“Will I need a hip replacement?” many patients fearfully ask when they first notice symptoms of lateral hip pain. But lateral hip pain, although frequently mistaken by patients for potentially crippling osteoarthritis, typically does not involve the hip joint itself. Instead, pain overlying the lateral aspect of the hip is most commonly associated with greater trochanteric hip bursitis, particularly when present in older individuals. But many times, a seemingly straightforward case of hip bursitis may be slow to respond to treatment, leaving clinicians scratching their heads as to why. 

Recalcitrant cases of lateral hip pain that are thought to be caused by hip bursitis may actually be stemming from hip abductor tendinopathies, in which the gluteus medius and/or gluteus minimus tendons are strained, torn, or ruptured.¹ Although under-recognized as a source of lateral hip pain by many physicians,² a torn gluteus medius muscle is increasingly being identified as one of the main causes of lateral hip pain.³ Consequently, many members of the medical community are looking at lateral hip pain in a new light, and as a result the terminology is changing: Regional pain syndromes of the lateral hip are now frequently being referred to as greater trochanteric pain syndrome (GTPS), a term that encompasses conditions affecting both the greater trochanteric bursae and the musculotendinous units of the nearby gluteus medius and minimus.⁴

Although greater trochanteric bursitis may indeed account for part of the etiology of a patient’s lateral hip pain, a recent histologic study examining bursal tissues harvested from individuals undergoing total hip arthroplasty revealed no signs of acute or chronic inflammation in the tissues, whether they were obtained from symptomatic individuals with preoperative lateral hip pain or those without.⁵ In the majority of cases, what appears to be a simple case of hip bursitis may actually be dysfunction of the gluteus medius or gluteus minimus muscles.⁶

Hip Bursae and Tendons

The function of a bursa, a fluid-filled sac lined with synovial tissue, is to reduce friction between opposing surfaces, such as tendon and bone. Among many, there are three main bursae that surround the greater trochanter of the lateral hip. Of the three, there are two major bursae, one of which is located superiorly and posteriorly to the proximal greater trochanter (subgluteus medius bursa); the other is positioned lateral to the greater trochanter (subgluteus maximus bursa). The third, minor, bursa is situated slightly anterior to the proximal, superior greater trochanter (gluteus minimus bursa).⁷

When inflamed, the lining of a bursa thickens and secretes extra fluids that can cause localized pain and inflammation, otherwise known as bursitis. Bursitis in the lateral hip region typically occurs in response to trauma or direct compression, altered lower extremity biomechanics from underlying knee or hip osteoarthritis or lumbar spine pathology, or the repetitive friction of tight overlying musculature such as occurs with hiking, running, and cycling.⁸

Because the three main lateral hip bursae are intimately positioned beneath the large hip stabilizer muscles (gluteus maximus, gluteus medius, and gluteus minimus), any pathology in the gluteal musculotendinous units can cause pain and swelling in the same region. Consequently, it can be difficult to distinguish between a case of bursitis and a situation in which one or more of the gluteal tendons are dysfunctional or torn. Gluteal strains and tears may be acute (traumatically induced) or chronic (degenerative), and they can cause scar tissue formation, weakness, tendon calcification, and localized bleeding that results in painful hematoma formation.

Because the gluteus medius muscle functions as a primary hip abductor, an internal rotator, and a pelvic stabilizer during gait, it can be especially vulnerable to chronic inflammation caused by overuse, repetitive movements, and friction from a tight overlying iliotibial band, resulting in a tear.⁹ Gluteus medius tears commonly occur at one or both of the two distinct tendon insertion sites of the muscle at the lateral and the superoposterior facets of the greater trochanter,¹⁰ becoming a major cause of lateral hip pain in conjunction with, or independently from, greater trochanteric hip bursitis.

