Why the Outside of Your Hip Hurts: Understanding Gluteal Tendinopathy
Pain on the outside of the hip is one of the most common reasons people come to see me. Walkers get it. Runners get it. People who have never set foot in a gym get it. It can sneak up gradually or arrive after what seems like a minor change in your routine.
Sleeping on that side becomes uncomfortable. Long walks feel different. Stairs suddenly hurt a lot and demand much more attention. Getting in and out of the car produces that sharp reminder that something is wrong.
.
For decades, we called this bursitis. And everyone got injections for it. Lots of injections. But were we treating the right pathology? No. And over time, injections can worsen the pathology. Let’s dive into why lateral hip pain is so common and how to manage it.
The bursitis label stuck. It was easy to say, easy to understand, and it made intuitive sense. There is a bursa on the outside of the hip, and if the area hurts, the bursa must be inflamed.
Except that usually isn’t what’s really going on. Much like shoulder pain used to be blamed on bursitis or a bone spur. We now know it’s usually the rotator cuff that started the process.
What we have learned over the last twenty years is that the problem is far more often the gluteal tendons—most commonly the gluteus medius and minimus. We have three gluteal muscles. The gluteus maximus is not usually involved in this. Once you understand that it’s primarily a tendon disorder, the condition begins to look very familiar. In fact, it behaves a lot like the rotator cuff in the shoulder.
Both are troublemakers.
Both can keep us up at night.
Both can make everyday activity miserable.
Both can hurt intensely without a tear.
Both can show tears on imaging and not cause much pain.
Both struggle when the load exceeds capacity.
Both respond best to progressive strengthening. Not rest!!
What these tendons actually do
The gluteal tendons attach to the outside of the femur at a bony prominence called the greater trochanter. Their job is simple but relentless: they stabilize your pelvis when you stand on one leg. They keep your pelvis level.
Which means they are working every time you walk. Every step.
If you walk a mile, that’s roughly two thousand repetitions of single-leg support. Add stairs, uneven ground, carrying groceries, chasing grandchildren, getting out of a chair, and you start to appreciate how busy these tendons are.
When their strength or resilience declines, but life continues to demand the same output, they protest.
How lateral hip pain typically presents
The pattern is remarkably consistent. People report pain on the outside of the hip. It’s tender to touch. Lying on that side can be miserable. Longer walks or hills tend to aggravate it. Sometimes the discomfort radiates down the outside of the thigh, but rarely below the knee.
What often surprises patients is that there wasn’t a dramatic injury. No pop. No fall. Just a gradual increase in irritation until normal life activities began to feel abnormal. This is a very common presentation for tendinopathies. No, you didn’t sleep the wrong way on them one day. Our tendons get used to doing what they do day in and day out. That’s the amount of load they can handle. If that load starts to change, they will begin to protest- sometimes loudly.
There are many other reasons why our tendons might start to bother us. Menopause, poor metabolic health, elevated uric acid are relatively common causes. I discussed how our metabolism influences our tendon health in the following article.
Why the bursitis story lasted so long
Because bursae exist, and they can become irritated. But when researchers and surgeons began looking more closely, they found that isolated bursitis was relatively uncommon. Much more frequently, the tendon showed “degenerative” changes or signs of overload, with the bursa reacting secondarily.
In many cases, the bursa is not the primary problem. It’s reacting to unhappy neighbors.
What’s actually happening inside the tendon
Most of the time, this is not a raging inflammatory process. It is a capacity mismatch.
The tendon is being asked to tolerate more than it is currently prepared for.
That mismatch can develop for many reasons. Activity may have increased. Body weight may have changed. Strength training may have faded away over the years. Gait can shift. Time sitting accumulates. Previous injuries alter mechanics.
Sometimes, the only real change is that we stopped preparing the tissue for what daily life requires. Reason 1245 to be in a gym.
Who gets lateral hip pain?
I see it most in midlife and beyond, and more often in women. Deconditioning plays a role. Rapid changes in walking or running volume play a role. Years of avoiding strength work play a role. Menopause, type 2 diabetes, fatty liver, elevated uric acid, and many other confounding issues almost certainly play a role too.
None of this should be mysterious. Our tissues require maintenance. When tissues are not asked to adapt and are exposed to inflammatory mediators or lack the hormones that protect them, they lose the ability to adapt.
What imaging shows—and why it scares people
MRIs frequently look dramatic. Words like tendinosis, partial tearing, degeneration, and fluid in the bursa. It can read like a disaster report.
But we’ve learned the same lesson here as with the rotator cuff: imaging findings and pain intensity often do not correlate well. Some people with ugly scans function quite well. Others with modest findings are very uncomfortable.
The scan is information. Nothing more. It doens’t predict whether you will or won’t have pain.
What the exam tells us
A careful physical exam usually gives the diagnosis away. Standing on one leg often reproduces pain. Resisting abduction hurts. Pressing over the tendon is tender.
In many cases, the exam provides more practical guidance than the MRI. Lateral hip pain can also be caused by lumbar spine issues. So a careful exam will include a neurological exam as well.
Why rest rarely fixes it
People naturally assume that if something hurts, it needs rest. A brief reduction of irritating activity can be helpful early on. But absolute rest is virtually never needed. I go into far more detail in this highly relevant post on tendon pain.
If rest becomes the primary strategy, the tendon’s capacity continues to fall. Then, when you resume walking or climbing stairs, the same problem recurs.
This is why so many people feel better temporarily, only to have the pain return.
What about stretching?
This surprises people. When something hurts, our reflex is often to stretch it. We assume the muscle is tight and needs to be lengthened. With gluteal tendinopathy, that approach frequently backfires. This has been studied a lot. Gluteal tendinopathy symptoms often worsen when these tendons are stretched.
Deep hip stretches—especially crossing the leg, pulling the knee toward the opposite shoulder, or dropping the hip into adduction—increase compression of the tendon against the bone. Remember, compression is one of the main things that irritates this tissue in the first place.
So instead of calming it down, aggressive stretching can keep the tendon sensitive.
This doesn’t mean flexibility is bad or that the hip should never move through these positions again. It means that in the irritated phase, repeatedly compressing the tendon is usually not helpful.
Early on, strength and controlled loading tend to outperform stretching.
As tolerance improves and the tendon becomes more resilient, those movements can gradually return.
What actually helps
Eventually, treatment almost always comes back to load. And we usually need far more load than you think. Tendons are strong. They require a lot of load to convince the tendon tissue to reorganize and heal. And this is also a very long process. It can take 3-8 months, or longer, for progressive loading to resolve severe cases of gluteal tendinopathy.
Appropriate, progressive loading.
Tendons remodel in response to demand. They get stronger when asked, gradually, to do more.
This is where physical therapy shines, especially when the program is thoughtful and progresses over time rather than stopping at the first sign of improvement. And clamshells with a band will never be enough. Not even close. You might start there… but you should progress beyond them rapidly.
Early exercises might be simple. Side-lying raises. Clamshells. Supported movements. As tolerance improves, we work toward more functional challenges, such as step-downs, carries, and single-leg deadlifts.
The treatment of gluteal tendinopathy will require load. Different types of loads and exercises. The following sections will dive deep into how we approach loading this area appropriately. Including work you should do to avoid lateral hip pain in the future.
