Gluteal Tendinopathy (Hip Bursitis)
Pain on the outside of the hip, worse lying on that side at night and worse climbing stairs, is one of the most common hip complaints in middle age, particularly in women between about forty and seventy. At Modern Physio we focus on understanding the root-cause of your problem & personalizing your treatment for lasting results.
Understanding Gluteal Tendinopathy (Hip Bursitis)
Pain on the outside of the hip, worse lying on that side at night and worse climbing stairs, is one of the most common hip complaints in middle age, particularly in women between about forty and seventy. For decades it was called trochanteric bursitis, and treated as inflammation of the small fluid sac over the bony point of the hip. That understanding has changed. In most people the problem is not the bursa but the tendons of the gluteus medius and minimus where they attach to that bony point, irritated by compression and by loads they have lost the capacity to tolerate. Any bursal inflammation is usually secondary. The name matters because it changes the treatment: a bursa suggests something to inject and calm down, while a tendon suggests something to load and rebuild. This is one of the better-evidenced conditions we treat. The LEAP randomised trial compared education plus exercise against corticosteroid injection and against a wait-and-see approach, and while injection gave good early relief, education and exercise produced better global improvement at fifty-two weeks, and a later economic analysis found it more cost-effective. At Modern Physio in Vaishali Nagar, Jaipur, we treat this with a progressive gluteal loading programme and, just as importantly, with specific advice about the positions that compress the tendon: crossing the legs, standing hanging on one hip, sleeping on the painful side without support, and deep stretching of the outer hip, which is one of the most common well-intentioned mistakes.
Common Symptoms
- Pain over the bony point on the outside of the hip, which is tender to press
- Pain that is worse lying on that side, often waking you at night
- Pain lying on the opposite side too, when the top leg drops across the body
- Pain climbing stairs, walking uphill, or getting out of a car
- Pain after standing for long periods, particularly when resting weight on one hip
- Pain that can spread down the outside of the thigh, but rarely below the knee
- Difficulty crossing the legs or sitting with knees together for long
- Weakness or fatigue in the hip when walking longer distances
- A limp or a hip that drops on one side when walking, in longer-standing cases
- Symptoms that came on gradually, often after a change in walking volume, a new exercise routine, or a period of reduced activity
How Common Is It?
Lateral hip pain of this type is one of the most common hip complaints seen in musculoskeletal practice, and it is markedly more frequent in women than men, typically between the ages of forty and seventy. It is frequently labelled bursitis, which is why many patients arrive expecting an injection, and the shift in understanding towards gluteal tendinopathy is comparatively recent. No India-specific prevalence data was identified for this condition. What we do see clinically is that floor sitting, cross-legged sitting and sleeping arrangements common in Indian homes all involve sustained positions that compress these tendons, so the load advice matters here at least as much as the exercise.
