14 Feb Hip Bursitis Versus Gluteal Tendinopathy
Do you have pain that is on the outside of one of your hips? Does it bother you when you are laying on your side or trying to sleep at night? If you have answered yes to one of these questions, you may be dealing with either hip bursitis or a gluteal tendinopathy. Both of these conditions can be difficult to differentiate in regards to their symptoms and clinical presentation; however, it is important to understand the differences between them both. In this article, we will help you understand why you may be having lateral hip pain, and what you can do to help manage your symptoms.
Lateral Hip Anatomy and Considerations
The hip complex is a strange and impressive place. Numerous different anatomical structures, with hundreds of different actions and responsibilities, all layered on top of one another. The metaphor of “peeling back layers of the onion” has never held so true when attempting to discern a pain generator in the hip as a clinician! Hip pain can present in a variety of different places, but one that often frustrates our patients is the lateral hip (outermost part of the hip). As a quick drill, palpate and feel the outside of your hip; if you find a large bony bump, that’s your greater trochanter.
Greater Trochanter Palpation
Keeping your greater trochanter in mind, take a look at the image below (1) and appreciate how closely the surrounding anatomical structures sit next to one other and this bony landmark you’ve just found.
Lateral Hip Anatomy
The lateral hip serves as an important attachment point for several large hip muscles. The ones that typically get the most attention include the glute medius, glute minimus, and piriformis. (Now, to be fair, there are a variety of other deep hip rotators that insert here too, but we’ll leave those for another day.) Again, you’ve already appreciated the congestion and proximity of how close these muscular structures sit next to one another. Now throw in another player often found in our musculoskeletal anatomy: bursae. A bursa is a fluid-filled sac that typically serves to decrease friction and provide padding in-between closely related anatomical structures. In the case of the lateral hip, we have three. Again, the most notorious and often discussed bursa here is the greater trochanteric bursa (labeled in our picture above as “C” and as its lesser known name, the subgluteus maximus bursa).
Trochanteric Bursitis versus Gluteal Tendinopathy
Now, I don’t mean to assume, but chances are that you’ve found yourself on this article suffering from some pain over your lateral hip. If you’ve seen a physician for this, I’d be willing to bet you’ve been told that you’re suffering from trochanteric bursitis. But what does that mean, is that accurate, and what can we do about it?
Traditionally, lateral hip pain has always been assumed to be trochanteric bursitis until proven otherwise. Trochanteric bursitis is when the bursa that lays over top of your greater trochanter (again, refer to the picture above for the bursa labeled as “C”) becomes inflamed and irritated. Irritated bursae are generally recognized as being particularly painful, making it a clear front-runner for the healthcare provider you’ve sought consult with. You’re especially prone to trochanteric bursitis if you’re a middle aged woman, you’re overweight or you’ve recently changed your walking mechanics secondary to another injury (2).
Over the last decade or so, especially in the rehabilitative field amongst physical therapists and sports medicine physicians, we’ve become increasingly more aware of gluteal tendinopathy. At a surface level, tendinopathy develops when a tendon’s capacity is exceeded often secondary to compressive or tensile loads (3). In turn, the tendon’s physical properties change at a cellular level (3), often resulting in pain. In the case of lateral hip pain, this often occurs with the glute medius or glute minimus tendon. More often than not, the glute medius typically gets the most blame. You’re especially prone to gluteal tendinopathy if you’ve recently had a sharp spike in training load, you’re a woman (sorry ladies, this just isn’t your day is it?) or you’re overweight (1).
But why does it matter?
Now does it matter what we call it? Your hip hurts. Who cares. Well, thankfully, the initial treatment for both of these pathologies involves non-operative interventions including physical therapy, activity modification, and (potentially) diagnostic or therapeutic injection. However, if we’re trying to raise your rehabilitative ceiling as high as we can, differentiating between gluteal tendinopathy versus greater trochanteric bursitis will place greater emphasis on some interventions over others.
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Which is it: Bursitis or tendinopathy? (some easy tests to try at home)
Now, as we’ve already appreciated, the structures involved with both of these pathologies are closely inter-related. Many of the symptoms will overlap, often making it challenging to determine if you’re dealing with a bursitis or a tendinopathy. However, generally a bursitis is exacerbated with compression. Tenderness to palpation (touch) and reproduction of symptoms while in side-lying, especially with sleep, are the two major tests available to you at home. When bad enough, an irritable trochanteric bursitis can be exquisitely painful — even to a light touch. A tendinopathy will also likely be irritated by side-lying, but typically not to the level of that experienced with a bursitis.
