Pain on the outside of the hip is a common complaint we treat here at Sport and Spinal Physiotherapy. I thought it would be a good idea to summarise how we currently diagnose and treat the most common person walking through our door with lateral hip pain as medical and anatomical knowledge continues to evolve.

This article will discuss the most common cause of lateral hip pain in females aged 40-60, as this demographic most often suffers from lateral hip pain.

greater trochanteric bursitis in runners

In previous years, a lot of people with pain on the outside of the hip would have been diagnosed with bursitis. Consequently, this would often be sent straight off for a steroid injection (to treat ‘inflammation’) with varying results.

Progressive studies and advances in knowledge may now explain why some people improved with an injection, and some people didn’t.

Bursitis at the lateral hip has been referred to as the ‘Great Mimicker’ because it was often mistaken for other conditions.

Let’s start with some definitions and specific diagnosis of lateral hip pain:

The most common cause of lateral hip pain is now referred to as Greater Trochanteric Pain Syndrome or GTPS, but what does this mean??

The greater trochanter is the bony point of the outside of your hip – an area of solid bone to which your gluteal muscles attach:Anatomy of hip

So what is Greater Trochanteric Pain Syndrome (GTPS)?

GTPS came about as it is sometimes difficult to elucidate the true cause of the symptoms with lateral hip pain. A review article described GTPS as a regional pain syndrome that often mimics pain generated from other sources, including, but not limited to:

  • Muscle pain
  • Arthritic joints
  • Referred pain from the spine

Pain definitively due to GTPS is attributable to tendinopathy of the gluteal tendons with or without pathology to a hip bursa (small cushioning sac which prevents irritation between tendon and bone).

People will often report pain with:

  • Lying on the affected side
  • Prolonged standing
  • Sitting with affected leg crossed
  • Climbing stairs
  • Running/walking faster, or other higher impact activities

Pain after activity may be experienced. Hip musculature can also be weak.

Approximately 50% of people with GTPS will experience pain radiating down the outside of the thigh to the knee.

Jenna has also written about GTPS here.

What causes GTPS?

As mentioned above, once conditions such as general muscle pain, joint-related pain, or lumbar spine referred pain has been ruled out GTPS can be attributable to tendinopathy of the gluteal tendons +/- bursal pathology.

As a result of loading detrimental changes can happen to a tendon – this is called tendinopathy. Sometimes the load will exceed what the tendon is capable of tolerating, and dysfunction may result. It is most commonly described as a non-inflammatory degenerative condition – characterised by collagen degeneration in the tendon due to repetitive overloading.

Bursal pathology describes irritation and swelling of a bursa – which is a fluid-filled sac which decreases friction between tendon and bone.

This conditions can come about due to :

  • prolonged pressure to the lateral hip (lying on one side a lot)
  • lots of repetitive movements (generally walking/running more than normal)
  • direct trauma ( ie due to a fall)
  • starting up vigorous exercise (when not accustomed to it)
  • hip instability (poor muscle control)
  • unusual body mechanics ( eg leg length difference)

Risk factors form GTPS

Being a female aged 40-60 is a risk factor for developing GTPS. Other pre-disposing factors include:

  • being overweight
  • weak gluteal musculature complex
  • previous/current history of back pain
  • some evidence that over-pronators (flat-feet) may contribute
  • Runners ( more than 30km  week)
  • Knee arthritis

Treatment of GTPS

Management of GTPS will involve:

  • Managing loads on hip joint
  • Reducing compressive forces across the greater trochanter
  • Strengthen gluteal muscles
  • Treating comorbidities

Managing loads on the hip joint:

To ease the pain on the outside of the hip, relative rest may be required. Tendinopathy may be the cause of the discomfort, easing the load on the tendon should ease the pain.

Aggravating activities/movements need to be identified, then reduced to a level where the pain is not exacerbated. Complete recovery will take place faster if you manage loads this way rather than stopping activity completely.

Altered body mechanics may be influencing the force that is put through hip – so a biomechanical assessment is important in managing the load. This can also play a role in reducing compressive forces:

 

Reducing compressive forces across greater trochanter:

Eliminating the compressive load is vital to the recovery of GTPS – Avoid positions that lengthen the affected hip including:

  • crossing your legs
  • ‘popping’ your hip out in standing (lazy standing)
  • lying on either side
  • walking on cambered surfaces
  • in the initial stages stretching the muscles on the outside of the hip may exacerbate pain

Strengthen gluteal muscles:

We have posted articles in the past regarding glut strengthening. Simon discusses 13 ways here, Jenna also has some tips in this article, and Simon backs up with some more info here.

Gluteal Muscles of the hip

Treating co-morbidities:

  • Being overweight is a major risk factor for developing GTPS. Addressing this is advantageous in getting rid of the pain.
  • Back pain is often a precursor to developing GTPS. This is possibly related to weakness throughout the trunk. Addressing this is a specialty at Sport and Spinal Physiotherapy. Previous articles cover this well – see excellent summaries from Jim, (x2), and Sophie.
  • In some cases, flat-feet (over-pronation) may be contributing. This is where the expertise of Your Podiatry Canberra can be invaluable.
  • Knee arthritis – physiotherapy input is a key cog in managing knee arthritis. Podiatry can also play an important role here, managing ground reaction forces from the foot up.

With a comprehensive physiotherapy programme GTPS will be well managed.  Don’t expect overnight miracles unfortunately!  Though once the symptoms are settled they will stay away!

References:

About Jamie Clough

Jamie graduated from the University of Otago, Dunedin, New Zealand in 2010 with a Bachelor of Physiotherapy. He spent several years working out of outpatient clinics and in the inpatient setting in Invercargill on the South Island, treating a wide variety of conditions both acute and chronic in nature. His special interests include the use of dry needling for pain relief and tissue alteration, sport specific injuries and rehabilitation, and post-operative orthopaedic rehabilitation.