Causes & Risk Factors
- Compressive load on the gluteal tendons where they wrap over the bony point of the hip, particularly in positions where the leg crosses the midline
- Weakness of the gluteus medius and minimus, so the tendons work closer to their capacity with every step
- A sudden increase in walking, hill work, or standing time beyond what the tendons were conditioned for
- Sleeping on one side without a pillow between the knees, which holds the top hip in a compressive position all night
- Habitually standing with weight dropped onto one hip
- Sitting with legs crossed for long periods, common at desks and on floor seating
- Hormonal and body composition changes around menopause, which is why this is much more common in women in midlife
- Aggressive stretching of the outer hip and iliotibial band, which increases compression at exactly the painful point
- Previous hip or back problems that changed how the hip muscles work
Our Diagnosis Process
- A history focused on which positions and activities provoke the pain, since the pattern of night pain, stairs and single-leg standing is highly characteristic
- Palpation over the bony point of the hip to confirm local tenderness
- Provocation testing, including single-leg standing held for thirty seconds and positions that bring the leg across the body
- Assessment of hip abductor strength, which is almost always reduced on the painful side
- Assessment of walking pattern, looking for the hip drop that indicates the abductors are not controlling the pelvis
- Screening of the lumbar spine and sacroiliac joint, since referred pain from the back can mimic this closely
- Consideration of hip joint pathology such as osteoarthritis and, in an appropriate patient, avascular necrosis, since groin pain rather than lateral pain points towards the joint itself
- Referral for imaging or medical review where the picture is unclear, where symptoms do not respond to a properly progressed programme, or where there are features suggesting something other than tendinopathy
Our Treatment Approach
- Education first, because in this condition the positions you spend hours in matter as much as the exercises you do for minutes
- Removing compressive positions: no leg crossing, no hanging on one hip when standing, a pillow between the knees at night, and avoiding deep outer-hip stretching
- Sleep advice, since night pain is often what drives people to seek help and is usually improved by simple positioning changes
- Isometric gluteal work early on, which can settle an irritable tendon while strengthening begins
- A progressive gluteal loading programme, built up over months, which is the core of the treatment and the part with the best trial support
- Progression from lying and standing exercises to functional loading such as steps, bridges and single-leg work
- Gradual reintroduction of walking distance, hills and stairs using symptom response over the following day as the guide
- Trunk and pelvic control work so the hip abductors are not compensating for a poorly controlled pelvis
- Honest discussion of injection: it can help in the short term, but the trial evidence favours exercise at one year, and repeated injections into a tendon carry their own concerns
- A defined review point, with onward referral if a properly delivered programme has not produced meaningful change
Key Highlights
Treatment based on the LEAP trial, where education plus exercise beat steroid injection at one year
Specific attention to the sustained positions that compress the tendon, including floor and cross-legged sitting
Practical advice for night pain, which is often the most disruptive symptom
Honest framing of injection as short-term relief rather than a solution
Recovery & Prevention Tips
- Stop stretching the outside of your hip, however much it feels like it needs it, because that position compresses the tendon that is already irritated
- Put a pillow between your knees when sleeping on your side, and a pillow behind you if you tend to roll
- Stop crossing your legs when sitting, including cross-legged on the floor, at least while symptoms are settling
- Stand evenly on both feet rather than resting your weight on one hip
- Expect this to take months rather than weeks, because tendons rebuild capacity slowly
- Keep walking, but build distance gradually and use how the hip feels the next morning as your guide
- Do the strengthening consistently rather than intensively, since regular moderate loading is what tendons respond to
- Use stairs one at a time in the early stages if they are painful, rather than avoiding them completely
- Do not judge progress by pain alone: how far you can walk and whether you sleep through the night are better measures
- If you have had an injection and the pain returns, that is common and is not a sign that nothing will work, it is a reason to do the loading work
Products That Can Help
Supports and equipment we fit at the clinic that patients with this condition commonly use alongside treatment, never instead of it.
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Evidence & Sources
The LEAP randomised controlled trial compared education plus exercise, corticosteroid injection, and a wait-and-see approach for gluteal tendinopathy. Both active treatments were better than wait and see at eight weeks, and at fifty-two weeks education plus exercise led to better global improvement than corticosteroid injection.
Mellor et al. - Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy (British Journal of Sports Medicine, 2018)A health economic evaluation of the same trial found that education plus exercise improved health-related quality of life and was cost-effective compared with corticosteroid injection and with a wait-and-see approach.
Economic evaluation of the LEAP trial (Journal of Physiotherapy, 2023)Frequently Asked Questions
Is it bursitis or tendinopathy, and does the difference matter?
It matters a great deal, because it changes what you should do. The condition was called trochanteric bursitis for decades, on the assumption that the painful structure was the fluid sac over the bony point of the hip. Current understanding is that in most people the problem is the gluteal tendons attaching at that point, with any bursal inflammation secondary. If you believe it is a bursa, the logical treatment is to inject and calm it down. If you understand it as a tendon, the logical treatment is to remove the compressive loads and progressively rebuild capacity, which is what the trial evidence supports.
Should I get a steroid injection?
