Orthopedics · Part Two · The Structures and How They Heal
Lesson 15 / 44
Lateral Hip Pain Reconsidered: Greater Trochanteric Pain Syndrome and the Tendon Under It
Pain on the outside of the hip is a mechanical story about tendons, not a simple case of an inflamed bursa.
Greater trochanteric pain syndrome is pain and tenderness over the bony point on the outside of the hip. In most cases the painful tissue is the gluteus medius and minimus tendon rather than the bursa beneath it. Of 877 patients scanned for lateral hip pain, 177 had bursitis and 438 had gluteal tendinosis. The Unified Model of Tone reads the trochanter as the place a whole-body load pattern runs out of capacity first.
Patients scanned for lateral hip pain who had trochanteric bursitis
177 of 877
Adults aged 50 to 79 reporting greater trochanteric pain syndrome
15.0 percent of women, 6.6 percent of men
Force under the iliotibial tract at the trochanter at 40 degrees of adduction
up to 106 newtons
Improved at 52 weeks with exercise, one injection, or no treatment
78, 57 and 52 percent
What sits at the greater trochanter
The greater trochanter is the wide bony flare at the top of the femur. Gluteus medius and gluteus minimus attach to facets on it. Small bursae lie between those tendons and the tissue above them, and the iliotibial tract runs across the whole assembly on its way down the thigh. In cadaver dissection that tract crosses the bone without fixing to it.
Why a tendon hurts where it turns a corner
A tendon that wraps around bone carries compression as well as tension. Moving the thigh across the midline presses the gluteal tendons into the trochanter, and the force rises as the angle increases. Repeated compression at that insertion, added to the pull of the muscle above it, is the mechanical setting in which the tendon becomes painful.
01The better diagnosis
The bursa is the minority finding in lateral hip pain
Sonographic review of 877 patients examined for lateral hip pain found trochanteric bursitis in 177 of them (Long 2013). Gluteal tendinosis appeared in 438, and a thickened iliotibial band in 250. The average patient was 54 years old and two thirds were women.
The traditional label of trochanteric bursitis assumes inflammation over the greater trochanter is the culprit. Modern understanding points deeper, to the tendons that stabilize the pelvis with every step. What looks like a stubborn inflammatory problem is more often a degenerative failure of the structures that hold the pelvis level during walking.
MRI says the same in a smaller series. Of 24 women with the syndrome, 15 had gluteus medius tendinitis and 11 had a tear of that tendon (Bird 2001). Two had a distended bursa, and neither bursa swelled without tendon pathology beside it.
The rotator cuff of the hip
Surgeons found the same lesion by accident. In 50 consecutive patients operated on for a fractured neck of femur, 11 had a tear at the insertion of gluteus medius and minimus (Bunker 1997). They titled the report Rotator-cuff tear of the hip.
The comparison is exact. Two abductor tendons wrap a bony prominence, hold a ball in a socket through range, and fail by degeneration at the insertion. Naming the condition accurately as greater trochanteric pain syndrome, or GTPS, changes everything about how it is understood and managed. Tendon Pain carries the pathology of the tendon itself.
02Findings
What the research shows
From an 877-patient sonographic series, two imaging studies, a population survey, two diagnostic accuracy studies and a three-arm randomized trial.
03The crane at the hip
Short lever arms concentrate the body weight at one tendon insertion
The hip abductors are the suspension system of the pelvis, and their short lever arms are exactly why their tendons wear out. This is an engineering problem before it is an inflammatory one.
During single-leg stance the gluteus medius and gluteus minimus support the full weight of the trunk and keep the pelvis from collapsing toward the opposite side. Picture a crane: the femoral head is the pivot, the gluteal muscles generate force through a very short lever arm, and their tendons suspend the upper body over the stance leg.
Because the lever arm is short, enormous muscular forces are required, and that stress concentrates at the tendon insertion on the greater trochanter. Ordinary walking already loads these attachments heavily. Running and jumping magnify the forces further. Repeated over decades, this predisposes the tendons to degeneration, partial tearing, and full-thickness tearing.
How common the failure is
Trochanteric pain is the second most frequent hip diagnosis in primary care, arriving at 1.8 patients per 1000 per year (Lievense 2005). Among 3026 adults aged 50 to 79, unilateral greater trochanteric pain syndrome was found in 15.0 percent of women and 6.6 percent of men (Segal 2007).