Gluteal Tendinopathy Versus Hip Bursitis
Since a tendinopathy is contractile, naturally a special test for this will be contractile (active) in nature. One of the best special tests for this is the resisted external derotation test, described by Dr. Reiman, Dr. Mather and Dr. Cook of Duke University in 2015 publication (4). It’s easy enough to try at home, although as you can appreciate, best to be performed with a skilled healthcare provider. If you’d like to give it a shot from home, have a friend or family member raise the knee of your painful hip towards your chest, and then bring your shin/foot up towards your opposite shoulder. (It’s almost as if you were going to cross your leg and place it over your other thigh like in a seated position.) Once in position, you’re going to attempt to “de-rotate” or “un-wind” your leg back to neutral positioning. It’s a bit challenging to understand through text, so take a look at the brief video below if I’ve lost you. Whether you try this test at home, or with a skilled healthcare provider (like a physical therapist), the accuracy of this test is high (4) in determining if you have a gluteal tendinopathy.
External Derotation Test
Resisted External Derotation Test (Reiman et al, 2015)
Which is it: Bursitis or tendinopathy? (some diagnostics your healthcare provider may utilize)
If you and your healthcare provider are still unsure as to the origin of your lateral hip pain, there are some other diagnostic tests he/she may chose to try. Again, I can’t stress enough none of these are immediately necessary, and should be left to the discretion of your clinician. We’re discussing them here today as conversation pieces. Radiograph, or x-ray imaging, can occasionally show calcifications within the bursa, but generally don’t provide much info otherwise (5, 6). A simple (and honestly, just a really cool test overall) diagnostic ultrasound can allow your clinician to see a bursitis or gluteal tendinopathy on screen in live-time. It’s easy, completely pain-free, safe and cheap. It’s the same technology used for fetal ultrasound with expecting mothers — just with a musculoskeletal perspective. And finally, likely used the least of the aforementioned, is a MRI. Again, let your physician make the call on whether or not this imaging is warranted.
A musculoskeletal ultrasound unit. Cheap, safe, pain-free.
Ultrasound of Greater Trochanteric Region
A snapshot of the greater trochanter. See the middle bottom arrow? If this bursa were inflamed, you’d see a collection of fluid here. (7)
If you are suspected to have a true case of greater trochanteric bursitis, your physician may attempt a local corticosteroid injection or anesthetic for pain relief. This often will provide a near full-resolution of pain if placed correctly (often performed under live-ultrasound), providing a powerful amount of insight as to the source of your pain (2). If you inject the bursa, and the hip feels better, you are likely struggling with a true case of greater trochanteric bursitis.
In extreme cases, once all other options have been exhausted, surgery may be warranted. This is usually only suggested after 6 months of conservative care and physical therapy.
Want to learn more about steroid injections? Listen to our [P]Rehab Audio Experience Podcast Episode below!
Alright, I get it. So how can I fix this?
Thankfully, there are some high-yield, low-hanging fruit for you to try at home. Again, appreciate that any of these tips may help provide some relief, regardless of what you call, or how you categorize, your hip pain. Being specific with what we call it may better help you tailor your self-treatment, or better help your therapist select the most impactful interventions to treat your pain.
How To Decrease Greater Trochanteric Bursitis Pain
Activity Modification: Chances are you experience a significant amount of your pain at night — especially if you’re a side-sleeper. If you sleep with your painful hip in contact with your mattress, the pressure likely increases your pain levels. If you sleep with your painful hip up towards the ceiling, the adduction at your knee (top knee falling in towards your bottom knee) also likely compresses the bursa with the surrounding musculature put on tension.
(Left) If the right hip is your painful hip, naturally, try not to sleep on it.
(Right) However, if you sleep with your painful hip up towards the ceiling, your knee may fall into adduction. This sharp angle can encourage compression over the greater trochanteric bursa / lateral hip musculature.