Points of Interest

GTPS is most frequently observed in women between the ages of 40 and 60, with a higher incidence seen in individuals who are overweight or in those who have recently changed their activities or sports training habits.¹¹ The prevalence of unilateral GTPS is 15% in women and 6.6% in men; bilateral GTPS occurs in 8.5% of women and 1.9% of men.¹² GTPS can be found in active and sedentary individuals alike, and it is thought to be associated with altered biomechanical forces of the lower limbs, as it is more common in adults with iliotibial band syndrome or knee osteoarthritis. GTPS is also a known complication of arthroscopic hip surgery.¹³

Patients with lower extremity osteoarthritis are estimated to have a nearly five-fold risk of experiencing persistent GTPS symptoms at one year post-diagnosis than their counterparts without osteoarthritis.¹⁴ Degenerative changes of the hip abductor musculature are seen in 20% of patients with concurrent hip osteoarthritis who are considering hip replacement surgery, especially those who are elderly and female.¹⁵ Degenerative spinal disease is also commonly associated with the gluteus medius tendonitis and trochanteric hip bursitis conditions that are characteristic of GTPS.¹⁶ In a significant number of patients who are initially thought to have sciatica, GTPS is discovered instead.¹⁷

Frequently, patients with GTPS will exhibit muscle imbalances of the abductor muscle group that result in myofascial trigger points, concurrent bursitis, and overuse strains of the gluteus medius and minimus muscles.¹⁸ In runners, hip injuries that cause gluteal muscle strains and tendonitis are often caused by sudden changes in speed or direction; they’re also caused by repetitive eccentric contractions of the hip musculature, such as occurs when running on uneven terrain or cambered roads.¹⁹

Strains and tears of the gluteal tendons and irritations of the trochanteric bursae can also result from repetitive friction of the tensor fascia lata and iliotibial band, and in some instances, a hyperadduction strain injury.²⁰ Although it seems logical that unequal leg length would be a factor in creating asymmetrical biomechanical forces that may affect the hip, it has not been proven that leg length discrepancy is a causative factor for GTPS: In one large study that measured leg length on full-limb anterior-posterior X-rays of patients with and without GTPS, there was no association of GTPS with a leg length inequality of greater than or equal to one centimeter.²¹

Getting to the Point

The classic presentation of GTPS is chronic, deep, intermittent aching situated over the lateral aspect of the hip, with pinpoint tenderness to palpation of the greater trochanteric region, usually at the posterolateral hip area. In many patients, increased soft tissue density and swelling of the greater trochanteric bursa may also be palpated. A diffuse, aching pain will be present over the hip bursae; it may radiate into the lower buttock and down the lateral aspect of the thigh as far as the knee, but it usually does not reach the foot. Occasionally, concurrent tightness of the distal iliotibial band may result in a friction irritation of the common peroneal nerve, causing lateral calf pain.

Symptoms of GTPS are usually aggravated by direct pressure, such as when lying on the affected side, but symptoms are also exacerbated indirectly when lying on the unaffected side if the painful hip is overstretched into adduction during the night. Other aggravating factors include getting in and out of a chair or car, sitting with the ankle of the affected side positioned on the opposite knee (figure four stretch), prolonged walking, stair climbing, and running. Most of the time, patients with GTPS will be able to recall either an acute traumatic event, such as a sudden fall onto the affected side or pain of insidious onset that is brought on by repetitive, cumulative trauma such as occurs with iliotibial band friction with walking or running.

Upon examination, hip range of motion is typically unrestricted at the joint with no increase of pain with flexion and extension, movements that are frequently symptomatic in the presence of degenerative osteoarthritis. There may be stiffness and lateral hip pain with passive external rotation and also with passive hip adduction or active hip abduction. Usually, there is an absence of groin pain in response to range of motion testing or with clinical tests such as the flexion, abduction, and external rotation (FABER) test with GTPS, this finding being more typical of degenerative changes of the hip joint.²² There is often observable tightness of the iliotibial band with the Ober test, in which the patient lies on the unaffected side and the therapist passively stretches the affected leg into abduction and mild extension while holding the knee bent at 90 degrees and then attempts to lower the leg into adduction.

In the course of ruling out alternate diagnoses and underlying or concurrent lumbar dysfunction, other clinical tests, such as the straight leg raise (SLR), should be performed; with simple GTPS, this test is typically negative. However, therapists must be alert to reports of night pain, noncapsular hip joint motion that is limited by pain rather than stiffness, and a positive “sign of the buttock” (i.e., when passive hip flexion with knee flexion is more limited and painful than passive hip flexion with knee extension as in a SLR), all of which can signify metastatic bone disease.²³