The cost of it is easy to underestimate. A case control study set 42 people with the syndrome against 20 with severe hip osteoarthritis and 23 without symptoms (Fearon 2014). The two symptomatic groups did not differ on quality of life, Harris Hip Score or Oswestry Disability Index.
Work told the same story. The probability of full-time employment was 0.29 with the syndrome, 0.52 with end-stage hip osteoarthritis and 0.68 without symptoms. A tendon at the outside of the hip disables people at the level of a joint heading for replacement.
04Compression, not friction
Adduction is the position that loads the gluteal tendons hardest
The provoking load at the greater trochanter is compression rather than friction, and the position that delivers it is adduction. Sensors placed beneath the iliotibial tract in 18 unfixed cadavers recorded force rising with adduction and falling with abduction (Birnbaum 2004). The maximum increase reached 106 newtons at 40 degrees, and measurements during 12 hip replacements agreed.
The same dissection explains why the trochanter takes the load. The iliotibial tract runs down the femur and passes over the greater trochanter without fixing to the bone. Everything under it is pressed rather than anchored, and bringing the thigh across the midline tightens that strap against the tendons beneath.
Ordinary positions do this all day. Standing with the weight hung on one hip, sitting with the legs crossed, and side-lying with the upper leg falling forward all place the hip in adduction. None of them is an injury. Each is a dose.
Why the stretch that seems obvious backfires
The classic advice for an aching outer hip is to stretch it, and the stretch position is the compressive position. Pulling the thigh across the body is the movement the cadaver work showed raises force at the trochanter. Load management here starts by removing sustained adduction rather than by adding it.
Both arms of a randomized trial in 94 postmenopausal women received education on avoiding tendon compression through activity modification (Ganderton 2018). The instruction was treated as basic care rather than as the variable under test.
Why night pain follows the same rule
Night pain is a hallmark: lying on the affected side compresses the diseased tendons, and as things worsen even lying on the opposite side hurts because the abductor mechanism is placed under tension. The second position looks innocent. It drops the upper hip into adduction and loads the painful tendon from above.
05Reading the pattern
The provoking activities name the pattern before any scan is ordered
Stairs, both up and down, load the abductors and provoke pain. Getting in and out of a car demands eccentric control of the same tendons. Prolonged walking flares symptoms as the abductors fatigue. Rising from a chair after prolonged sitting is painful because a degenerative tendon is suddenly loaded.
The pain sits over the lateral hip and radiates into the upper lateral thigh. Groin pain and anterior thigh pain are notably absent, which is what separates this from disease inside the hip joint itself. A careful physical examination checks abductor strength, pelvic stability during single-leg stance, and pain reproduction with resisted abduction.
What the clinical tests are worth
Those tests have been measured against MRI. In 65 patients with lateral hip pain, pain reported within 30 seconds of standing on the affected leg carried a specificity of 100 percent (Grimaldi 2017). A nominal 50 percent pretest probability moves to 98 percent on that finding.
Palpation runs the other way. Tenderness over the greater trochanter was 80 percent sensitive, so a hip that is not tender there is unlikely to show gluteal tendinopathy on MRI. In the same series, 20 of the 65 patients had the tendon change on MRI while testing clinically negative.
Trendelenburg sign was the most accurate of three physical signs for predicting a gluteus medius tear, at 72.7 percent sensitivity and 76.9 percent specificity (Bird 2001).
The guarding that builds around a painful trochanter is the body doing what it does whenever it reads a tissue as a threat. It shifts into a protective tone state that amplifies the signal. When a response to an injection fades, the injection has stopped being a treatment and started being information. What it reports is durability, and not which tissue was the problem.
06Hip joint or hip tendon
The differential separates the tendon outside the joint from disease inside it
Hip osteoarthritis is the first thing to separate out, and the clinical examination does most of that work. A systematic review pooled six studies covering 1324 hips, of which 509 showed radiographic osteoarthritis (Metcalfe 2019). Among patients presenting to primary care with hip or groin pain, 34 percent had radiographic disease.