We recommend sleeping with your painful hip up towards the ceiling with a pillow between your knees. This will help provide for better alignment, helping to take off some of the pressure experienced at the greater trochanteric bursa. Any normal pillow will do, but remember, we’re trying to find “neutral” alignment; meaning that your hip and leg will stay in a straight plane. If you’d like to invest financially, there are many specialized pillows to help you accomplish this. When possible, always test them out before purchasing!
Try sleeping with a pillow in-between your legs. This can discourage compression at the lateral hip. Feel free to add more than one pillow depending on the relief it provides.
Soft Tissue Intervention: Appreciate the influence that tight musculature laying over top of the trochanteric bursa can have in the severity of lateral hip pain / symptoms. Refer back to the first picture of this article. In particular, notice how the tensor fasciae latae creates a roof over the trochanteric bursa. There are a variety of different ways we can influence muscle tone here. Take your pick: foam rolling, a soft tissue percussion tool, soft tissue massage. If you’re working with a health care provider who is certified, you could do dry needling here as well. Regardless of what you pick, your soft tissue intervention should be applied above (not on top of) the greater trochanter. As you can probably imagine, adding more compression over an already irritated bursa doesn’t make much sense. That hard bump on the outside of your hip is not a muscle — so don’t try and roll it out. Work above it please.
With Your Physician:Again, leave this decision to the discretion of your physician. However, it’s very common to perform a local corticosteroid injection to the bursa. Studies have shown significant improvement up to 3 months, with the greatest effect at 6 weeks (8, 9). Unintended side effects are minor and rare such as mild skin color changes in the area (depigmentation) and post-injection discomfort (10).
Activity Modification / Load Management: Much like we discussed earlier, you may find changing your positioning while sleeping to be beneficial. If you’ve recently introduced a new activity to your regular schedule, remove it, and try to decrease your weekly load. This may mean backing off of your regular exercise routine (weekly mileage, weight at the gym, etc.) to try and establish a low level, stable, baseline of discomfort. After an initial period of deloading, and you’ve found a place where your symptoms are managed and predictable, you can begin to progressively load your gluteal musculature.
Progressive Loading: If you’re struggling with a true gluteal tendinopathy, know that you’ve exceeded your “tissue’s capacity” (11). Understand that when dealing with tendinopathy, and after a brief period of deloading, one must load the affected tissue to increase its capacity again. We can do this in a thoughtful and skilled manner, gradually overloading by progressing the intensity and complexity of movements specific (11) for the glute medius. This is where a skilled physical therapist can really shine; dosing exercise appropriately is the bread and butter of the physical therapy profession. However, here are 3 basic loading exercises you can try below starting from easiest, to hardest. For even more detail into the best exercises, please see Tommy Mandala’s great article here with the Prehab Guys, The Best Exercises for the Glute Med.
Level 1: Sidelying isometric hip abduction (with neutral alignment)
Laying on your side, painful hip up towards the ceiling, place a pillow between your knees to give your painful hip neutral alignment (taking tension off the lateral hip musculature and greater trochanteric bursa). Then, place a belt around your thighs, just above the knee joint. From here, we’re going to perform some basic hip abduction isometrics for introductory loading and (possibly) some pain relief benefits (11). Working at an exertion that keeps your pain below a “3” on a scale of “0 to 10” (0 being no pain, 10 being a maximal amount of pain), try and perform 5 sets of :45s seconds each.
Level 2: Sidelying hip abduction
A classic, middle of the road glute medius exercise (12), lay on your side with your painful hip up towards the ceiling. Keep your bottom leg bent a bit for some extra support. Your uppermost leg should stay straight, and keep it slightly behind your torso line. Raise the uppermost leg up towards the ceiling, then lower it back to the original starting position. Shoot for 3 sets of 12 repetitions, but adjust your reps and sets as needed to remain below a “3” on a scale of “0 to 10” pain.
Level 3: Side plank with hip abduction
An exercise shown to be one of the best activators of the glute medius (12), get into a side plank with your painful hip down towards the ground. Raise yourself up into a side plank, and then once stable and balanced, perform hip abduction with your uppermost leg up towards the ceiling. Abduct the uppermost leg for 2 beats, then return to starting position over the course of another 2 beats. Shoot for 3 sets of 5 repetitions initially, and gradually build up to 3 sets of 12 repetitions. Adjust your reps and sets as needed to remain below a “3” on a scale of “0 to 10” pain.
