Gluteal Tendinopathy: The Side Hip Pain That Is Usually Not Bursitis

It usually starts as an ache on the outside of the hip. Before long you cannot lie on that side at night, and lying on the other side is not much better because the top leg drops across and pulls on the sore hip. Stairs, getting out of the car and standing in a queue with your weight on one leg all start to hurt.

If you have seen a doctor about it, you may well have been told it is hip bursitis and offered a cortisone injection. That often helps for a few weeks before the pain comes back.

The reason it keeps coming back is that, in most people, the bursa is not the main problem. The tendons are.

What is gluteal tendinopathy?

Gluteus medius and gluteus minimus are the muscles on the side of your hip that keep your pelvis level when you stand on one leg, walk or climb stairs. Their tendons attach to a bony point on the outside of the thigh bone called the greater trochanter.

Gluteal tendinopathy is when these tendons become irritated and can no longer cope with the load you put through them. The structure of the tendon changes and it becomes sore, especially when it gets squashed against the bone.

You may also hear the term greater trochanteric pain syndrome (GTPS), which is a catch-all for pain on the outside of the hip. Gluteal tendinopathy is now recognised as the main cause of it (Grimaldi and Fearon, 2015).

Why it is usually not bursitis

For decades, pain on the outside of the hip was called trochanteric bursitis. The bursa is a small fluid-filled sac between the tendons and the bone, and the assumption was that it had become inflamed.

When researchers looked with ultrasound, the bursa turned out to be the culprit far less often than expected. In a study of 877 patients with outer hip pain, only 20.2% had any bursitis. Nearly half had changes in the gluteal tendons and just over a quarter had a thickened iliotibial band (Long et al., 2013).

The label matters because it changes the treatment. If you think it is an inflamed bursa, the natural response is to rest it and inject it. If it is a tendon that has lost its capacity, you need to stop irritating it and then gradually build it back up, and the research shows that approach works much better over time.

Who gets it?

Women get it far more often than men. In a large American study of people aged 50 to 79, 15.0% of women had pain on the outside of one hip and 8.5% had it in both, compared with 6.6% and 1.9% of men (Segal et al., 2007). Low back pain and knee osteoarthritis on the same side were also linked with a higher risk.

It is especially common after menopause (Grimaldi and Fearon, 2015). Oestrogen plays a role in tendon health and lower levels are thought to leave tendons less resilient, although that link is still being researched. We look at this in more detail in our article on menopause and joint pain.

We also commonly see it after a sudden increase in walking, running or hill work, in people with weak hip muscles or who carry extra weight and in anyone who spends a lot of time standing with their weight shifted onto one hip. Wider hips increase the angle the tendons wrap around the bone, which may be another reason it is more common in women.

How to recognise it

The typical signs are:

Pain on the outside of the hip, sometimes spreading down the side of the thigh towards the knee
Tenderness when you press on the bony point on the side of the hip
Pain lying on that side at night, and often on the other side too
Pain going up stairs or walking uphill
Pain standing on one leg, for example when putting on trousers or shoes
Pain after sitting with your legs crossed or in a low chair

Standing on one leg is a surprisingly good test. In a study of patients whose gluteal tendinopathy was confirmed on MRI, pain within 30 seconds of standing on the affected leg was a strong sign of the condition, while having no tenderness at all on the side of the hip made it unlikely (Grimaldi et al., 2017). A 2024 review found that tenderness over the bone combined with pain when resisting outward movement of the leg was one of the most reliable ways to confirm it (Kinsella et al., 2024).

Pain on the outside of the hip can also come from the lower back or the hip joint itself, so part of our assessment is ruling those out.

What the research says works

Education and exercise do better than injections

The best-known study on this is the LEAP trial, published in the BMJ in 2018. Researchers randomly split 204 people with gluteal tendinopathy, mostly women with an average age of about 55, into three groups: education plus a targeted exercise programme, a single cortisone injection or wait and see (Mellor et al., 2018).

