You know the pain. It sits right on the point of your hip, the bit you’d lean on if you were resting against a wall. It’s worse lying on that side at night. It flares walking uphill, climbing stairs, or after a longer walk than usual. For years, this was called trochanteric bursitis, and people were told the bursa, a small fluid-filled cushion over the hip bone, was inflamed and needed rest, anti-inflammatories, or a cortisone injection.
The research has since moved a long way past that explanation, and it matters, because the old story leads to the wrong treatment.
Let’s unpack it during this installment of Praxis What You Preach.
IT’S USUALLY THE TENDON, NOT THE BURSA
Lateral hip pain like this is now more accurately called greater trochanteric pain syndrome, or GTPS, and the influential clinical work of physiotherapist and researcher Dr Alison Grimaldi has been central to redefining how we understand it. Imaging and surgical studies have consistently found that the primary source of pain in most cases is the gluteus medius and gluteus minimus tendons, not the bursa sitting over them. The bursa can become irritated as a secondary feature, but treating it as the main problem, with rest and injections aimed purely at calming inflammation, misses what’s actually driving the pain: a tendon that has lost load capacity, much like Achilles or patellar tendinopathy elsewhere in the body.
This condition is common, particularly in women between 40 and 60, and the pain and disability it causes has been shown to affect quality of life to a similar degree as end-stage hip osteoarthritis. It is not a minor, inconsequential ache.
WHY IT FLARES WITH THE THINGS YOU’D THINK WOULD HELP
One of the more counterintuitive parts of gluteal tendinopathy is that the position many people find most comfortable, standing with weight shifted onto one hip, or lying on the unaffected side with the sore hip pulled up and across the body, actually compresses and loads the irritated tendon against the bone underneath it. Research comparing hip biomechanics in people with gluteal tendinopathy has found they walk with greater hip adduction, meaning the hip drops in toward the midline more than normal during each step, which increases compressive load on exactly the tendons that are already struggling. Stretching the outside of the hip, foam rolling the ITB, or sitting with legs crossed all do the same thing: they compress an already irritated tendon rather than letting it settle.
WHAT ACTUALLY WORKS
The strongest evidence we have comes from a large Australian randomised trial that compared a physiotherapist-led education and exercise program against a single corticosteroid injection and against a “wait and see” approach. At eight weeks, both the exercise program and the injection outperformed doing nothing, but the education and exercise program outperformed the injection itself, with more people reporting meaningful improvement and less pain. At twelve months, the exercise program remained ahead of the injection for overall improvement. Cost-effectiveness analysis of the same trial found the education and exercise approach was also better value over the following year.
In practice, that means load management first: understanding which everyday positions and habits are compressing the tendon and adjusting them, followed by a progressive strengthening program for the hip abductors that respects the tendon’s tolerance rather than aggravating it further. Corticosteroid injections aren’t off the table, they can help settle a significant flare, but the evidence is clear that they shouldn’t be the primary or only treatment, and they work best alongside, not instead of, a structured exercise program.
The Takeaway
Lateral hip pain is usually a gluteal tendon problem, not bursitis, and that distinction changes what actually helps. The stretches and rest positions that feel intuitive often compress the tendon further, while a properly dosed load management and strengthening program, guided by a physiotherapist, has been shown to outperform a cortisone injection both in the short and long term.
Book an appointment at one of our Brisbane clinics today and start moving forward with a clear plan.
Until next time, Praxis What You Preach…
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References
Allison K, Hall M, Hodges PW, Wrigley TV, Vicenzino B, Pua YH, Metcalf B, Grimaldi A, Bennell KL. Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics. Gait & Posture. 2018;61:459-465.
Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. Journal of Orthopaedic and Sports Physical Therapy. 2015;45(11):910-922.
Grimaldi A, Mellor R, Nasser A, Vicenzino B, Hunter DJ. Current and future advances in practice: tendinopathies of the hip. Rheumatology Advances in Practice. 2024;8(2):rkae022.
Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education 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. 2018;361:k1662.
Wilson R, Abbott JH, Mellor R, Grimaldi A, Bennell K, Vicenzino B. Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial. Journal of Physiotherapy. 2023;69(1):35-41.