The findings that raise the probability of osteoarthritis are joint findings. A squat causing posterior pain carried a likelihood ratio of 6.1, groin pain on passive abduction or adduction 5.7, and decreased passive internal rotation 3.2. Normal passive hip adduction was the most useful finding against the diagnosis.
One overlap deserves care. Abductor weakness carried a likelihood ratio of 4.5 for hip osteoarthritis, so weakness at the outside of the hip does not by itself name the tendon as the source. Range of motion separates them better. Hip internal rotation range did not differ by trochanteric pain status across 3026 adults (Segal 2007).
The spine and the knee sit in the same picture
Lumbar and sacroiliac referral is the other half of the differential, and the epidemiology says these problems arrive together. In the same 3026 adults, the syndrome was associated with low back pain at an odds ratio of 2.79. Knee osteoarthritis on the same side gave 3.47, and iliotibial band tenderness 1.72.
The company the lateral hip keeps is mechanical and regional. That is why the examination reaches the low back and both knees before it settles on the trochanter. Beyond the Single Joint sets out how regions load each other.
07What imaging reveals
Trochanteric spurs on a plain film do not identify the syndrome
Imaging in lateral hip pain is read as a set of clues about tendon loading, not as a search for one inflamed pocket. The radiographic sign most often quoted for this condition has been tested and it failed. Three surgeons read blinded pelvic radiographs from 38 patients with the syndrome and 100 controls (Barrett 2020).
Trochanteric spurs of 2 mm or more returned a sensitivity of 64.0 percent and a specificity of 25.7 percent. Three quarters of the positive readings were false. The observers agreed with one another at a coefficient of 0.75, and the sign still could not separate the hips that hurt.
What the film actually reveals
Plain radiographs remain the reference standard for hip osteoarthritis, which is the reason to order them here (Metcalfe 2019). Preserved joint space argues against severe joint disease and moves the question back to the outside of the hip.
Coexisting lumbar findings such as spondylosis, facet arthrosis, and disc narrowing at L4-L5 and L5-S1 are common with age and should not automatically be assumed to explain the outer hip. Findings in People Without Pain carries their prevalence in people with no symptoms, and Why MRI Misleads follows what happens when they are treated as the answer.
When symptoms persist, MRI is aimed at the gluteal tendons for tendinosis and tears, and at the bursa to establish whether distension is present at all (Bird 2001). A clinician who refers for that scan and reads the report alongside the history keeps the outer hip in view rather than defaulting to the joint or the spine.
08Loading the tendon
Education plus exercise beat one corticosteroid injection at a year
The largest trial randomized 204 people with MRI-confirmed gluteal tendinopathy, 167 of them women, to one of three arms (Mellor 2018). The arms were 14 sessions of load management education plus exercise over eight weeks, one corticosteroid injection, or a wait and see approach.
Success at eight weeks went to 51 of 66 in the exercise arm, 38 of 65 in the injection arm and 20 of 68 in the wait and see arm. Pain in the past week averaged 1.5, 2.7 and 3.8 out of 10.
At 52 weeks the ranking held and the injection had drifted, at 51 of 65, 36 of 63 and 31 of 60. Pain scores were 2.1, 2.3 and 3.2, with no difference left between exercise and injection on pain.
The trial that found nothing
A second randomized trial found no difference between its exercise arms. Ganderton and colleagues gave 94 postmenopausal women either a 12-week targeted gluteal loading program or a sham program (Ganderton 2018). Intention to treat showed no between-group difference on the Victorian Institute of Sport Assessment gluteal tendon score.
Both groups improved at 12 weeks and held it at 52 weeks. Among participants who responded, those in the targeted program scored better than responders to sham on that score and on three other measures. The authors report a subgroup that benefits and no average benefit.
Natural history belongs beside those trials. In a primary care cohort of 164 patients, at least 36 percent still had trochanteric pain at one year and 29 percent at five years (Lievense 2005). Patients who had received a corticosteroid injection had a 2.7-fold chance of recovery at five years.
Why conservative care wins the first move
Conservative care is the smartest first move in lateral hip pain because it is the path that either resolves the problem or rules things out carefully before anything invasive is considered. Management shifts from suppressing presumed inflammation toward respecting tendon mechanics, progressively loading the abductors, and restoring pelvic stability.
