Gluteal Tendinopathy: Causes, Symptoms, and Treatment

Gluteal tendinopathy is a condition in which the tendons of the gluteus medius and gluteus minimus muscles, where they attach to the bony prominence on the side of the hip, become damaged and painful. It is the most common cause of lateral hip pain and is especially prevalent among postmenopausal women, though it affects people of all ages and activity levels. For years this pain was blamed on an inflamed bursa (“trochanteric bursitis”), but imaging research has shifted the diagnosis squarely toward the tendons themselves, and that distinction matters because it changes how the problem is treated.

Why It Is Not Really Bursitis

If you have been told you have “trochanteric bursitis,” the label is probably outdated. Imaging studies have consistently found that lateral hip pain is more commonly the result of gluteus minimus or medius tendon injury than bursal inflammation.¹ When researchers used MRI on patients with refractory lateral hip pain, every patient showed tendinopathy or bursitis of the gluteal tendons, and many had evidence of tearing.² The bursa can certainly be irritated alongside a damaged tendon, but it is rarely the primary problem. This reframing matters practically: a cortisone shot into the bursa may temporarily quiet the inflammation but does nothing to address the structural tendon issue driving the pain.

What Causes It

The core mechanism is a combination of compressive and tensile loading on the gluteal tendons at their attachment to the greater trochanter. Hip positions that involve excessive adduction, meaning the thigh crossing the midline of your body, press the tendons against the bone while they are simultaneously being pulled tight. That combined load is thought to be the most damaging.³

This explains why certain everyday habits contribute to the problem. Standing with your hip hitched to one side, sitting with your legs crossed, or sleeping on your side without a pillow between your knees all place the tendons in sustained compression. Walking and stair-climbing studies have shown that people with gluteal tendinopathy tend to walk with more trunk lean toward the opposite side and greater pelvic drop, both of which increase the adduction load on the affected hip.⁴ During stair climbing, people with the condition were roughly four and a half times more likely to demonstrate a movement pattern associated with high adduction loading and greater lateral pelvic shift at heel strike.⁵ Whether these movement patterns cause the tendinopathy or develop as a consequence of the pain is still debated, but either way they keep the tendons overloaded and the cycle going.

Who Gets It and Why Women Are Hit Hardest

Gluteal tendinopathy is especially common in women after menopause.⁶ Several factors converge. Women have wider pelvises on average, which increases the angle at which the gluteal tendons pull across the trochanter. Declining estrogen levels after menopause appear to affect tendon health, and hormonal changes can also accelerate bone density loss at the attachment site. A randomized trial tested whether menopausal hormone therapy improved outcomes in postmenopausal women with greater trochanteric pain syndrome: among women with a healthy BMI, those receiving hormone therapy alongside exercise and education had meaningfully better pain and function scores than those on placebo, and the benefit persisted at one year.⁷ That finding does not mean hormone therapy is a standalone treatment, but it supports the idea that hormonal changes play a real role in why this condition clusters so heavily in postmenopausal women.

Other risk factors include higher body weight, sedentary behavior, rapid increases in walking or running volume, and occupations or hobbies that involve prolonged standing on one leg. Runners are not immune: any training habit that repeatedly loads the hip in adduction, like running on a cambered road or with a narrow stride, can provoke the condition.

What It Feels Like

The hallmark symptom is pain on the outside of the hip, directly over or just behind the bony bump you can feel when you press the side of your hip. The pain often radiates down the outer thigh. It is typically worst during weight-bearing activities that demand work from the gluteal muscles on one leg at a time: climbing stairs, walking uphill, getting in and out of a car, or standing for prolonged periods. Lying on the affected side at night is a very common complaint and frequently disrupts sleep.⁸

A cross-sectional study of people with the condition found that around 80 percent qualified as poor sleepers based on standardized questionnaires, and median sleep duration was only about six hours per night. Nearly a quarter slept fewer than five hours.⁹ Sleep disruption is not just a side effect here. Poor sleep amplifies pain sensitivity and slows tissue recovery, so it can feed the cycle.