Our honest position is that injection is worth considering for short-term relief when pain is severe enough to prevent sleep or to stop you doing the rehabilitation at all, but it is not the answer on its own. The LEAP trial found injection gave good early results, yet at fifty-two weeks education plus exercise produced better global improvement. Repeated injections into or around a tendon also carry concerns about tendon quality. Our usual approach is to start with load management and exercise, and to discuss injection with your doctor if pain is preventing progress rather than as the first move.
Why does it hurt so much at night?
Because side lying puts the gluteal tendons into their most compressed position. When you lie on the painful side, the bony point of the hip presses directly into the mattress. When you lie on the other side, the top leg drops across the body, which wraps the tendon tightly over the bone. Both compress exactly the irritated tissue, for hours at a time. This is why a pillow between the knees, and often one behind the back to stop rolling, makes such a difference. Night pain is frequently the symptom that improves first once positioning changes.
I have been stretching my hip and it is getting worse. Why?
Because the stretch you are almost certainly doing brings the leg across the body, and that is the position that compresses the tendon against the bone. It is one of the most common and most understandable mistakes in this condition: the hip feels tight, so stretching seems obviously right, and it often feels better briefly before being worse afterwards. Outer hip and iliotibial band stretching, foam rolling over the bony point, and deep figure-four positions are the usual culprits. Stopping them is frequently the single change that lets everything else start working.
How long will this take?
Plan for months rather than weeks. Tendons rebuild load capacity slowly, and this one has usually been irritated for a while before people seek help. Many people notice night pain and stair pain improving within the first few weeks from the positioning changes alone, which is encouraging but is not the same as the tendon being stronger. The durable improvement comes from the loading programme, and that needs consistent work over a proper period. We track walking distance, sleep and strength rather than pain alone, because those change more reliably and show progress even in slow weeks.
Could my hip pain be coming from my back instead?
It can, and it is one of the main things we screen for. The lumbar spine and sacroiliac joint both refer pain into the lateral hip and outer thigh, and back-related pain can be tender to press over the hip as well. Features that point towards the tendon rather than the back include pain clearly worse lying on that side at night, pain reproduced by standing on one leg, and tenderness precisely over the bony point. Features pointing towards the back include pain below the knee, pins and needles, and symptoms that change clearly with spinal movement. The two can also coexist.
Is it safe to keep walking and exercising?
Yes, and stopping entirely usually makes things worse over time because the tendon loses more capacity. What needs adjusting is volume and the specific aggravating elements: long hilly walks, lots of stairs, and prolonged standing on one hip are the usual provocations. We would rather reduce your walking to a level the hip tolerates and build from there than have you stop and lose fitness. Gym work is generally fine with modification, and gluteal strengthening is the treatment itself, so it is very much encouraged once it is set at the right level.
Why is this so common in women in midlife?
The pattern is clear in the clinical literature, with lateral hip pain of this type most frequent in women between roughly forty and seventy, though the reasons are not fully settled. Contributing factors that are discussed include hormonal changes around menopause affecting tendon tissue, differences in pelvic width and hip angle that alter how the tendons wrap over the bone, and changes in activity patterns in midlife. What matters practically is that it is a recognised and treatable pattern rather than something unusual, and that it responds to the same loading principles as tendon problems elsewhere in the body.
Medically Reviewed
This content was reviewed for medical accuracy by Dr. Surabhi Bansal, BPT, MPT (Ortho) with 14+ years of clinical experience.
At Modern Physio, all medical content undergoes a thorough review process to ensure accuracy and alignment with current physiotherapy standards. Our content is created to educate and should not replace professional medical advice. Learn more about our review process.
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Recommended Treatments for Gluteal Tendinopathy (Hip Bursitis)
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Exercise Therapy
Progressive gluteal loading, the treatment with the strongest trial evidence for lateral hip pain.
Assessment & Education
Identifying the sustained positions that compress the tendon, and the strength deficits behind the pain.
Manual Therapy
Hands-on treatment for the surrounding muscles as an adjunct alongside the loading programme.
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