Question 1

Which conditions can I manage with this plan?

Accepted Answer

Research shows outer hip pain is often due to a combination of gluteal tendinopathy and hip bursitis (also known as trochanteric bursitis). As a result, clinicians often call outer hip pain Greater Trochanteric Pain Syndrome.

Gluteal tendinopathy, hip bursitis, and Greater Trochanteric Pain Syndrome are all caused and aggravated by similar activities.

This rehab plan is designed to help with all 3 of these diagnoses.

Question 2

Overview of gluteal tendinopathy

Accepted Answer

Gluteal tendinopathy is the most common name for pain over the outside of your hip. It affects one or more of the tendons of the deep gluteal muscles (gluteus medius and minimus).

The top of your thigh bone has a prominent bump on the side, called the greater trochanter. It is where your gluteal tendons attach and there are also several bursae in that area. A bursa is a small fluid-filled sac that helps to reduce friction between bones and tendons. Unfortunately, these bursae can also become injured (leading to bursitis).

This treatment plan is designed to help with the following diagnoses:

Gluteal Tendinopathy
Hip Bursitis
Greater Trochanteric Pain Syndrome

Question 3

Symptoms of gluteal tendinopathy

Accepted Answer

When you have gluteal tendinopathy or hip bursitis, you will feel the pain mainly over the outer side of your hip, in the area of the bony prominence (greater trochanter). You may also feel pain down the side of your leg and a little bit below your knee. Although you may feel some pain in your buttock and lower back, your primary pain will be on the side of your hip. Pain that refers all the way to your foot is more likely to come from your lower back. Activities that commonly increase the pain include:

Activities that stretch your gluteal muscles: These may not cause immediate pain but can lead to it worsening later. For example, glute or IT band stretches, cross-legged sitting, or standing with your pelvis dropped and hanging on your hip.
Sleeping on either side may hurt: When you lie on your injured side, you compress that area, which can make it hurt. If your injured leg is on top, that knee will likely rest in slight adduction (be pulled closer to the midline), causing a low-level stretch in the gluteal muscles. It can hurt more if you stay in this position for an extended period.
Standing on one leg (e.g., while getting dressed): If your injury is mild, you may not notice it as much; it may only hurt after balancing on one leg for 30 seconds or longer.

Other factors that can worsen your symptoms:

Walking up hills or stairs (aggravates it more than walking on flat terrain)
Walking or standing for a long time
Sitting in low chairs
Sitting for long periods

Gluteal tendinopathy and hip bursitis are often misdiagnosed. Sometimes the pain is attributed to lower back pain. Other times, all 3 conditions may be present simultaneously, but only one is diagnosed.

Question 4

When to see a doctor

Accepted Answer

You should consult your doctor or physical therapist before using the app to ensure you have the correct diagnosis and are ready to start rehab exercises.If you have any concerns about your injury after you've started your rehab, schedule a review with your doctor, particularly if:

You feel a sudden sharp pain during an activity - this may mean you've strained or torn something, and the app's program may no longer be appropriate
You notice bruising - gluteal tendinopathy and bursitis do not cause bruising
Any part of your leg (thigh, calf, or foot) is swollen, red, hot to the touch, or throbs with pain - these signs can indicate a blood clot, and you should have it investigated as soon as possible
You have severe pain at night that keeps you awake or interrupts your sleep
You feel pins and needles or tingling in your leg - this can indicate an injured nerve, and our rehab plan may not suit you
Your symptoms are getting worse
Your injury is not recovering as expected (see expected recovery times below)

Question 5

Causes of gluteal tendinopathy

Accepted Answer

Overuse

Gluteal tendinopathy and hip bursitis are overuse injuries. The overuse can happen during a single hard training session (sudden overuse) or develop slowly over a more extended period (gradual overuse).

Sudden overuse occurs when you do a training session that's much harder than you're used to, and often includes activities like stair climbing, running, or fast walking. For example, you may have had a break from training due to illness, injury, work, or pregnancy then suddenly returned to exercising. In that case, your tendons and bursae were likely not strong enough to tolerate the job you were asking them to do, and they became injured.

Gradual overuse usually happens because you're not allowing your body to fully repair and recover after exercise. This could be because you're:

Not allowing enough recovery time between training sessions, or
Doing too many high-intensity training sessions in short succession.

Excessive compression

The gluteal tendons and bursae naturally compress against the top of the thigh bone when you move or place your body in certain positions. This usually is not a problem. However, excessive compression may cause overload and injury.

Activities that can lead to excessive compression over the outer hip include:

Regularly doing lots of strong glute and side bending stretches
Poor biomechanics - if your pelvis drops excessively or your thigh bone turns in or crosses too far over the midline (adduction) when you walk or run, it can pull the gluteal tendons tighter over the thigh bone, causing more compression on the tendons and bursae
When you have one leg longer than the other, the gluteal tendons on the longer leg may be more stretched and compressed
Standing with one knee bent and hanging on the other hip, instead of standing equally supported on both legs
Always sitting cross-legged
Running on a steep camber (affects your top leg’s hip)
Always running in the same direction around an athletic track

Other causes

Falling on your outer hip
Menopause - the drop in estrogen levels during menopause reduces the body's ability to produce and repair collagen fibers (the main building blocks of tendons), which increases your risk of developing tendon injuries
Fluoroquinolone antibiotics - these medications can cause tendon injuries, including tendinopathy and tears
Inflammatory conditions - conditions like gout, rheumatoid arthritis, and psoriasis also cause tendon pain and can easily be mistaken for tendinopathy
Significant weight gain