If conservative care restores function, a person avoids a life altering surgical repair.
If it does not, and significant tendon tearing, progressive weakness, or persistent disability remain, then the case for surgery analogous to a rotator cuff repair is made on solid ground. The alternatives have already been excluded. This is not a diagnosis and every hip deserves individual assessment, yet the principle holds: conservative first is careful first. Conservative First makes the general case.
09Claims removed from this page
Three claims from the earlier version were removed
Small enthesophytes at the superior aspect of the greater trochanter were listed as the imaging clue that matters most, on the reading that a spur there signals chronic traction at the gluteal insertion. The accuracy study above puts the specificity of that sign at 25.7 percent (Barrett 2020). A failed cortisone injection was listed as a tell that points away from bursitis.
Neither the largest trial nor the primary care cohort supports reading it that way, since injected patients did better than untreated ones in both (Mellor 2018, Lievense 2005). A third line, that fatty infiltration or atrophy of the muscle on MRI shapes prognosis, came off because no source cited here measured it.
10The model on lateral hip pain
What the Unified Model of Tone claims about lateral hip pain
Everything above is established science, including the trial that found no difference between its two exercise arms. What follows is our model’s reading, stated as ours rather than drawn from the papers cited.
Tone is the integrated organization through which the body’s interacting processes relate to one another at a given moment. It gathers mechanical tension, neural excitability, autonomic regulation, sensory gain and behavioral readiness. Our model holds that the most symptomatic site is frequently a compensation splinting a distortion elsewhere. The loudest tissue is the weakest link rather than the origin.
The lateral hip rarely announces itself alone. It kept company with low back pain, knee osteoarthritis and iliotibial band tenderness across 3026 adults (Segal 2007). Each body carries a different pattern of constraint, and a disturbance surfaces wherever that body is least able to absorb it. At the hip that place is the tendon that turns a corner around bone.
The dose, not the movement
Too little input is not registered. Matched input is integrated. Excessive input becomes defense, noise or damage. Adduction is not an injury, and 40 degrees of it raised the force under the iliotibial tract to 106 newtons (Birnbaum 2004). The same position is loading at one dose and provocation at another.
That reading is what makes the failed stretch intelligible, and it is our reading of the null trial. A fixed program delivered to every woman in the targeted arm averages a matched dose and a mismatched one across a sample never stratified by tone (Ganderton 2018). Responders in that arm did better than responders to sham.
The prediction
Grimaldi and colleagues found that 20 of 65 patients with lateral hip pain carried gluteal tendinopathy on MRI while testing clinically negative (Grimaldi 2017). Our model predicts that the difference between those hips and the painful ones is measurable, and measurable away from the tendon as well as at it.
Four measures recorded together in the same people will share one underlying factor rather than varying independently. They are pressure pain threshold over the greater trochanter, hip abductor torque during single-leg stance, resting heart rate variability, and time to return to baseline pain after a standardized side-lying compression load.
Our model further predicts the direction of change under an input that restores regulation. People who begin high on that threshold and people who begin low both move toward the middle, and the spread narrows. This is a claim about how lateral hip pain is organized rather than about what treatment does.
If pressure pain threshold over the greater trochanter, hip abductor torque in single-leg stance, resting heart rate variability and recovery time after a compression load move together, the unification claim is confirmed.
11The tone reading
How lateral hip pain expresses tone
Every topic in this library expresses all of tone. In greater trochanteric pain syndrome three aspects carry the signature, because the tissue that hurts is the one holding a load the whole body handed to it.
Load
The trochanter fails at the dose rather than the movement. Force under the iliotibial tract there rose to 106 newtons at 40 degrees of adduction.
Constraint
A guarding hip narrows its gait, and the narrowed pattern parks the tendon in the compressed position it was trying to avoid all day.
Gain
Twenty of 65 patients carried the tendon change on MRI with no clinical sign, so the tissue is not the structure setting the volume.
The remaining foundations run through the lateral hip as well. Set point: the resting level of abductor tone decides how much adduction it takes to provoke the tendon. Input quality: a pelvis that reports its position poorly is steered from a blurred picture. Coupling: the painful hip arrived with low back pain and with knee osteoarthritis on both sides. Prediction: expecting pain on the first stair changes the step before the tendon is loaded. Time course: at least 36 percent still had trochanteric pain a year later, which is a regulator holding a setting rather than a tissue failing to heal. Oscillation: pain that peaks at night and eases by mid-morning reports a rhythm rather than a rupture. These are readings of one organization rather than separate systems, which is the core claim of the Unified Model of Tone.
