Pain on the Outside of the Hip – Not Always 'Bursitis'

Pain on the outside of the hip, often worst when lying on that side at night, has long been labelled 'trochanteric bursitis' – inflammation of the bursa. More recent research has shown this is usually the wrong diagnosis, and that changes treatment fundamentally.

It's usually the tendon, not the bursa

On the outer part of the femur sits a bony prominence called the greater trochanter. Here the gluteal muscles gluteus medius and gluteus minimus attach, and between tendon and bone lie several bursae that reduce friction.

When patients with pain in this area are examined with imaging, changes in the tendon insertion itself are found far more often than isolated inflammation of the bursa. This is why the field has moved to the terms gluteal tendinopathy or greater trochanteric pain syndrome (GTPS).

The shift isn't academic hair-splitting. Bursitis would logically call for anti-inflammatory treatment – whereas a tendon disorder requires gradual loading to build the tendon's capacity. The two approaches point in opposite directions.

What the large BMJ trial showed

The LEAP trial, published in the BMJ in 2018, is the most influential study in this area. 204 patients with persistent gluteal tendinopathy were randomised to three groups: education combined with exercise, corticosteroid injection, or 'wait and see'.

After eight weeks, 77% in the exercise and education group reported being at least 'moderately better', versus 58% in the injection group and 29% in the wait-and-see group. The difference held at one-year follow-up, and the exercise group additionally reported less pain than both other groups.

The exercise group also came out ahead on function, quality of life and self-efficacy. The conclusion is clear: supervised exercise combined with a good understanding of the condition beats corticosteroid injection – both short and long term.

Why education is part of the treatment

That 'education' featured as an equal component in the successful arm of the trial is worth noting. Gluteal tendinopathy is provoked by specific positions and movements that many people adopt unconsciously all day:

• Sitting with legs crossed or knees held close together
• Standing with weight resting on one leg, hip pushed out to the side
• Lying on the painful side at night – or on the good side without a pillow between the knees
• Taking long strides downhill or on stairs

Exercise that actually targets it

Rehabilitation is built on rebuilding capacity in the gluteal muscles, with particular emphasis on their ability to stabilise the pelvis when standing on one leg. Early in the course, isometric exercises are often used, providing good loading without large ranges of motion across the irritated tendon insertion.

Loading is then gradually increased towards heavier strength work and functional exercises such as single-leg standing, stair climbing and eventually running or sport-specific demands. Classic 'stretches' where the knee is pulled across the body should be approached with caution, however – they compress the tendon against the bony prominence and can worsen symptoms.

Assessment: distinguishing the sources

Pain on the outside of the hip can also come from the hip joint itself, from the lower back, from the iliotibial band, or be referred from nerve roots in the spine. Clinical examination with specific loading tests – such as sustained single-leg standing and resisted tests for the gluteal muscles – provides good direction.

Ultrasound is well suited to this area because the tendon insertions lie relatively superficially. I can see directly whether the tendon is thickened or structurally changed, whether there actually is fluid in the bursa, and whether partial tears are present. That clarifies which of the two conditions dominates – and in cases where the bursa genuinely is the main problem, a precise, ultrasound-guided injection can be appropriate as a supplement to the exercise.

Sources

1. Mellor R, Bennell K, Grimaldi A, et al. "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.