Gluteal tendinopathy: symptoms, treatment, exercises and recovery

Cambridge University Hospitals says the best treatment, according to the most up-to-date evidence, is physiotherapy. A physiotherapist will do a detailed assessment of your hip and your postural and movement habits, and treatment focuses on reducing the compression of the tendons over the greater trochanter and an exercise programme that concentrates on control, recruitment and capacity of the muscles around the hips and pelvis. Because the condition is multifactorial, they will also discuss contributing factors such as weight management, diet, hormones and activities.

The Royal Orthopaedic Hospital explains that because the tendons are not normally inflamed, the typical approach of rest and anti-inflammatory medication fails to resolve the issue in many cases. It says most experts accept that the problem is degenerative, but that for most people it is rectifiable: if the rate of wear becomes faster than the rate of repair, healthy tendons can start to become weaker until they become painful, and a specific rehabilitation programme can strengthen the gluteal muscles and tendon and improve tolerance to activity.

Cambridge University Hospitals says the most recognised feature is pain and tenderness on the outside of the hip, directly over the greater trochanter, the bone at the side of the hip. Pain can extend down the outer thigh to the knee, and may be sharp, aching or burning. Sharp pain may come with snapping or clicking, and some people report a feeling of giving way during weight-bearing tasks.

Pain can be felt when lying on either side, on single-leg loading such as standing on one leg to get dressed, on sitting for a long time in low chairs or a car, on rising from a chair for the first few steps, on walking up hills or stairs, on running and when touching the outer hip bone. The Royal Orthopaedic Hospital adds that symptoms are often felt after a long period of rest, when lying on the painful side and during deep squatting, stair climbing or impact exercise.

Cambridge University Hospitals explains that pain over the side of the hip has traditionally been called trochanteric bursitis, where a fluid-filled sac that protects the tendon is inflamed. It says problems with the bursa are rare in isolation, shown in only 2% of patients, and that tendon problems co-exist with bursa problems in 88 to 98% of patients. The condition is therefore now known as greater trochanteric pain syndrome (GTPS) and gluteal tendinopathy.

Arthritis UK says trochanteric bursitis is now known to affect the muscles and tendons around the trochanteric area as well as the bursa, and that you may be told you have greater trochanteric pain syndrome, trochanteric tendinobursitis or gluteal tendinopathy.

Cambridge University Hospitals says the exact causes are still being explored, but it is often associated with weakening of the gluteal muscles and movements that increase the stress on the gluteal tendons. Compression of the tendons over the greater trochanter is thought to be a key factor, and can be linked to postural habits such as hanging on one hip.

It lists other contributing factors including increased weight around the stomach, diabetes, genetic factors, previous use of fluoroquinolone antibiotics, high cholesterol, hormone changes, vascular issues, age and spinal or hip problems. It says symptoms often begin when a weak tendon is exposed to a sudden increase in loading, such as hill walking or climbing lots of stairs, or after a direct impact such as a fall onto the hip, although it is often difficult to identify a specific incident.

The Royal Orthopaedic Hospital adds that exercise loads, fitness levels, body fat, hormonal changes, stress, postures and limb alignment and previous injuries all affect the wear and repair process.

Cambridge University Hospitals says the quickest way to make a difference is to reduce the compressive load on the tendon by avoiding postures that aggravate it. The Royal Orthopaedic Hospital gives a list of dos and don'ts.

• Do not stand with one hip hung to the side, such as when holding a child on your hip.

• Do not sit cross-legged or bring the knee across the body, and minimise time with ankles or legs crossed.

• When you sit, aim to have your hips higher than your knees and avoid low chairs; a wedge cushion may help.

• If you sleep on your side, avoid the sore hip and place a pillow between your knees; if both hips are painful you can sleep on your back with pillows under your knees. A mattress topper may help.

• Avoid hill walking and stairs where possible, and use a rail on the opposite side to the painful hip.

• Avoid stretching the area, including gluteal stretches, strong lumbar rotation stretches and iliotibial band stretches, because stretching increases the compression of the tendon.

• Avoid massaging the sore spot with deep pressure; massaging the gluteal muscles may help relieve symptoms (Royal Orthopaedic Hospital).

• Do not rest completely, as resting decreases the tendon's ability to take load; listen to your pain but try to stay active (Royal Orthopaedic Hospital).

Cambridge University Hospitals explains that studies show gluteal strength is affected in both hips when there is pathology in one, with the symptomatic side on average 32% weaker and the non-symptomatic side 23% weaker than in people without gluteal tendinopathy, so it is important to strengthen both hips. It lists static and dynamic stage 1 exercises that help reduce pain and aid strengthening, and advises that if you do floor-based Pilates you avoid clams and side-lying leg lifts, which increase compression.

The Royal Orthopaedic Hospital says a progressive strengthening programme slowly increases the tolerance of the tendon to load, and that exercise is safe and pain does not mean harm: carry out exercise even if there is mild discomfort that eases after exercise. It adds that if you regularly push into moderate to severe pain that continues for extended periods and disturbs sleep, you may be doing too much. A physiotherapist can tailor the programme to you.

The Royal Orthopaedic Hospital says the rehabilitation process often takes months because tendons do not have a rich blood supply, so adaptation to exercise can be slow. Depending on how long you have had tendinopathy, it can take 6 to 12 months for symptoms to resolve with exercise therapy. In the majority of cases, if you stick with the programme, it says this approach is successful and leads to long-term successful outcomes.

Cambridge University Hospitals describes a continuous cycle in which pain leads to tendon irritation from day-to-day overload or compression, then to muscle fatigue, reduced movement, too much rest and weakness, and more pain, which is why a structured plan matters.

Cambridge University Hospitals says in most cases your doctor or physiotherapist will suspect gluteal tendinopathy from the symptoms you describe and from a cluster of tests when they examine your hip, such as palpation of the side of the hip, a single-leg balance test, a resisted side-lying abduction test and a hip rotation test. Ultrasound or MRI scans are sometimes used but are not required to confirm the diagnosis.

Arthritis UK says MRI scans can show what is happening to the soft tissue such as muscles and tendons inside your hip, and that steroid injections are usually very helpful in treating conditions affecting the trochanteric area on the outside of the hip.

Arthritis UK says most of the time you can treat hip pain yourself with simple self-help treatments. If your hip pain is extremely bad or has not improved after two weeks of regularly taking painkillers, you should see your doctor.

It says to see your doctor straight away if you have had a fall or injured your hip, the pain is getting worse, you have difficulty with daily activities such as walking, going up stairs or leaning forwards when sitting, or you feel feverish or unwell or have been losing weight.

On the NHS, a GP can assess outer hip pain and refer you to physiotherapy. In many areas you can refer yourself to NHS musculoskeletal (MSK) physiotherapy services. The Royal Orthopaedic Hospital notes that self-referral routes to physiotherapy exist and that GPs can refer too.

Some people choose private physiotherapy for quicker access to sessions. The approach described by the NHS trusts above is the same whichever route you take: education, reducing compression, and progressive loading, with injections reserved for selected cases.