After eight weeks, 77% of the education and exercise group said their hip was much better or fully recovered, compared with 58% of the injection group and 29% of those who waited. At one year, education and exercise was still ahead of the injection, at 78% versus 57%. The injection gave faster short-term relief for some people, but the benefit did not last as well.

More recent reviews agree. A 2025 systematic review found exercise combined with education had the strongest evidence of any treatment (Bremer et al., 2025), and a 2025 network meta-analysis of 19 trials found exercise gave the biggest improvements in pain and function (Wang et al., 2025).

Take the pressure off the tendon

A key part of the LEAP education was avoiding positions that compress the gluteal tendons against the bone (Mellor et al., 2018). The main ones to watch are sitting with your legs crossed (or knees together and feet apart), standing with your weight hanging on one hip, lying on your side without a pillow between your knees and stretches that pull the leg across your body, like the classic ITB stretch or figure-four stretch.

That last one catches a lot of people out. The side of the hip feels tight, so they stretch it hard, which usually makes gluteal tendinopathy worse. Changing how you sit, stand and sleep is often enough to noticeably reduce night pain within a week or two.

Build the tendon back up

Tendons get stronger when they are loaded in the right way. Rehab starts with gentle holds that strengthen the hip muscles without compressing the tendon, then moves on to bridges, step-ups, squats and single-leg work as your hip settles. How quickly you progress depends on how irritable the tendon is, but most programmes run over 8 to 12 weeks.

Shockwave therapy

Shockwave therapy is useful, particularly when the pain has been there for months and has not responded to exercise alone. One early study compared home exercise, cortisone injection and radial shockwave in 229 patients. The injection worked best at one month, but by four months shockwave had the highest success rate of the three (68%), and at 15 months both shockwave and home exercise were well ahead of the injection (Rompe et al., 2009).

A 2024 meta-analysis of eight randomised trials found shockwave reduced pain more than other treatments at two to four months, and focused shockwave did better than radial (Rhim et al., 2024). The quality of the trials varies, so we use shockwave to support the exercise programme rather than replace it, which is also how the latest reviews position it (Bremer et al., 2025). At our practice we use the EMS Swiss DolorClast Smart20 and usually combine shockwave with rehab in the same appointment.

Hands-on treatment

The hip does not work in isolation. Stiffness in the lower back and SI joints, tight surrounding muscles and the way you move all affect how much load goes through the tendon. Chiropractic adjustments, mobilisation, dry needling and soft tissue work help reduce pain and make the exercises easier to do. They support the rehab, but the rehab is what fixes the tendon.

Should you have a cortisone injection?

An injection can settle a very painful hip quickly, and it has a place when night pain is bad enough to stop you sleeping or exercising. The LEAP trial showed that on its own it does not match education and exercise in the long run, and repeated injections into a tendon are generally not advised. If you do have one, use the break from pain to get started on the right exercises.

How we treat it

At our Sandton practice we start by examining the hip, lower back and pelvis to make sure the pain really is coming from the gluteal tendons. We then explain what is going on in the tendon and which everyday positions you need to change so it stops being aggravated.

From there we build a loading programme around how irritable your hip is and what you want to get back to, whether that is walking the dog, playing padel or just sleeping through the night. We add shockwave where it is likely to help, especially for pain that has been around for a while, along with hands-on treatment for the back, pelvis and surrounding muscles.

In most people the night pain improves first, followed by stairs and walking over the next couple of months.

When to get it checked

Book an assessment if:

Pain on the outside of your hip has lasted more than a few weeks
You cannot lie on your side at night
Stairs, hills or standing on one leg are painful
The pain came back after a cortisone injection
You were told it is bursitis but nothing has helped

You can read more about other causes of hip pain on our hip pain page. If your hip is keeping you up at night, get in touch or book an appointment and we will work out what is going on and how to fix it.

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