Pain located on the outside of the hip – which might also spread down the outside of the leg is a fairly common condition that sends folks limping to the physiotherapist’s office for treatment.
Pain in this region – the outside or lateral aspect of the hip – is common enough that studies estimate 1 in every 4 to 10 people may develop this problem at some point. And if you are female and over 40 you are at slightly higher risk!
In the past, pain and tenderness over the lateral hip were often diagnosed as bursitis – or more specifically “trochanteric bursitis”. We now know that there is seldom swelling present in this bursa when people present with lateral hip pain thus ruling out a diagnosis of bursitis.
A more up to date term to describe pain on the outside of the hip is greater trochanteric pain syndrome (GTPS). More on this to follow. Let’s first look at some hip anatomy.
The Hip Joint and its Muscles
The fashion industry has us thinking of our “hips” as the circumference below our waist and around our buttocks that we measure to choose our pants size. But the hip joint is actually located where the thigh bone (femur) meets the pelvis and it is where we “hinge” to lift our knee to our chest or to sit down.
Stand up and run your hand down your side; you will feel a small bony prominence under your hand at the top of your leg. This is the greater trochanter at the top of the femur and is the important location of the attachment of the some of the hip muscles. It is also often the focal point of lateral hip pain.
The outer muscles in your buttock – the muscles that create the shape of or lack thereof of the buttocks – are called the gluteal muscles. There are 3 of them: the outermost muscle is gluteus maximus, the next one is gluteus medius, and gluteus minimus is the deepest gluteal muscle.
These muscles have very important functions to move the hip joint in certain directions and they also work to stabilize the pelvis during activity. Gluteus minimus and medius are attached to the greater trochanter (that prominence at the outside of your hip) by the gluteal tendons.
Tendons are the strong tissues that attach muscles to bones and when a gluteal tendon is injured or unhealthy it can be the cause of lateral hip pain and the diagnosis of GTPS. If a tendon is damaged or unhealthy the term used to describe it is gluteal tendinopathy. Gluteal tendinopathy is the most common cause of GTPS.
What Causes Gluteal Tendinopathy?
Normally within a healthy tendon, there is a balanced cycle of tissue breakdown and repair. Problems arise however when there is more breakdown of cells in the tendon tissue than repair and this imbalance leads to damage within the tendon called tendinopathy.
This process of increased break down within the gluteal tendon might be triggered by an increase in running mileage or hill walking or hiking with a lot of inclines.
The intensity and the frequency of these types of activities result in longitudinal loading through the hip joint and if there is inadequate recovery or adaptation time factored into training or recreational schedules the gluteal tendon is stressed toward injury.
The other important contributing factor to the development of gluteal tendinopathy is perpendicular loadingthrough the hip joint which is referred to as compression.
Examples of compression loading through the lateral hip are numerous and include lying on the side of the painful hip, sitting with legs crossed, standing with weight shifted to one side (“hanging on your hip”) and stretching exercises of hip muscles such as the Pigeon pose in yoga.
The combination of compression (perpendicular load) and high tensile loads (longitudinal load) seems to be the most damaging to the gluteal tendon. These loads, in combination with increased activity, can sometimes be too much for the tendon and lateral hip pain results.
How Do I Know if I Have Gluteal Tendinopathy?
The most common symptom is pain on the outside of your hip. The pain can become quite acute and it can refer down the outside of your leg to above or occasionally below the knee.
The pain of gluteal tendinopathy tends to be worse:
Lying on the affected side
Sitting with crossed legs
Standing on one leg
Going up or down the stairs
Walking – you may develop a limp with longer walking distances
If you are having lateral hip pain you will benefit from a physiotherapy assessment to determine your specific situation and an individualized treatment program. Special testing, such as x-rays and ultrasound imaging is not usually necessary, but if the physiotherapist has any concerns they will communicate with your doctor.
3 Key Steps for Successful Treatment of Gluteal Tendinopathy
Identify unhealthy longitudinal loads on the hip and reduce or eliminate these loads. An example: reduce walking or running mileage.
Identify unhealthy compression loads on the hip and reduce or eliminate these loads. Two examples: stop sitting with legs crossed and when standing keep weight evenly distributed on both legs.
Work with your physiotherapist to learn gradual resisted exercises in pain-free hip positions and progress as tolerated through graduated strengthening, movement retraining and functional loading exercises.
Managing load is important throughout the recovery period but it is even more important in the acute stages when the tendon is very painful and possibly swollen.
A Surprising Tip to Help You Immediately
Stretching of hip muscles or the iliotibial band (ITB) does not help gluteal tendinopathy to heal. In fact, stretches that bend the hip into flexion and across the midline of the body compress the tendons of gluteus medius and minimus and likely perpetuate the problem and the lateral hip pain.