Gluteal tendinopathy: pathology of lateral hip pain

When you hear the words lateral hip pain, what is the first thing you think of?


That’s OK, most people do.

Examination of the hip and pelvis often does reveal an inflamed trochanteric bursa, but evidence suggests that this may just be a symptom, rather than the underlying pathology.

Dr Henry Wajswelner (FACP) is a Specialist Sports Physiotherapist, and he recently visited Perth for a series of presentations on this subject. Those that attended the WA Symposium went home pretty inspired to examine more patients with lateral hip pain.

Henry gave a great overview of the presence of gluteal tendinopathy, as the underlying pathology in these lateral hip pain presentations.

Mechanisms of lateral hip pain

Did you know one in four women over the age of 50 have been shown to have gluteal tendinopathy?1

One in four!

As has been described in recent models of tendon pathology, it is thought that these gluteal tendons undergo the same failed adaptation to persistent load.

Without adequate time to rest and unload, these tendons undergo an increase in proteoglycan production, resulting in a separation and disorganisation of the matrix2.

Clinically, we observe this progressive overload as a difficulty in bearing load during weight-bearing tasks (particularly single leg tasks).

Kong et al (2007) presented an interesting visual illustration of the changes found on magnetic resonance imaging (MRI) and ultrasound (US)3. They show evidence of direct pathology (tendinopathy, tendinosis, partial and complete tendon tears) as well as indirect pathology (bursal fluid, bony sclerosis and fatty atrophy of muscles)3.

Bursitis, although present, may be a secondary manifestation of this primary gluteal tendinopathy.

Henry gave generously of his clinical experience, and described commonly reported mechanisms such as:

An increase in exercise (e.g. walking, running), particularly in active woman, 40-60 years of age.
Pain associated with side-lying, both on the affected side (compression), as well as lying on the unaffected side. This is because the symptomatic limb can rest in a position of flexion and adduction.
Prolonged sitting, particularly in low chairs. Sitting with crossed legs will further increase tension and compression of lateral hip structures.
Compression of the deep surface of gluteus medius and minimus tendons can often occur in the stance phase of weight bearing exercise. This compression, combined with repeated overload (without adaptation), may be a key component in this continuum of tendon pathology.

Movements that create the most compression (and provocation):

hip flexion
hip adduction
hip internal rotation
Tendinopathy: What to look for on examination?

Examining functional tasks, such as standing (single/double leg) and walking, may demonstrate a positive trendelenberg sign.

Patients may demonstrate a waddling gait, compensating for this impaired muscle function in the horizontal plane.

A strong waddling gait, may indicate more than weakness of gluteus medius, such as a tear or complete tendon rupture.

Gluteal tendinopathy management

Henry describes that the factors you avoid, are just as important as the aspects you facilitate in rehabilitation.


Low sitting.
Crossing legs.
Standing with more weight on one leg, such as carrying a child on your hip.
Position of hip flexion, adduction and internal rotation. This includes trying to stretch the iliotibial band, which Henry reminds is not possible, being a non-contractile tissue.
Corticosteriod injections. This may create disagreement, however evidence suggests that corticosteroid use in the tendon dysrepair phase may promote further matrix breakdown.
Rehabilitation Principles

Strengthen gluteus medius and gluteus minimus with the focus on restoring normal functional movement.
Dry needling can provide short term pain relief.
Exercise Prescription

Start with slow, sustained holds (isometric) at inner range for gluteus medius.

This can be performed in crook lying, sitting or standing.

You can test this yourself in sitting or standing by having your feet shoulder-width apart, and initiating an isometric squeeze of your legs into abduction (push sideways on the floor). You can feel gluteus medius activating on palpation.

A good measure of performance before progressing, is to perform 10 sets of 10 second holds, without symptom provocation.

Exercise progressions are vast, but general guidelines could include:

Progress from bridging, to sit-to-stand, ensuring engagement of gluteus medius, minimus and maximus.
Progress with appropriate variations of squats.
More advance functional retraining can be aided with different gym-based equipment, such as pilates reformers.
The aim is to promote pain-free load bearing capacity of the gluteals in single and double leg functional positions.
Further progression can be tailored for sports-specific purposes.
Patients should be encouraged to work into fatigue and discomfort (<5/10), as this is needed to create a training effect.

Important factors to consider

As part of your clinical reasoning process, it is also important to identify any other contributing factors in each patient’s presentation.

This includes considering psychosocial factors, particularly cognitive factors around the patient’s thoughts and perceptions of their condition.

Various lifestyle factors can contribute to ongoing lateral hip pain, such as poor sleep.

It is also important to identify any workplace variables that may be continuously provoking symptoms, most importantly around prolonged sitting and any repeated compression of gluteus medius tendon.


The primary pathology in lateral hip pain is tendinopathy, not bursitis.
Use known models for tendinopathy to guide your exercise rehabilitation.
Avoid hip flexion, adduction and internal rotation.
Structured and progressive strength training is necessary to condition these tendons.
Always consider a biopsychosocial approach to help identify all contributing factors.
Many thanks to Dr Henry Wajswelner (FACP) for sharing his knowledge in this area. Be sure to check out any future education opportunities with Henry.

Additional Resources

Physio Edge Podcast – Lateral hip pain interview with Alison Grimaldi.


Segal et al 2007, ‘Greater trochanteric pain syndrome: epidemiology and associated factors’, Arch Phys Med Rehabil, vol. 88, no. 8, pp. 988-992. [PMID: 17678660]
Cook J and Purdam C 2009, ‘Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy’, British Journal of Sports Medicine, vol.43, no. 409-416. [PMID: 18812414]
Kong et al 2007, ‘MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome’. Eur Radiology, vol. 17, no. 7, pp. 1772-1183. [PMID: 17149624]
Creative Commons image courtesy of Robert Bejil.