Lateral Hip Pain Adults

Lateral hip pain in adults is one of the most common lower-limb presentations in musculoskeletal practice and yet one of the most frequently mismanaged. Contemporary evidence has moved the field decisively away from the term “trochanteric bursitis” and toward the more accurate label Greater Trochanteric Pain Syndrome (GTPS), reflecting the dominant role of gluteal tendinopathy — chiefly the gluteus medius and gluteus minimus tendons — in the clinical picture. Load management, not passive bursa treatment, is the cornerstone of care.

Primary resources:

Anatomy and Pathological Basis

The gluteus medius and minimus insert on the greater trochanter via distinct footprints. The gluteus medius has a posterior superior and an anterior lateral facet insertion; the gluteus minimus inserts on the anterior facet. Both are compressed by the iliotibial band (ITB) as it passes over the greater trochanter, particularly in positions of hip adduction.

The pathological continuum in GTPS mirrors the model used for other tendinopathies:

  • Reactive tendinopathy: rapid load increase, sudden compressive stress (e.g. starting a new walking programme, postural change during pregnancy).
  • Dysrepair/failed healing: disorganised collagen with partial intratendinous change visible on imaging.
  • Degenerative tendinopathy: extensive intratendinous pathology; may include partial or full-thickness tears of the gluteal tendons.

A key biomechanical concept is the distinction between tensile and compressive load at the tendon insertion:

  • Tensile load (hip abductor contraction) is generally beneficial and part of rehabilitation.
  • Compressive load (ITB pressed against the tendon, particularly in hip adduction or cross-leg sitting) is the primary driver of pain and must be reduced early in management.

Knowledge Check

Which loading pattern is the primary driver of pain in gluteal tendinopathy and should be reduced early in management?
Answer: Compressive load from ITB contact, especially in hip adduction
Positions that bring the ITB into contact with the gluteal tendon insertion (cross-leg sitting, hip drop in gait, stretching across midline) drive compressive tendon load and must be modified early.

Clinical Presentation and Diagnosis

GTPS is most common in women aged 40–60 years, though it affects men and younger active adults too. The typical presentation includes:

  • Pain localised to the lateral hip, often with point tenderness over the greater trochanter.
  • Pain with lying on the affected side at night.
  • Pain with sustained standing, walking, or stair climbing.
  • Pain aggravated by sitting with legs crossed, or by standing with weight shifted to the affected hip (“hip hang” posture).

Imaging (ultrasound or MRI) can confirm tendon pathology and exclude full-thickness tears, but diagnosis is primarily clinical. Imaging findings must always be interpreted in the context of the clinical story, as asymptomatic tendinopathic change is common on imaging.

Useful Clinical Tests

  • Single-leg stance test: reproduces lateral hip pain during a sustained, load-bearing, compressive position.
  • FABER test: hip flexion, abduction, and external rotation — useful to screen for intra-articular pathology and to differentiate from groin-based sources.
  • FADER (Flexion, ADduction, External Rotation): the most compressive position for the gluteal tendon insertion and a useful provocation test for GTPS.
  • Trendelenburg sign: assessing hip abductor strength and neuromuscular control in single-leg stance.
  • Palpation of the greater trochanter: localised tenderness at the posterior and superior facets correlates with gluteus medius involvement.

Knowledge Check

Which test position places the most compressive load on the gluteal tendon insertion at the greater trochanter and is therefore a useful provocation test for GTPS?
Answer: FADER (hip flexion, adduction, external rotation)
FADER is the most compressive combination for the gluteal tendon insertion. It is used both as a clinical provocation test and to inform which positions to avoid in early management.

Management: Load Management Then Progressive Loading

The evidence-based framework for GTPS follows a two-phase approach:

Phase 1: Reduce Compressive Load

Before loading the tendon, compressive provocations must be minimised:

  • Avoid sitting with legs crossed or with knees higher than hips.
  • Avoid the “hip hang” posture (resting weight through one hip in standing).
  • Avoid stretching the ITB (e.g. cross-body hip stretches, pigeon pose in yoga) — these compress the tendon against the trochanter.
  • Modify walking terrain and gradients that provoke symptoms (e.g. side slopes that increase relative hip adduction).
  • Sleep positioning: pillow between knees if side-lying, or sleep supine.

Phase 2: Progressive Tendon and Hip Abductor Loading

Once compressive irritability is controlled, progressive loading follows the standard tendinopathy progression:

  • Isometric: side-lying hip abduction holds, standing hip abduction against a wall. Early pain management and safe entry to loading.
  • Isotonic: clamshells, side-lying hip abduction with resistance, hip hitching, progressing to bridge variations and lateral band walks.
  • Functional / sport-specific: single-leg squat, lateral step-down, running gait re-education, sport-specific loading. Ensuring adequate trunk and pelvis control throughout.

The LEAP (Load Exercise for the Abductor Progressively) trial demonstrated that a targeted exercise programme for GTPS was superior to corticosteroid injection and to wait-and-see at 8 and 52 weeks. This is now the recommended first-line treatment. Corticosteroid injection provides short-term pain relief but does not improve longer-term outcomes and may impair tendon healing.

Differential Diagnosis: What Else Causes Lateral Hip Pain

Not all lateral hip pain is GTPS. Consider:

  • Hip osteoarthritis: often presents with lateral hip pain, but also groin pain, and restricted passive hip ROM (especially internal rotation and flexion). Radiographic joint space changes confirm.
  • Iliotibial band syndrome: lateral knee pain predominates in runners; lateral hip pain is secondary.
  • Lumbar referred pain: L4/5 or L5/S1 referral can mimic lateral hip pain. Lumbar spine examination is part of the assessment.
  • Meralgia paraesthetica: lateral femoral cutaneous nerve entrapment causes lateral thigh burning and paraesthesia, without localised trochanteric tenderness.
  • Gluteal tendon tears: partial or full-thickness tears may present with severe weakness, a positive Trendelenburg, and acute onset after minor trauma. MRI is diagnostic.
  • Femoroacetabular impingement (FAI): typically causes anterior or antero-lateral hip pain with groin pain; end-range hip flexion provocation. Consider particularly in younger active adults.

Knowledge Check

The LEAP trial demonstrated that which first-line treatment for GTPS produced the best outcomes at 1 year?
Answer: Education and targeted progressive exercise (load exercise for the abductor progressively)
The LEAP trial is the landmark RCT for GTPS. Education plus progressive hip abductor loading was superior to corticosteroid injection and to wait-and-see at both 8 weeks and 52 weeks.

Bottom Line

Lateral hip pain in adults is usually gluteal tendinopathy at the greater trochanter, not bursitis. The key clinical insight is that compressive load is the primary pain driver: positions that press the ITB against the gluteal tendon insertion must be identified and modified before any loading programme begins. Progressive hip abductor loading, patient education about load modification, and addressing contributing biomechanical factors (pelvis control, gait pattern, hip strength) form the backbone of an evidence-based programme. Corticosteroid injection provides short-term relief but should not be used as first-line care or repeated in the same tendon.