To give you further instruction, here are [P]Rehab videos of a couple of the hip exercises shown above!
- HOW: Begin the exercise by laying on your side, the side closest to the ground will be doing most of the work. Lift up into a full side plank with your feet stacked or one foot in front of the other, keeping your body in one straight line from your heels to your hips to your shoulders.
- FEEL: You will feel your shoulder, hip, and core working – specifically the side facing the floor.
- COMPENSATION: Avoid allowing your shoulder blade to sag back. Avoid allowing your hips to dip towards the floor when holding at the top
Side Plank With Abduction
Sidelying Hip Abduction
Want to learn more about hip strengthening? Watch this video!
- Lateral hip pain is often diagnosed as trochanteric bursitis without much forethought. In many cases, lateral hip pain may actually be gluteal tendinopathy. At times, someone may be dealing with both.
- While symptoms overlap, it can help better individualize your rehab if you can determine which you’re struggling with in specific. If you can’t — no worries. Focus on treating your symptoms rather than assigning the correct name.
- Getting with a thoughtful health care provider who will give a detailed exam, perform the right diagnostic tests, and start from a more conservative angle (activity modification, physical therapy) and progress at an appropriate pace towards less conservative interventions (injection, surgery, etc) will help you on your path to resolving your hip pain.
- If you’d like to try some basics at home, you’ve now been equipped to do so. If you find yourself aggravating your pain or struggling to get on a clean, upward trajectory with your symptoms, schedule an appointment with a musculoskeletal healthcare provider of your choice. A great physical therapist can help get you off on the right foot.
- The longer you’ve been struggling with your pain (especially in the case of a tendinopathy), likely the longer you’ll be rehabbing. Stay the course, try not to worry and know that you’ll work through this!
- Reid, D. The management of greater trochanteric pain syndrome: A systematic literature review. Journal of Orthopaedics. 2016; 13: 15-28.
- Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2008; 24(12): 1407-1421.
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009; 43: 409-416.
- Reiman MP, Mather RC, Cook CE. Physical examination tests for hip dysfunction and injury. British Journal of Sports Medicine. 2015; 49: 357-361.
- Baker CL, Massie V, Hurt WG, Savory CG. Arthroscopic bursectomy for recalcitrant trochanteric bursitis. Arthroscopy. 2007. 23: 827-832.
- Walker P, Kannangara S, Bruce WJM, Michael D, Van der Wall H. Lateral hip pain: Does imaging predict response to local injection? Clinical Orthopedic Related Research. 2006; 457: 144-149.
- Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, et al. Musculoskeletal ultrasound technical guidelines, IV. Hip. European Society of Musculoskeletal Radiology.
- Cohen SP, Strassels SA, Foster L, et al. Comparison of fluroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial. British Medical Journal. 2009; 338: 1088.
- Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteoid injections for greater trochanteric pain syndrome: A ramdomized controlled trial in primary care. Ann Fam Med. 2011; 226-234.
- Coombes BS, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomized controlled trial. Lancet. 2011; 376: 1751-1767.
- Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. BJSM. 2015; 0: 1-8.
- Boren K, Conrey C, Coguic JL, Paprocki L, Voight M, Robinson TK. Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises. IJSPT. 2011; 6(3): 206-223.
About The Author
Chris Lefever PT, DPT, SCS, CSCS, USAW
[P]Rehab Content Creator
Originally from Reading, Pennsylvania, Chris graduated with his bachelor’s degree in exercise science and a doctorate of physical therapy from Slippery Rock University. He afterwards completed a sports physical therapy residency at the Memorial Hermann IRONMAN Sports Medicine Institute. He later completed a division 1 sports physical therapy fellowship at Duke University where he worked closely with Duke football, basketball and lacrosse. He returned to Houston afterwards with Memorial Hermann to help develop an emerging division 1 sports physical therapy fellowship. Present day, he practices with the sports medicine team at the United States Olympic and Paralympic Committee in Colorado Springs, CO. Chris is board certified sports clinical specialist (SCS), certified strength and conditioning specialist (CSCS) and certified in dry needling. He has a particular interest in post-operative rehabilitation of the athletic knee, shoulder, hip and elbow.