Glute/Hip Tendon Pain

Can be called “Lateral” Hip Pain, Greater trochanteric pain syndrome, Gluteal tendinopathy, and mistakenly diagnosed and managed as hip bursitis.

How common is it?

• Hip tendon pain is the most common type of tendon pain and is more common during mid life (Greater trochanteric pain syndrome: A multicentre service evaluation). 

  
  

Clues or common symptoms?

• Tendon pain on the side of your hip is typically confirmed by your description of your story and experience. Symptoms often affect only one hip and can travel down the side of the leg, as indicated by the blue-shaded areas on the diagram below. The hip tendon can be very sore to touch, and many sustained positions that will likely be helpful for your hip tendon long term, can hurt (Diagnostic Accuracy of Clinical Tests for Assessing Greater Trochanteric Pain Syndrome + Performance, measurement properties and discriminant analysis of functional tests for women with greater trochanter pain syndrome). Symptoms can be confused for back, hamstring, or hip bone stress pain, which a good chat with a health care provider can differentiate  (High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic). Symptoms often develop slowly, often randomly, and can be life-changing in impact (The experiences and perceptions of patients with Greater Trochanteric Pain syndrome + “I feel I have been taken seriously” Women’s experience of greater trochanteric pain syndrome treatment).

Symptoms are often spread around the hip and down the leg leaving many confused and stuck.

What is wrong? Why me?

• Tendon pain is caused by a complex interaction of lifestyle and general health reasons (“I Don’t Know Why I’ve Got this Pain!” Allostasis as a Possible Explanatory Model | Physical Therapy). Do not blame “doing too much exercise” on hip tendon pain, as we know exercise is good for tendons and tendon pain. “Bursitis” does not explain hip tendon pain (Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain+ Trochanteric bursitis: refuting the myth of inflammation + Hip Bursitis? - E3 Rehab) and occurs equally in those with or without pain (Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination). Our Method Health Tendon Pain Resolution should cover everything helpful to know about tendon pain, but here are some known risk factors that contribute to hip tendon pain, discussed now. 

  • Recent years of weight gain contribute to poor tendon health and seemingly sudden intolerance for usual amounts of hip movement (Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy).

  • Hip osteoarthritis commonly occurs with hip tendon pain, reflecting an unhappy hip joint (Gluteal tendinopathy and hip osteoarthritis + Osteoarthritis-Related Joint Pain Management). However, know that non-surgical management of hip osteoarthritis and hip tendon pain are very similar. Surgery for unbearable hip OA can also contribute to an unhappy hip tendon. 

  • Non-modifiable risk factors include a specific age range of 40 to 60 years (for unknown reasons) and being female. You may well have been targeted with collagen or magnesium supplements, “special” pillow or mattress ads on social media that begin with an extensive first-person narrative about how nothing helped them or their clients' unbearable hip pain. Beware such non-fact-checked ads, likewise, “theories” of “being old” or “female fragility” used to sell products, or just lazy explanations of the complex causes of pain (Women's Health + Managing Menopause).

  • Unhelpful beliefs like pain being “due to tendon damage” or “painful movement is bad for my hip” contribute to increased pain and reports of depression and anxiety. These beliefs also contribute to an understandable but unhelpful avoidance of hip exercises, thereby worsening general health. Harmful pessimistic beliefs not managed well contribute more to the pain impact than known imaging changes in the hip tendons (Psychological factors not strength deficits are associated with severity of gluteal tendinopathy + Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence). 

What can I do about it?

• Having a good understanding of what does and does not contribute to hip tendon pain while improving your general health, mental health, and sleep habits is the key to managing hip tendon pain (Mediators and Moderators of Education Plus Exercise on Perceived Improvement in Individuals With Gluteal Tendinopathy).

• Short-term modification, rather than complete avoidance of painful movements, is often advised. These modifications do not need to be used for life (How physiotherapists treat gluteal tendinopathy by Dr Alison Grimaldi). This could include walking with your legs spread wider (if walking is uncomfortable), sleeping with a pillow under your legs in any comfortable position (don’t worry about trying to find the “perfect pelvic posture”). Any comfortable, sustained sleeping position is safe for your hip tendons, and the same position that is intolerable right now is safe in the long term.  

• Seeking help/support to maintain and exceed the Australian Physical Activity Guidelines is important for hip health, as it supports overall health and helps reduce hip tendon pain (Effects of exercise-based interventions on gluteal tendinopathy). Often this might include modifying irritable movements, rather than stopping them completely, as some are well-intended but mistakenly told. 

• Weight loss can be helpful, as with most painful conditions, due to a reduction in adipose-related inflammation (Greater trochanteric pain syndrome: a review of diagnosis and management in general practice).

• Injections should be saved for those not tolerating life with persistent hip symptoms, but be aware of risk of multiple injections on worsening tendon health and sciency sell of a “quick fix”  (Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy + Assessing Standardisation in Platelet-Rich Plasma (PRP) Injections for the Management of Greater Trochanteric Pain Syndrome).