Question 6

Treatment, recovery times & prevention

Accepted Answer

Treatment

Research suggests the most effective way to treat this type of injury is with the right combination of rest and exercise tailored to you (the individual). Therefore, a well-rounded rehab plan for outer hip pain should include the following:

Relative rest: Cut out aggravating activities and reduce your training program to allow your pain to settle
Initially, avoid positions that compress or stretch the gluteal tendons and bursae
A slow, progressive strength training plan: Gradually restores the load tolerance of the tendons and bursae
General strength and control exercises: Condition your core and other supporting muscles (glutes, hamstrings, and calf muscles) to help share the load when you walk, run, and jump
Mobility and range of movement exercises: Gain and maintain good mobility in all your lower body joints and muscles to reduce the strain on your outer hip
Movement retraining: Learn how to use your whole kinetic chain (all the interconnected parts of your body) optimally while standing, walking, and running
Stop bad habits that may be contributing to your injury, e.g., favoring one leg and hanging on one hip when standing

The rehab plan in the app includes all of these components. It starts with low-load exercises that help settle your pain; then, as your tendons and bursae strengthen and heal, exercise intensity slowly increases. Other treatments you may encounter:

Complete rest: It may calm your pain initially, but resting for prolonged periods is not advised as it can cause your tendons to lose more strength
Massage: May help reduce pain, but it does not strengthen your tendons, and vigorous massage over the outer hip can also irritate the tendon and bursae further
Electrotherapy (like an an ultrasound): Not recommended by current research
Shockwave therapy: Can help reduce pain and may improve recovery when combined with rehab exercises
Corticosteroid injections: Can reduce your pain in the short term but may have a detrimental effect on long-term recovery
Hormone replacement therapy (HRT): Research in this area is still sparse, but there's evidence that if you're in perimenopause or menopause, taking HRT may improve your recovery from tendon-related injuries

Recovery times

Recovery can take between 12 weeks (for mild cases) and 18 months for more severe cases. However, recovery rates vary dramatically between patients, and there are no clear timelines described in the research. Factors that can increase your recovery time include:

Waiting several months before starting the correct treatment
Being in perimenopause or menopause

Prevention

You can reduce your risk of developing outer hip pain by:

Allowing enough recovery time after intense training sessions
Varying your training, e.g., don't go to your limit in every session, or switch the direction you run around the track
Avoiding sudden increases in training intensity or volume, e.g., slowly ease back into exercise if you’ve had a break from it
Avoiding bad habits that increase outer hip compression, e.g., sitting with your legs crossed
Avoiding excessive gluteal stretching, e.g., long, sustained stretches in yoga
Adjusting your shoe height if you have a leg length discrepancy
Adjusting your training to compensate for the changes in collagen production when you enter perimenopause

Once you've completed your rehab, you can switch to the injury prevention plan in the app - it’s designed with all these elements in mind.

Question 7

Research References

Accepted Answer

Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: a systematic review. British Journal of Sports Medicine 2017;51:97-104.
Bremer, T., Nicklen, P., Fearon, A., & Morrissey, D. (2022). Management of gluteal tendinopathy: A systematic review and meta-analysis of all interventions. Physiotherapy, 114, e187-e188.
Clifford, C., et al. (2019). "Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study." BMJ Open Sport & Exercise Medicine 5(1): e000558.
Disantis, Ashley E., and RobRoy L. Martin. "Classification Based Treatment of Greater Trochanteric Pain Syndrome (GTPS) with Integration of the Movement System." International Journal of Sports Physical Therapy 17.3 (2022): 508.
Ebert, J. R., Edwards, P. K., Fick, D. P., & Janes, G. C. (2017). A systematic review of rehabilitation exercises to progressively load the gluteus medius. Journal of sport rehabilitation, 26(5), 418-436.
Fearon, A., Neeman, T., Smith, P., Scarvell, J., & Cook, J. (2017). Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: a cross sectional study. Gait & Posture, 52, 237-243.
Grimaldi, A., & Fearon, A. (2015). Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy, 45(11), 910-922.
Grimaldi, A., Mellor, R., Hodges, P., Bennell, K., Wajswelner, H., & Vicenzino, B. (2015). Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine, 45(8), 1107-1119.
Ladurner, A., Fitzpatrick, J., & O’Donnell, J. M. (2021). Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthopaedic Journal of Sports Medicine, 9(7), 23259671211016850.
Lall, A. C., Schwarzman, G. R., Battaglia, M. R., Chen, S. L., Maldonado, D. R., & Domb, B. G. (2019). Greater trochanteric pain syndrome: an intraoperative endoscopic classification system with pearls to surgical techniques and rehabilitation protocols. Arthroscopy techniques , 8(8), e889-e903.
Nasser, A. M., Fearon, A. M., Grimaldi, A., Vicenzino, B., Mellor, R., Spencer, T., & Semciw, A. I. (2022). Outcome measures in the management of gluteal tendinopathy: a systematic review of their measurement properties. British Journal of Sports Medicine
Plinsinga, M. L., Coombes, B. K., Mellor, R., Nicolson, P., Grimaldi, A., Hodges, P., ... & Vicenzino, B. (2018). Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross‐sectional study. European Journal of Pain, 22(6), 1124-1133.
Ramon, S., Russo, S., Santoboni, F., Lucenteforte, G., Di Luise, C., de Unzurrunzaga, R., ... & Vulpiani, M. C. (2020). Focused shockwave treatment for greater trochanteric pain syndrome: a multicenter, randomized, controlled clinical trial. JBJS, 102(15), 1305-1311.

Gluteal tendinopathy rehab plan