12Across the library
How this page relates to the rest of the library
The lateral hip is where several of this section’s arguments meet one tendon.
The pathology of the painful tendon and the loading principles this page applies to the hip.
The same compressive story one bone over, where the tendon wraps the ischium instead of the trochanter.
Why a painful hip is examined alongside the low back and both knees rather than on its own.
How often the incidental lumbar findings on a hip film appear in people with no symptoms at all.
Why the least invasive input that can carry the message is the correct place to begin.
The receptor and dorsal horn detail behind a tendon that reports threat rather than damage.
Load as a measurable regulatory variable, with the instruments used to read accumulated demand.
13Frequently asked
Questions patients ask about lateral hip pain
What causes pain on the outside of the hip?
Most lateral hip pain is gluteal tendinopathy, a tendon problem of the gluteus medius and minimus, rather than simple bursitis. Of 877 patients scanned for pain at the greater trochanter, 438 had gluteal tendinosis and 177 had trochanteric bursitis. The pain sits over the bony point on the outside of the hip and spreads into the upper outer thigh. It is provoked by lying on that side, by stairs, and by rising from a low chair after sitting.
Why did my cortisone injection not fix my hip pain?
A corticosteroid injection helps many people in the short term and its advantage fades. In the largest trial, 38 of 65 injected patients reported success at eight weeks. By 52 weeks the injection arm stood at 36 of 63, while an education and exercise arm reached 51 of 65. A fading response reports how durable the input was, and not which tissue was involved. Load management changes what the tendon meets all day rather than the chemistry it sits in.
Is lateral hip pain the same as hip arthritis?
No. Hip arthritis usually causes groin pain and reduced joint motion, while lateral tendon pain sits over the outer hip. A clinician distinguishes them carefully, and the examination does most of that work. Groin pain on passive abduction or adduction carries a likelihood ratio of 5.7 for hip osteoarthritis, and reduced passive internal rotation carries 3.2. Hip internal rotation range did not differ by trochanteric pain status among 3026 adults surveyed, so a stiff hip points into the joint.
Why does it hurt most at night?
Because both available sleeping positions load the tendon. Lying on the painful side presses the gluteal tendons directly against the greater trochanter. Rolling onto the other side lets the upper leg fall across the midline, which is adduction. Cadaver measurements recorded force under the iliotibial tract rising to 106 newtons at 40 degrees of adduction, and falling again in abduction. Night pain in this condition is a mechanical reading rather than a sign that the problem is worsening.
Should the painful side be stretched?
The classic stretch for an aching outer hip pulls the thigh across the body, and that is the position which raises compressive force at the greater trochanter. Load management for gluteal tendinopathy therefore begins by removing sustained adduction. That means crossed legs, low seats, and standing with the weight hung on one hip. Both arms of a randomized trial in 94 postmenopausal women received that education before any exercise was assigned, because it counts as basic care rather than as a treatment under test.
Does a scan settle the question?
Not on its own. Tested against 38 patients with the syndrome and 100 controls, trochanteric spurs on a plain radiograph returned a specificity of 25.7 percent and a false-positive rate of 74.3 percent. MRI is more informative and still imperfect, since 20 of 65 patients with lateral hip pain carried gluteal tendinopathy on MRI while testing clinically negative. The history and the examination decide what a scan is asked to answer, and the report is read alongside them.
What does the Unified Model of Tone say about lateral hip pain?
That the greater trochanter is the site rather than the source. Our model holds that the loudest tissue is the weakest link, and the epidemiology fits, since lateral hip pain arrives with low back pain and with knee osteoarthritis far more often than chance allows. From that the model predicts that pressure pain threshold at the trochanter, abductor torque in single-leg stance, heart rate variability and recovery time after a compression load share one underlying factor rather than varying independently, with compensation deciding how far each one moves.
14The sources
References
12 primary sources, each linked to its record. Figures quoted on this page were checked against the published abstract.
Related evidence