Resisted testing of the affected lower extremity can reveal painful and weak hip abduction and internal rotation, implicating a dysfunctional gluteus medius. Both resisted hip internal rotation tested in the supine position and the single leg stance test held for 30 seconds are specific and sensitive clinical tests for the diagnosis of gluteal tendinopathy with trochanteric bursitis in cases of refractory GTPS, as confirmed on MRI.²⁴

Other important clinical tests include observance of the patient’s gait pattern, as it is thought that a positive Trendelenburg gait pattern is one of the most specific, sensitive signs that is commonly associated with a gluteus medius tendinopathy or tear that can be verified on MRI.²⁵ However, not all gluteus medius tendon tears may be visualized on MRI, and some may only be confirmed at the time of surgery.²⁶ But when there is an acute, progressive onset of a Trendelenburg gait pattern in a patient with lateral hip pain, a gluteus medius tear is often the reason.^27,28

Once the lateral hip region is generally confirmed to be the source of the patient’s pain and GTPS is suspected, the patient must be carefully assessed to rule out alternate or overlapping pathology such as stress fractures of the femoral neck, lumbar radiculopathy, metastatic bone disease, femoral head avascular necrosis, rheumatoid arthritis, meralgia paresthetica, and iliotibial band syndrome. To this end, X-rays of the hip and lumbar spine may be advisable to aid in differential diagnosis. In the majority of patients with GTPS, radiographic findings will be unremarkable; however, in up to 40% of cases, small calcifications ranging in size from several millimeters to 4 centimeters in diameter may be visualized around the greater trochanter.²⁹

Although GTPS is normally diagnosed without the need for extensive imaging tests, bone scans and MRIs may also be performed and correlated to clinical findings, and in many cases reveal changes at the greater trochanteric region that highlight injury at the gluteus medius or gluteus minimus tendon insertions.^30,31,32 However, despite the presence of peritrochanteric T2 abnormalities on the MRIs of all patients with GTPS in one study, these abnormalities are not necessarily predictive of GTPS as this finding is also frequently seen in patients without GTPS.³³ Diagnostic ultrasound has a positive predictive value in successfully identifying gluteal tendon dysfunction in a preoperative setting, confirming that many patients who have failed conservative treatment for trochanteric bursitis may actually be harboring hip bursitis that co-exists with gluteal tendon tears.^34,35

Targeting Treatment

Medical management of GTPS in the acute phase usually begins with over-the-counter nonsteroidal anti-inflammatory medications and ice to reduce pain and inflammation, and activity modification to avoid aggravating movements and positions. Patients are instructed to limit sleeping on the painful side to reduce direct compression on the gluteal tendons and bursae, and also advised to use an adductor pillow to decrease indirect compression of the lateral hip structures by overlying tight hip abductors. Relative rest is indicated, with avoidance of stair climbing, low chairs, and prolonged walking; in some cases, reduced weight bearing during ambulation may be necessary to decrease symptoms, which may be achieved by asking the patient to use a crutch or cane to offload the affected side.

In many cases, physical therapy treatment is offered as a front-line intervention for GTPS, including therapeutic modalities, soft tissue mobilization and stretching, and patient education (Table 1).

When GTPS symptoms persist, patients are frequently offered a peritrochanteric corticosteroid injection, which can be diagnostic as well as therapeutic, especially if the patient is difficult to palpate due to obesity.³⁶ Overall, 70% of patients with GTPS will respond to a steroid injection of the lateral hip, and more than 90% will improve with a second injection; however, one-quarter of patients will relapse after injection, experiencing a return of their symptoms.³⁷ This type of bursal injection may be performed in the physician’s office without the need for expensive fluoroscopy: In one study at Johns Hopkins School of Medicine, 47% of patients with “blind” injections and 41% of patients having had an injection under the fluoroscope continued to have positive outcomes with reduced pain at three months post injection.³⁸ Patients who receive a corticosteroid injection, typically mixed with a local anesthetic, in one of the hip bursae are more than twice as likely to resolve their painful symptoms as those who do not have an injection.³⁹

In rare cases, surgery may be indicated to repair a complete tear of the gluteus medius tendon, arthroscopically remove a chronically inflamed bursa, or longitudinally release a refractory shortened tensor fascia lata or iliotibial band, but for most patients the road to recovery involves physical therapy treatment.^40,41,42 Comprehensive physical therapy treatment for GTPS involves a mixture of therapeutic modalities, hands-on soft tissue mobilization, stretching, strengthening, patient education, gait retraining to eliminate biomechanical abnormalities with ambulation or running, and a home exercise program.

