Hip Bursitis (Greater Trochanteric Pain Syndrome): Rarely "Just Inflammation"

Pain on the outside of the hip has a familiar script. It aches when you lie on that side at night. It hurts to climb stairs, to get out of a low chair, to stand on one leg putting on a boot. Someone tells you it's bursitis. You're told to rest, ice it, maybe take an anti-inflammatory, and if that fails, get a cortisone injection.

The trouble is that for most people, the bursa isn't the main problem, and the inflammation model leads to treatments that don't hold up. The condition has a more accurate name now, greater trochanteric pain syndrome, and understanding what's really going on changes what you should do about it.

What's actually hurting

The greater trochanter is the bony bump you can feel on the side of your hip. Two important muscles, gluteus medius and gluteus minimus, attach to it by tendons, and a few small fluid-filled bursae sit nearby to reduce friction. For a long time, pain here was blamed on an inflamed bursa, hence "trochanteric bursitis."

When researchers actually imaged these hips, the story changed. In one study of people with lateral hip pain, MRI showed changes in the gluteus medius tendon in the large majority, while a swollen bursa alone was uncommon.¹ The dominant finding was tendinopathy, often with partial tearing of the tendon at its attachment, and sometimes bursal thickening alongside it as a secondary feature. The bursa, in other words, is usually a bystander.

This fits with what we understand about tendons generally. Tendon pain is better explained as a load-related process than an inflammatory one: the tendon is asked to do more than it's currently adapted for, its structure changes in response, and it becomes painful and less tolerant of load.² Treating it like a sprain or a swollen joint misses the point.

Why it happens, and who gets it

Gluteal tendinopathy is most common in women over 40, though it occurs in runners and active people of any age. The gluteal tendons are loaded most when the hip is in adduction, that is, when the thigh moves toward or across the midline. Standing with your weight shifted onto one hip, sitting with legs crossed, lying on your side with the top knee dropped forward, and running or walking with the pelvis dropping on the swing side all compress the tendons against the trochanter.³

Compression plus tensile load, repeated over time, is a reliable recipe for tendon irritation. It's why the pain is worst at night lying on the side, and why a sudden increase in walking, hill work, or stairs often precedes it. A new running program or weeks of walking on uneven snow and ice can tip a tendon over.

Weakness of the hip abductors on the painful side is common, and it feeds the cycle: a weaker gluteus medius lets the pelvis drop more during single-leg stance, which increases compression on the tendon, which makes it more painful and harder to strengthen. This is also why we look above and below the hip. How the trunk, pelvis and foot are working affects the load on these tendons, a principle we've discussed under regional interdependence.

Why rest and injections underdeliver

If the problem is a tendon that isn't tolerating load, complete rest reduces pain in the short term but also reduces the tendon's capacity further. People often feel better after a few weeks off, return to normal activity, and find the pain comes straight back. The tendon didn't get stronger; it just got quieter.

Corticosteroid injection works on a similar timeline. The best trial on this question, published in the BMJ, compared education plus a progressive exercise program against a single cortisone injection and against a wait-and-see approach in people with gluteal tendinopathy.⁴ At eight weeks, both the exercise group and the injection group were doing better than wait-and-see. By one year, the exercise and education group had the best outcomes, and the injection group had drifted back toward the wait-and-see group. The injection bought time; the exercise built something that lasted.

Stretching the outer hip, including the popular IT band stretch, tends to make things worse, because stretching into adduction is exactly the position that compresses the tendon.

What sensible management looks like

The approach that works for gluteal tendinopathy is the same one that works for Achilles and patellar tendons, which we've covered in our post on loading rather than resting a tendon. The specifics for the hip:

• Reduce compression first. Avoid crossing your legs, standing on one hip, and side-lying without a pillow between your knees. Sleep on the other side or on your back if you can. These changes alone often settle night pain within a couple of weeks.
• Load the tendon progressively. Start with low-load isometric holds of the hip abductors, which tend to ease pain, then build toward slow, heavy strengthening: bridges, sit-to-stand, step-ups, and eventually single-leg work. Some discomfort during exercise is acceptable; a sharp increase afterward or the next morning means the dose was too high.³
• Retrain how you move. Learning to keep the pelvis level during stairs, walking and single-leg stance reduces the compression that started the problem.
• Expect months, not weeks. Tendons adapt slowly. Most people see steady improvement over eight to twelve weeks, with continued gains beyond that.

There are no bad exercises here, only too much too soon,⁵ and the skill is in finding the dose the tendon can tolerate and nudging it upward. That's a core part of how we assess and manage sport and overuse injuries, whether the person is a runner or someone who just wants to sleep through the night again.

If you've been told you have hip bursitis and have been resting, icing and stretching without lasting change, it's reasonable to suspect the tendon was the issue all along. The good news is that tendons respond well to the right load. They just don't respond to being left alone.

References

1. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44(9):2138-2145.
2. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416.
3. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015;45(11):910-922.
4. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662.
5. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273-280.