Why Your Hip Pain is Not Bursitis!
What is it?
Hip bursitis or “trochanteric bursitis” has historically been used to describe pain on the outside of the hip. Recent research has found that only 20% of individuals presenting with pain on the outside of the hip have bursal thickening on ultrasound (Grimaldi & Fearon, 2015).
Whereas changes in the gluteus medius and gluteus minimus tendons are much more commonly observed on scans. Bursal changes are now known to be an incidental finding, with bursal swelling occurring as a protective mechanism to reduce damage to the tendons. As such, hip bursitis is now referred to as gluteal tendinopathy and is recognised as the primary cause of pain and tenderness on the outside of the hip that may extend down the outside of the thigh.
Who gets it?
Gluteal tendinopathy affects 10-25% of the population and is experienced by one in four women aged over 50 years (Mellor et al., 2018).
Females tend to be at the highest risk of developing the condition, with a 4:1 ratio compared to males. Clinically, it is also commonly seen in runners and those with prior hip injuries or hip surgery.
Why does it occur?
Gluteal tendinopathy occurs as a result of repetitive compression of the tendons against the greater trochanter (the bone you can feel on the outside of your hip). Repetitive loading of the gluteus medius and gluteus minimus can overload these tendons, as they are unable to adequately withstand the demands placed upon them.
Continually applying excessive load to the tendons progressively worsens the condition, as small micro tears occur in the tendons causing inflammation, pain and dysfunction.
Typical activities causing compression and irritation of the gluteal tendons include running, walking upstairs, crossing the legs or sleeping on the affected side at night.
How do I know if I’ve got Gluteal Tendinopathy?
Gluteal tendinopathy is characterised by pain on the outside of the hip and outer thigh. Typically people with gluteal tendinopathy experience at least one or more of the following symptoms –
Pain sitting with crossed legs
Pain going from sitting to standing
Pain with prolonged standing or pain standing on the affected leg
Pain going up stairs
Pain with walking/running
Difficulty lying on the sore side at night
How did I get it?
Gluteal tendinopathy can develop due to a number of contributing factors such as –
Muscular weakness (glutes)
Commencing a new activity e.g. gym, vigorous walking
A recent increase in training load
Biomechanical abnormalities e.g. overstriding
How do I fix it?
The first stage in managing gluteal tendinopathy is to control pain by minimising the compression on the greater trochanter and managing load on the tendons. Depending on the severity of the condition, this may involve temporarily limiting aggravating activities such as running and stairs, to enable healing and allow time for symptoms to settle.
Once symptoms are better controlled, overwhelming research evidence supports commencing strength training of the gluteal muscles. Studies have shown significant strength deficits of the hip abductors (glute med & glute min) in individuals with gluteal tendinopathy, with those who had gluteal tendinopathy being 32% weaker on the painful side and 23% weaker on the non-painful side (Allison et al., 2016).
Tailored strength programs targeting these muscles can effectively improve pain and restore function, by increasing the capacity of the tendons to cope with the demands of everyday activities.
The good news is the majority of individuals who undergo a progressive strengthening program will recover from gluteal tendinopathy within 3 months.
Two Best Exercises for Hip Pain
What to avoid?
To prevent further irritation, it is necessary to reduce compression of the tendons. This can be achieved through the following management strategies –
Reducing time with legs crossed
Not ‘hanging’ on one hip in standing
Reducing stride length when walking
Using a rail to climb stairs and placing feet wider when walking up stairs
Avoiding stretching of the glutes
Placing a pillow between the knees when sleeping on the side
Should I get an Injection for my hip bursitis?
Corticosteroid injections have traditionally been used to treat help manage pain in gluteal tendinopathy, however recent evidence suggests they may actually prolong recovery.
A 2018 Australian study comparing individuals with gluteal tendinopathy who received corticosteroid injections to those who underwent strengthening exercise, found exercise to be superior both in the short and longer-term. While both groups had similar reductions in pain at both 8 and 52 week follow-up, the exercise group reported a significantly better global improvement in function than corticosteroid injection use (Mellor et al., 2018). Thus, exercise is considered the current cornerstone treatment for non-surgical management of gluteal tendinopathy.
Take home messages:
Gluteal tendinopathy (previously hip bursitis) is an overload problem related to activity
It is reversible and can be improved with non-surgical management
Corticosteroid injections may prolong recovery
STRENGTH training is best!
Allison, K., Vicenzino, B., Wrigley, T. V., Grimaldi, A., Hodges, P. W., & Bennell, K. L. (2016). Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Med Sci Sports Exerc, 48(3), 346-352. doi:10.1249/MSS.0000000000000781
Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther, 45(11), 910-922. doi:10.2519/jospt.2015.5829
Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., . . . Vicenzino, B. (2018). 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. Br J Sports Med, 52(22), 1464-1472. doi:10.1136/bjsports-2018-k1662rep