aggravating Postures and Gait Cues

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  • Certain day-to-day postures and positions can stretch or compress an already irritated gluteal tendons and aggravate pain. Examples are hip adducted positions (sitting with legs crossed) or direct compression (e.g side lying). Teaching patients about reducing or avoiding these postures will reduce the load on the tendon.
  • Tips to reduce pain while sitting include; (i) Sit with hips higher than knees, (ii) Avoid sitting for prolonged periods in a long chair, (iii) Avoid sitting with legs crossed, (iv) Use a cushion in a low car seat.
  • Tips to reduce pain while walking include; (i) Shorten stride length, (ii) Land with a softer heel strike, (iii) Reduce walking volume or remove hills from the route.
  • If limping while walking, temporary use of a crutch on the opposite side may be helpful for load management.
  • Tips to reduce pain on the stairs include; (i) Cue patients to place feet wider on the step and use the rail on opposite side.
  • Night pain can be a significant issue for some patients and its worthwhile spending time on finding comfortable resting positions.
    1. If the painful side is uppermost, use thicker pillows positioned between both the thighs and lower legs. Avoid the upper leg falling into an adducted position.
    2. When sleeping on the affected side, straighten out the underneath leg. Wedge a pillow under the tummy and top hip and roll forwards ¾ way. Use an eggshell topper or soft cover to reduce direct mattress compression.

Exercise Therapy

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  • The LEAP randomized clinical trial found education and exercise to be superior to a corticosteroid injection and the wait and see approach for gluteal tendinopathy, at both the 8 week and 52-week follow-up time point (see infographic).
  • A progressive strengthening programme is recommended that will slowly increases the strength of the gluteal muscle and increase the tendon’s tolerance to load.
  • Rehab should follow a careful and staged approach. Start with low load isometrics to recruit the gluteal muscle and not the iliotibial band. Avoid single limb work initially and exercises involving positions of gluteal tendon compression (where knee is adducted relative to hip position).
  • Exercise technique is important. As load is progressed, some degree of supervision is recommended to ensure correct exercise technique.
  • Iliotibial band and gluteal stretching are not advised, as this tends to compress the gluteal tendon and aggravate symptoms.

Injections, Shortwave Therapy and Surgery

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  • Corticosteroid injection is not considered first line management. Outcomes are no better in the longer term than awaiting spontaneous recovery. It may have adverse tissue effects (e.g. reduced collagen synthesis, and increased collagen disorganisation), based on evidence from other tendinopathies.
  • Evidence is lacking for the efficacy of shockwave therapy (SWT) in the treatment of gluteal tendinopathy.
  • Low‐quality evidence established some clinical improvements over control. NICE recommends SWT for only chronic or recalcitrant cases as an adjunct to exercise and education.
  • Surgery is considered a last resort. It is more likely to be indicated in those with substantial gluteal tendon detachment.

Download Tips for Diagnosis and Management of Lateral Hip Pain PDF
SOURCES OF INFORMATION

The information in this website page was informed by the following sources/references:

  • Cook JL, Purdam C (2012). Is compressive load a factor in the development of tendinopathy? Br J Sports Med;46(3):163-168.
  • Fearon, AM. et al. (2017) ‘Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study’, Gait and Posture. doi: 10.1016/j.gaitpost.2016.12.005.
  • Fearon AM, et al (2013). Greater trochanteric pain syndrome: defining the syndrome. Br J Sports Med; 47(10): 649–653.
  • French, HP., et al. (2020) “Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice.” Physiotherapy 109: 111-120.
  • Grimaldi A, et al (2017). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med. 51(6):519-524
  • Ganderton, C., et al (2017). Demystifying the Clinical Diagnosis of Greater Trochanteric Pain Syndrome in Women. Journal of Women’s Health, 26(6), pp.633-643.
  • Kinsella, Rita, et al. (2024) “Diagnostic accuracy of clinical tests for assessing greater trochanteric pain syndrome: a systematic review with meta-analysis.” Journal of Orthopaedic & Sports Physical Therapy 54.1 (2024): 26-49.
  • Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis & Rheumatology 2008;59:241-246
  • Mellor R, et al. (2018). Eduation 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;360:K1662.
  • Moerenhout et al., (2021). Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: a secondary analysis of a randomized trial. J. Orthop. Traumatol.: Surgery & Research, 107 (8) (2021), Article 102709.
  • Plinsinga et al., (2018). Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: a cross-sectional study. Eur. J. Pain, 22 (6), pp. 1124-1133
  • Skibicki et al. (2021) Lateral trochanteric pain following primary total hip arthroplasty: incidence and success of nonoperative treatment. J. Arthroplasty, 36 (1) (2021), pp. 193-199.
  • Stephens, G et al. (2020) “It’s just like a needle going into my hip, basically all of the time”. The experiences and perceptions of patients with Greater Trochanteric Pain syndrome in the UK National Health Service. MSK Sci and Prac, 47. ISSN 2468-7812.
  • Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2013;47(14):893-902.
  • Rhim, HC et al. (2024). Extracorporeal Shockwave Therapy for Greater Trochanteric Pain Syndrome: A Systematic Review with Meta-Analysis of Randomized Clinical Trials. JBJS Reviews 12(8):e24.00091. | DOI: 10.2106/JBJS.RVW.24.00091.