Gluteal tendinopathy: the cause of most lateral hip pain

Greater trochanteric pain syndrome, lateral hip pain, was historically diagnosed as trochanteric bursitis. Clinical evidence from the past decade shows that in most cases, the bursa is not the primary structure involved. The driver is gluteal tendinopathy: degeneration of the gluteus medius and minimus tendons at their insertion on the greater trochanter.

This distinction is clinically important because the treatment for bursitis (rest, anti-inflammatory injection) is different from the treatment for tendinopathy (progressive loading). Injection can temporarily reduce pain but accelerates tendon degeneration if it is the tendon, not the bursa, that is the primary structure.

The gluteal tendons are compressed against the greater trochanter when the hip is in adduction, when the leg crosses the midline. Activities that load the hip in this position include: sitting with crossed legs, sleeping on the side (the lower hip), walking with a wide pelvis-drop gait, and running with excessive hip adduction.

Post-menopausal women are the highest-risk group (hormonal changes affect tendon matrix), but it also presents in runners of both sexes and in people with sustained desk sitting positions.

Unlike mid-portion Achilles tendinopathy where tensile load is the driver, gluteal tendinopathy is primarily a compression problem. The tendon is compressed between the greater trochanter and the overlying tensor fascia latae and IT band when the hip adducts.

This is why the first treatment principle is load management: reduce compressive positions. No crossing the legs. No hip drop when standing. Side-sleeping with a pillow between the knees. These reduce the compression load while the tendon is reactive.

Once the reactive phase is managed, progressive loading begins. Standing hip abduction, single-leg stance with control, lateral band walks, all in positions that avoid hip adduction past neutral. The protocol progresses to single-leg exercises and eventually plyometric loading for athletes.

The tempo of loading matters: slow, controlled movements maintain tendon load without the compressive spike of rapid movements. Heavy slow resistance principles apply.