Glenn Wellmann DPT

Pain on the outside of your hip has a recognizable pattern. It sits over the bony bump on the side of your hip, the greater trochanter, and can spread down the outer thigh. It wakes you lying on that side. It flares when you stand on one leg to pull on pants, on stairs, and after sitting a long time with your legs crossed.

If that is your hip, the likely diagnosis is gluteal tendinopathy: an irritated, load sensitive state in the gluteus medius and minimus tendons where they attach to the side of your hip. It is the primary local source of lateral hip pain, most common after age 40, and it affects women more often than men by a ratio of roughly 2.4 to 4 to 1 (Grimaldi and Fearon, Journal of Orthopaedic and Sports Physical Therapy, 2015).

Why “bursitis” is usually the wrong label

For decades this was called trochanteric bursitis, which implied an inflamed fluid sac and pointed treatment toward injections. Imaging and surgical findings shifted that picture: the tendons are typically the involved structure, and bursal irritation tends to be a passenger rather than the driver. The umbrella term now is greater trochanteric pain syndrome, and gluteal tendinopathy is the usual cause inside it.

Why that matters to you: a tendon problem is a load problem, and load problems respond to changing load, not to waiting out inflammation. It is the same logic behind how I approach other stubborn tendons, like in my breakdown of the 2025 rotator cuff tendinopathy guideline.

Why it happens

Gluteal tendons dislike two things: too much load too fast, and being squashed. The squashing part is what most people have never heard. When your hip moves into adduction, meaning the thigh crosses toward the midline, the tendons get compressed against the bone underneath. Hold that for hours and a sensitive tendon stays under pressure. Common culprits:

• Side lying at night. On the painful side the tendons press into the mattress. On the other side the top hip drops into adduction and compresses that side instead, which is why lying on either side can hurt.
• Sitting with legs crossed, or knees pressed together in a deep chair.
• Standing hung into one hip, weight shifted with the pelvis dropped to one side.
• Aggressive iliotibial band and piriformis stretching. Those stretches pull the hip into adduction and compress the tendons you are trying to help. In older programs built on them with no direct abductor work, results were poor, and the authors argued that minimizing compression and adding abductor strengthening should do better (Grimaldi and Fearon, 2015).
• An activity spike on top of weak hip abductors: a new hiking block, a jump in walking, or a return to running.

What the evidence actually says

The LEAP trial randomized 204 adults aged 35 to 70 with lateral hip pain lasting over three months and MRI confirmed gluteal tendinopathy into three groups: education plus exercise, one ultrasound guided corticosteroid injection, or wait and see. The exercise group had 14 physiotherapy sessions over eight weeks plus a daily home program of 4 to 6 exercises targeting hip abductor strength and control of adduction.

At eight weeks, 77.3 percent of the exercise group rated themselves moderately better or more, versus 58.5 percent after injection and 29.4 percent with wait and see. Average pain was 1.5 out of 10 with exercise, 2.7 after injection, and 3.8 with wait and see. At 52 weeks the gap held: 78.6 percent versus 58.3 percent success, a risk difference of 20.4 percent (95 percent CI 4.9 to 35.9), while injection was no longer clearly better than doing nothing (Mellor et al., BMJ, 2018;361:k1662).

A 2025 systematic review that accepted only medium to high quality, low risk of bias trials agreed. Exercise plus education showed the largest short term effects of any conservative option for pain (standardized mean difference 0.95, 95 percent CI 0.58 to 1.33) and function (0.91, 95 percent CI 0.53 to 1.28), while corticosteroid injection managed only a small short term pain effect (0.51, 95 percent CI 0.16 to 0.86) (Bremer et al., Clinical Rehabilitation, 2025).

The honest catch: in that review, exercise and education effects shrank from medium to small at longer follow up, and heterogeneity prevented a true meta analysis. This works, but it is not one and done. I am digging into the treatment comparisons in a separate Research Bites post on gluteal tendinopathy treatments later this month.

Step one: stop compressing the tendon

Before any strengthening, I change positions. This alone often calms the night pain within a couple of weeks.

1. Fix the sleep setup. Avoid lying directly on the painful side. On the other side, put a pillow between your knees and ankles thick enough that the top hip stays level rather than dropping in.
2. Stop crossing your legs, and skip deep chairs that pull your knees together and up. Feet flat, knees about hip width.
3. Stand on both feet evenly. If you catch yourself hanging into one hip, split your weight and keep the pelvis level.
4. Shelve the IT band and piriformis stretches and anything that pulls the knee across your body, for now.
5. Trim provocative load for two to three weeks: fewer stairs, shorter walks more often instead of one long one, and no steep downhill hiking. Do not stop moving. Tendons need load, just the right amount.

A progressive loading program

Stay at 3 out of 10 or less during exercise, back to baseline within 24 hours. Tendons reward consistency, not heroics.

1. Isometric hip abduction: press the outside of your thigh into a wall, 5 holds of 30 to 45 seconds, once or twice daily.
2. Double leg bridge: 3 sets of 12, daily. Cue: push through both heels, ribs down.
3. Level pelvis single leg stand: 20 to 30 seconds, 3 reps per side, daily, keeping the standing side hip level rather than dropping out.

1. Side lying hip abduction, non painful side down: 3 sets of 12 each side, 4 days a week. Cue: heel slightly behind the body, no rolling back, no hip hiking.
2. Standing banded hip abduction: 3 sets of 12 each side, 4 days a week, pelvis level.
3. Single leg bridge: 3 sets of 10 each side, 3 days a week.
4. Sit to stand or shallow squat: 3 sets of 10, 3 days a week, knees tracking over mid foot.

To progress: all sets at 3 out of 10 or less, and night pain clearly reduced.

1. Loaded split squat or step up: 3 to 4 sets of 6 to 8 each leg, 2 to 3 days a week, adding weight.
2. Single leg calf raise: 3 sets of 12 each side, 3 days a week.
3. Side plank progression or standing hip hitch: 3 sets of 20 to 30 seconds each side, 3 days a week.
4. Walking or hiking rebuild: add about 10 percent a week, distance or grade, not both. Downhill last.

Expect months, not days. In the LEAP trial the supervised block was eight weeks and the benefit was still there at a year, so aim for a habit you keep. If hiking is your motivation, my post on hiking and joint health is a good companion once the hip settles.

Red flags: when to get it looked at in person

• Hip pain after a fall, or you cannot bear weight on the leg
• Fever, warmth, redness, or feeling unwell
• Night pain getting worse week over week despite reducing load
• Unexplained weight loss, or a cancer history with new bone pain
• No change after about 12 weeks of consistent, well managed loading
• Numbness, tingling, or progressive leg weakness
• A sudden loss of hip strength, which can point to a tendon tear

Where to go from here

If cortisone bought a few good weeks before the pain returned, the missing piece is usually structured loading plus the positional changes above, not another injection. A comprehensive evaluation gives us a full hour to sort out what is driving it and build a plan around your sleep, your job, and your hikes. If you already know the diagnosis and want the program written and progressed for you, that is my home exercise program service.

References

• 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. doi:10.1136/bmj.k1662. https://www.bmj.com/content/361/bmj.k1662
• Bremer T, Nicklen P, Fearon A, Morrissey D. The efficacy of gluteal tendinopathy treatments: a systematic review. Clinical Rehabilitation. 2025;39(5):600. doi:10.1177/02692155251327298. https://pubmed.ncbi.nlm.nih.gov/40223303/
• 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. doi:10.2519/jospt.2015.5829. https://www.jospt.org/doi/10.2519/jospt.2015.5829