PT for GTPS

When pain is a significant issue with initial treatment, therapists can use modalities such as ice, iontophoresis, and transcutaneous electrical neuromuscular stimulation (TENS) to control swelling and discomfort. Therapeutic modalities can also be effective when there is a component of calcific trochanteric bursitis to the lateral hip pain: In a 2002 case study, physical therapy treatment that included intensive pulsed ultrasound treatment and iontophoresis was effective in providing resolution of painful bursal calcifications.⁴³

Once the acute phase of GTPS has passed, moist heat, therapeutic ultrasound, and phonophoresis may be implemented for the subacute and chronic phases of recovery.⁴⁴ Low-energy extracorporeal shock wave therapy has shown promise as an effective modality in treating chronic cases of GTPS that have a gluteal tendinopathy component, demonstrating statistically significant improvements in pain and functional mobility in patients treated with the modality as compared to controls.⁴⁵

Other PT interventions for GTPS should include gently and progressively stretching out tight overlying soft tissue structures (tensor fascia lata and iliotibial band) and then carefully strengthening the weak and/or strained gluteal muscles as the patient improves, in order to correct the underlying soft tissue imbalances. Myofascial release, soft tissue mobilization, and contract-relax techniques may all be employed to improve soft tissue extensibility and length of the tensor fascia lata and iliotibial band.⁴⁴ If functional mobility is severely compromised or if a Trendelenburg gait pattern is present, an assistive device used on the patient’s contralateral side to help offload the affected extremity may be indicated; this serves to control pain and to protect the gluteus medius from a complete rupture in its weak and elongated state.

As the patient improves, progressive strengthening exercises should focus on hip abductors, external rotators, and hip extensor muscle groups. Specific strengthening exercises for weak hip abductors should be delayed until the acute stage has resolved for fear of provoking a gluteal tendonitis or worsening a gluteal tear; however, strengthening is an essential part of recovery.¹¹ It may be beneficial to perform manual therapy strengthening exercises with the overstretched target gluteal muscle in a shortened position, to enhance normal muscle length and to ensure that the muscle is not performing at end-ranges of the length-tension ratio.⁴⁶ Taping techniques and movement re-education strategies may facilitate safe functional strengthening without stressing the healing muscle. Eccentric exercises and proprioceptive activities should also be added to enhance muscle strength and dynamic control as the patient transitions back to normal daily and recreational activities.

When GTPS is thought to be caused by faulty movement patterns and postural adaptations (such as habitually sitting with the legs crossed, frequently standing on one leg with the hip cocked in a lateral pelvic tilt, or routinely sleeping in sidelie with the top leg overstretched into adduction onto the bed’s surface) that elongate a weakened gluteus medius muscle, the patient must be educated in alternate postural strategies. The patient should also be instructed to avoid movement patterns that repetitively overuse an already tight tensor fascia lata/iliotibial band complex to maintain a level pelvis during stance and ambulation and to decrease the risk of iliotibial band friction syndrome that adversely affects the trochanteric bursa.⁴⁷

Because many patients with GTPS exhibit chronic overactivation of selected muscular soft tissues around the hip, a detailed biomechanical assessment with interventional gait training is another important component of treatment. Additional factors that are amenable to therapeutic intervention are excessive foot pronation, knee instability, or lumbar stiffness; obesity; and training regimens in which athletes practice on cambered or hard surfaces. In such cases, shoe inserts, orthotics, weight management strategies, or patient retraining may be necessary to resolve underlying movement patterns and lifestyle habits in order to successfully modify behavior.⁴⁸ 

The end goals of treatment are to improve pain-free hip abductor muscle strength, resolve tenderness to palpation and direct pressure at the lateral hip, facilitate a normal gait pattern, and restore the patient’s ability to perform previous levels of activity. It is expected that as symptoms resolve and functional strength is restored, patients will demonstrate an absence of a Trendelenburg gait pattern and will regain the ability to stork stand without pelvic drop or lateral hip pain. At this time, there is unfortunately only a small amount of research literature that supports the efficacy of physical therapy treatment techniques for this common diagnosis, but as clinicians become more familiar with GTPS as being more than just a case of simple hip bursitis, no doubt interest in targeted research will follow.