How It Is Diagnosed

A clinician experienced in hip conditions can usually diagnose gluteal tendinopathy with a handful of physical tests, without needing imaging. The most common things that cause lateral hip pain are gluteal tendinopathy, hip osteoarthritis, and nerve-related pain radiating from the lower back. A careful history helps sort these out: dermatomal patterns with numbness or tingling point toward the lumbar spine, deep groin pain and stiffness with rotation suggest the hip joint, and pain directly over the trochanter that worsens with single-leg loading points toward the gluteal tendons.⁸

One of the most useful bedside tests is simply standing on the affected leg for 30 seconds. In a study comparing clinical tests to MRI findings, pain reproduced within 30 seconds of single-leg standing moved the probability of gluteal tendinopathy on MRI from roughly 50 percent to 98 percent.¹⁰ Other clinical tests that involve hip flexion, adduction, and external rotation (sometimes with added resistance) also show good accuracy, and combining several of them gives a reliable clinical picture without radiation or scanning cost.

When imaging is needed, both MRI and ultrasound can identify tendon abnormalities, but neither is perfect. A systematic review found that ultrasound had sensitivity between roughly 79 and 100 percent and a very high positive predictive value, while MRI sensitivity ranged widely from 33 to 100 percent depending on the study, though its specificity was consistently high.¹¹ Ultrasound is cheaper and more accessible, but it depends heavily on the skill of the operator. A smaller comparison study found that ultrasound detected most pathological tendons but also over-called normal tendons as abnormal, while MRI was somewhat more conservative but missed a number of pathological tendons.¹² Neither modality reliably distinguishes between tendinosis (degeneration without tearing) and partial-thickness tears. In practice, imaging is most valuable when the diagnosis is uncertain or surgery is being considered.

Exercise and Education as First-Line Treatment

The strongest evidence for treating gluteal tendinopathy supports a combination of exercise and patient education over both corticosteroid injections and a wait-and-see approach. A landmark randomized trial compared these three strategies head-to-head. At eight weeks, about 77 percent of participants in the exercise-and-education group reported a successful outcome, compared with roughly 58 percent in the corticosteroid group and 29 percent in the wait-and-see group. Pain scores followed the same pattern, with exercise-and-education producing the lowest pain ratings.¹³ At one year, the exercise group still outperformed both alternatives, while the corticosteroid group’s initial advantage over wait-and-see had narrowed considerably. An economic analysis of the same trial found that the exercise approach was also more cost-effective and improved overall quality of life compared with the other options.¹⁴

A meta-analysis pooling results from multiple trials confirmed that exercise outperformed minimal intervention for function in both the short and long term.¹⁵ A separate systematic review characterized the strength of the evidence as moderate, with meaningful effects on both pain and function, and concluded that exercise and education should be considered the core approach, potentially supplemented by other treatments.¹⁶

The education component matters. It typically involves teaching people to modify the positions and habits that compress the tendon: avoiding crossing your legs, not standing with your weight shifted to one side, sleeping with a pillow between your knees, and reducing unnecessary stretching of the outer hip (that common IT-band stretch where you lean away from the wall is one of the worst things you can do for this condition). The exercise component progresses from isometric holds through slow, heavy loading in progressively more challenging positions, gradually rebuilding the tendon’s capacity to handle force.

Why Cortisone Injections Are a Short-Term Fix

Corticosteroid injections remain widely used, and they do reduce pain in the short term. In the trial described above, the injection group improved faster than wait-and-see in the first eight weeks. But by one year, the injection group’s outcomes had drifted back toward those of people who did nothing at all.¹³ This pattern is familiar across tendinopathies: cortisone suppresses inflammation and pain quickly but may actually impair tendon healing over time. There are also concerns about repeated injections weakening the tendon tissue, increasing the risk of a tear. A cortisone injection is not unreasonable as a bridge to get severe pain under control so that a person can begin exercising, but relying on injections alone as a long-term strategy is not supported by the evidence.

Platelet-Rich Plasma Injections

Platelet-rich plasma (PRP) is an injection made from your own blood, concentrated to contain a high dose of growth factors. For gluteal tendinopathy, two randomized controlled trials have compared PRP to corticosteroid injections and found PRP to be the better long-term option. In one trial, PRP and corticosteroid produced similar results at two and six weeks, but by 12 weeks the PRP group had significantly better pain and function scores, and a larger proportion achieved a clinically meaningful improvement.¹⁷ A second trial using a leucocyte-rich PRP formulation followed patients for two years and found that the improvement after PRP was sustained at two years, whereas the corticosteroid group’s benefit peaked at six weeks and was not maintained beyond six months.¹⁸

PRP is promising but not a magic bullet. It is expensive, rarely covered by insurance, and there is no standardized preparation protocol, which means the product varies between clinics. It also has not been compared head-to-head with structured exercise and education in a rigorous trial, so it is unclear whether PRP adds anything on top of a good rehabilitation program. For now, it occupies a reasonable middle ground for people who have not responded adequately to exercise alone and want to avoid surgery.

Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) sends acoustic waves into the tendon. The proposed mechanism involves stimulating blood flow and cellular repair at the insertion site. A randomized trial comparing focused ESWT to standard ultrasound therapy found significantly greater pain reduction in the shockwave group at both two and six months, though functional improvements were similar between groups.¹⁹ A longer follow-up study tracking patients after shockwave therapy found that the initial success rate of about 83 percent dropped to roughly 56 percent at long-term follow-up, with a tendency for pain scores to creep back up over time.²⁰ Shockwave therapy is not typically a standalone cure, but it can be a useful add-on for people who need help getting pain under control enough to engage with their exercise program.

When Surgery Is Considered

Surgery is reserved for cases that have failed to respond to at least six months of conservative management. Most candidates have a partial or full-thickness tear of the gluteus medius or minimus tendon confirmed on imaging. The two main approaches are open repair and endoscopic (keyhole) repair. A systematic review comparing the two found similar outcomes on pain, function, and strength recovery. The main difference was a higher complication rate in the open group.²¹ A direct comparison of 45 patients confirmed equivalent mid-term results between the techniques, with the endoscopic group showing a greater reduction in opioid use.²² A more recent review concluded that both open and endoscopic repair produce meaningful improvements in patient-reported outcomes with low complication and retear rates for both partial and full-thickness tears.²³

Recovery from gluteal tendon repair is slow. Most protocols involve six to eight weeks of protected weight-bearing with crutches, followed by several months of progressive rehabilitation. Return to full activity typically takes four to six months at a minimum. If you are considering surgery, the question to ask your surgeon is whether the tendon has an actual structural tear or is simply degenerated. Surgery makes the most sense for tears; for degeneration without tearing, the evidence still favors continued rehabilitation.

The Role of Psychology and Pain Sensitivity

Gluteal tendinopathy is not purely a structural problem. A cross-sectional study found that people with more severe symptoms had significantly higher levels of pain catastrophizing and depression, while hip muscle strength was not different between severity groups.²⁴ In other words, what predicted worse symptoms was not weaker muscles but a more distressed and threat-sensitive nervous system. This does not mean the pain is “in your head.” Tendon damage is real. But how much that damage bothers you, how disabled you feel, and how much it disrupts your life are heavily influenced by psychological state, sleep quality, and stress levels. Addressing these factors is not optional fluff alongside the “real” physical treatment; it is part of the treatment.

Practical Day-to-Day Management

If you have been diagnosed with gluteal tendinopathy or suspect you have it, a few daily modifications can reduce the compressive load on the tendon while you work on building its capacity back up through exercise:

Sleeping: Place a firm pillow between your knees if you sleep on your side. If your pain is severe, try sleeping on your back with a pillow under your knees to reduce pressure on the trochanter entirely.
Sitting: Avoid crossing your legs. Sit with your knees roughly hip-width apart or slightly wider, and avoid low, soft couches that drop your knees higher than your hips.
Standing: Distribute your weight evenly on both feet. The classic pose of hanging on one hip while standing in a queue is a direct tendon compressor.
Stretching: Stop doing classic “IT band stretches” or any stretch that involves pulling the leg across the body. These feel like they are targeting tightness, but they are compressing the exact tendon you need to protect.
Walking and stairs: Shorter, wider steps reduce peak hip adduction. On stairs, use the handrail to reduce single-leg loading during recovery.

These modifications are not permanent lifestyle changes. They are load-management strategies designed to calm the tendon down while a progressive exercise program builds it back up to tolerate normal demands. Once the tendon is stronger, most of these precautions become unnecessary.

How Long Recovery Takes

Tendon problems are slow healers compared with muscles. Tendons have a limited blood supply, and the collagen turnover that underlies repair and remodeling is a gradual process. Most people with gluteal tendinopathy who commit to a structured rehabilitation program see meaningful improvement within eight to twelve weeks, but full resolution often takes six months or longer. The one-year data from the exercise-and-education trial showed continued improvement well beyond the initial treatment period.¹³ Patience is genuinely part of the treatment. People who expect a quick fix and stop exercising after a few weeks of progress often relapse. The tendon needs sustained, progressively challenging loading over months to rebuild its tolerance to everyday forces.

If your symptoms have not improved after three to four months of consistent, supervised rehabilitation, re-evaluation is warranted. Imaging to check for a tear, consideration of PRP or shockwave therapy as adjuncts, and a reassessment of contributing factors like sleep, weight, and psychological state are all reasonable next steps before considering surgery.