(All these great exercises for the hips. Find the starting dose you can tolerate and progress from there)

How long will it take?

• Promises for symptom improvement should not be given for timeframes of less than 3 months after seeking care for persistent symptoms. A third of people will have persistent symptoms after a year (Prognosis of trochanteric pain in primary care + The natural history of greater trochanteric pain syndrome: an 11-year follow-up study). However, while you might have persistent symptoms, you should still be able to do everything you want, maybe in amounts you're not happy with at the moment, but be confident this is not ‘forever’ (Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management).  

Busting Myths and Common Unhelpful Beliefs! 

• Weakness or inflexibility does not cause more pain. Other factors like mental stress are much more important to focus on to reduce hip tendon pain (Psychological factors not strength deficits are associated with severity of gluteal tendinopathy). Perceived weakness is likely a consequence of pain rather than the cause (Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy). Strength exercise does not need to strengthen your hip tendon to be helpful (Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome). Stretching is often overemphasised due to old-fashioned beliefs and can be replaced with an equivalent time of aerobic or strength exercise for the same benefits (The Case for Retiring Flexibility as a Major Component of Physical Fitness).

• Hip movements during walking are unlikely to cause hip tendon pain, but, like rubbing salt on a wound, can still be provocative when symptoms persist (Experimentally reduced hip-abductor muscle strength and frontal-plane biomechanics during walking).

• Imaging is unlikely to be helpful for hip tendon pain as:

  • Most changes in tendons as seen on imaging occur without pain, which could be described as examples of just “grey hairs” in the hip (Correlation of MRI findings with clinical findings of trochanteric pain syndrome + Trochanteric spurs and surface irregularities on plain radiography are not predictive of greater trochanteric pain syndrome + Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome).

  • Imaging results do not need to change for your symptoms to improve (Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence).

  • Often highlight “red herrings” which do not explain tendon pain like “bursitis” or “tendon tears”, make people seek unnecessary care like injections or surgery, and cause behaviour change unhelpful for pain, like increased perceived need for rest and concern about exercise (Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis).

• Hormone therapy is not more effective for hip pain than a placebo (Does Menopausal Hormone Therapy, Exercise, or Both Improve Pain and Function in Postmenopausal Women With Greater Trochanteric Pain Syndrome?). Males also get hip tendon pain. 

• As those with hip tendon pain likely will have imaging findings similar to those without symptoms, surgery targeting imaging findings in non-traumatic cases makes very little sense, but surgical recommendations for traumatic, persistent cases despite high quality management still exist (The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS)). Be aware that no study has shown that real surgery is superior to placebo surgery for hip tendon pain, as has been disputed in other tendon pain areas (Arthroscopic subacromial decompression + Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial - PubMed). Any surgical management is supported by exercise, so there are likely no cases where exercise is not helpful for hip tendon pain (ICON 2020—International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy). 

What can our Physiotherapist at Method Health offer you?

• We can offer individual lifestyle medicine advice to help you modify physical activities so you can keep up with life while managing hip tendon pain. Hip tendon pain should not stop you from doing the things you love, and these concerns might contribute to worsening joint health anyway. 

• We can be your support crew to encourage lifestyle changes that can improve your general health, like coaching around sleep and guiding you through ways to reduce stress, or adding things to your life to better cope with the stress of a hip tendon pain flare-up.

• If you have had persistent hip tendon pain and are very confused about why you still have it, we can help you make sense of the pain, highlight areas of management to prioritise or be more optimistic about, and provide individual guidance to help you manage and resolve it.

• We can help you reduce your perceived need for injections or surgery if you do not wish to receive these management options or increase your realistic evidence-informed expectations of how injections or surgery might help you. We can also help support your physical and mental preparation and return to your valued activities with less pain and discomfort if you elect for hip surgery.

More guidance for helping manage your hip tendon pain:

• The E3 Rehab Podcast: 22. Lateral Hip Pain w/ Dr. Alison Grimaldi 

• How physiotherapists treat gluteal tendinopathy by Dr Alison Grimaldi + Clinical Edge - Physio Edge 009 Lateral Hip Pain With Dr Alison Grimaldi 

• Gluteal tendinopathy chat with Chris Clifford - Talking Tendons

• Gluteal Tendinopathy - E3 Rehab

• Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence - ScienceDirect

• Myths, Realities & Clinical Pearls in Gluteal Tendinopathy with Dr. Alison Grimaldi BJSM Podcast

• The Greater Trochanteric Pain Syndrome: Clinical Presentation, Diagnosis, and Management | Current Treatment Options in Rheumatology | Springer Nature Link

• Physiotherapy management of gluteal tendinopathy - ScienceDirect

• Clinical Edge - Lateral hip pain - planning treatment + Clinical Edge - Part 2 Lateral hip pain  + Clinical Edge - Lateral hip pain video 3 - Progressive rehab