Tendinopathy of the hip is a broad term for painful, degenerative changes in any of the tendons that attach around the hip joint, and it is one of the most common sources of persistent hip and buttock pain in both active and sedentary adults. The condition was long misdiagnosed as “bursitis,” but research over the past two decades has reframed the problem as primarily a tendon disorder rather than an inflamed fluid-filled sac. Gluteal tendinopathy, which causes pain on the outer side of the hip, is the most frequently encountered form, though the hamstring and hip-flexor tendons can also be affected. The good news is that conservative treatment, especially structured exercise, is effective for most people and is considered the first-line approach.
What “Tendinopathy” Actually Means at the Hip
A tendon is the tough, fibrous cord that anchors a muscle to bone. Tendinopathy refers to a state in which the tendon’s internal structure has broken down: collagen fibers become disorganized, blood vessels may grow into areas that are normally avascular, and the tissue loses its ability to handle load the way a healthy tendon can. This is not the same as acute inflammation (tendinitis), though a flare of inflammation can certainly accompany the degenerative process. What drives tendinopathy is an imbalance between the load placed on the tendon and the tendon’s capacity to recover from that load. The tendons around the hip are especially vulnerable because they bear the repetitive forces of walking, running, climbing stairs, and standing on one leg, which is something you do with every single step.
Several distinct tendons can develop tendinopathy around the hip. The gluteal tendons (gluteus medius and gluteus minimus) attach at the greater trochanter, the bony prominence on the outside of the hip, and their breakdown is now recognized as the primary local source of lateral hip pain, previously called trochanteric bursitis or greater trochanteric pain syndrome (GTPS).1Journal of Orthopaedic & Sports Physical Therapy. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management The proximal hamstring tendon attaches at the ischial tuberosity (the “sit bone”) and can become painful with prolonged sitting, sprinting, or deep hip flexion. The iliopsoas tendon, the main hip flexor, can cause groin pain. Each of these has a slightly different symptom pattern and set of aggravating activities, but they share the same underlying pathology: overloaded tendon tissue that has not been given the right conditions to adapt.
Causes and Risk Factors
The core cause of any hip tendinopathy is load that exceeds the tendon’s tolerance, either because the load is too high (overtraining, sudden increases in activity) or because the tendon’s tolerance is too low (deconditioning, hormonal changes, aging). For gluteal tendinopathy, compressive load on the tendon where it wraps over the greater trochanter is a key factor. Positions that increase this compression include standing with your hip hitched out to one side, crossing your legs, or lying on the affected side at night. For proximal hamstring tendinopathy, compression and shear force at the ischial tuberosity during hip flexion and adduction is a central driver.2PubMed Central. Clinical Progression and Load Management For Proximal Hamstring Tendinopathy In A Long-Distance Runner Deep lunging, sprinting, and even prolonged sitting can all provoke it. The iliopsoas tendon tends to be irritated by repetitive hip flexion, such as in kicking sports or activities that involve lots of stair climbing.
A major risk factor that often surprises people is hormonal status. Gluteal tendinopathy is disproportionately common in postmenopausal women. As estrogen levels decline after menopause, collagen production drops, tendons become thinner, and rates of tendon pathology and rupture increase.3PubMed Central. Does menopausal hormone therapy (MHT), exercise or a combination of both, improve pain and function in post-menopausal women with greater trochanteric pain syndrome (GTPS)? Before menopause, women are actually less likely than age-matched men to develop lower-limb tendinopathy. That protective effect reverses sharply once estrogen declines. Body composition plays a role as well: higher body mass loads the hip tendons more with every step. Other recognized risk factors include sudden spikes in training volume, weakness in the hip abductor muscles, and biomechanical patterns such as excessive hip adduction during walking or running.
It is worth noting that hip tendinopathy is not exclusively an athlete’s problem. Proximal hamstring tendinopathy, for instance, can develop in nonathletes when daily activities impose repetitive tensile or compressive loading on the ischial tuberosity.4PubMed Central. Successful Treatment of Hamstring Tendinopathy in a Nonathlete with Ultrasound-Guided Injection to the Ischial Tuberosity An office worker who sits on a hard chair for eight hours, a retiree who ramps up gardening in the spring, or a person recovering from hip surgery who shifts their weight to one side can all develop tendinopathy without setting foot on a playing field.
Recognizing the Symptoms
The hallmark of gluteal tendinopathy is pain on the outer side of the hip, right over or just behind the bony point of the greater trochanter. It typically worsens with single-leg loading: walking, climbing stairs, standing on one leg, or lying on the affected side in bed. Nighttime pain that wakes you when you roll onto that hip is one of the most commonly reported complaints, and it is a significant contributor to poor sleep quality and reduced quality of life. Pain can also radiate down the outer thigh, which sometimes leads to confusion with sciatica or referred pain from the lower back.
Proximal hamstring tendinopathy presents differently. The pain sits deep in the buttock, right over the sit bone, and tends to be worst during or after activities that load the hamstring in a stretched position: sprinting, hill running, deep squatting, or prolonged sitting on hard surfaces. In contrast, iliopsoas tendinopathy causes groin pain, often felt deep in the front of the hip, and is provoked by bringing the knee up toward the chest, kicking, or rising from a seated position.
One useful clinical test for gluteal tendinopathy is strikingly simple: stand on the affected leg for 30 seconds. In a study of people presenting with lateral hip pain, pain reported within 30 seconds of single-leg standing moved the probability of MRI-confirmed gluteal tendinopathy from roughly 50 percent to 98 percent.5PubMed. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain On the other hand, no pain on palpation of the greater trochanter was a strong indicator that gluteal tendinopathy was not the cause. For iliopsoas-related groin pain, a combination of specific provocation tests has shown high diagnostic accuracy, with the hip-external-rotation-flexion-ceiling test and resisted seated hip flexion performing best.
How Imaging Fits In
Many people with lateral hip pain end up getting an MRI or ultrasound. Both can be helpful, but neither is perfect, and imaging results need to be interpreted carefully alongside the clinical picture. In one study comparing the two modalities, ultrasound correctly identified the majority of pathological gluteus medius tendons but also incorrectly flagged most normal tendons as abnormal. MRI was slightly more specific but less sensitive, rating only about two-thirds of pathological tendons as abnormal.6Musculoskeletal Science and Practice. Identification and differentiation of gluteus medius tendon pathology using ultrasound and magnetic resonance imaging Both imaging techniques were poor at distinguishing between tendinosis (degenerative change without a tear) and partial-thickness tears.
A systematic review of imaging for gluteal tendon tears found that MRI sensitivity ranged widely, from 33 to 100 percent depending on the study, while specificity was consistently high. False positives were common, though high signal located superior to the trochanter had a stronger association with actual tears. Ultrasound had a sensitivity of 79 to 100 percent and a positive predictive value of 95 to 100 percent for tears.7PubMed. The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tears–a systematic review The practical takeaway is that imaging can confirm a suspected tear but should not be the sole basis for diagnosis. A substantial number of people have abnormal-looking tendons on MRI or ultrasound without symptoms, and others have genuine tendinopathy that imaging misses.
Conditions That Mimic or Overlap With Hip Tendinopathy
Lateral hip pain does not automatically mean gluteal tendinopathy. The greater trochanteric pain syndrome label encompasses several overlapping conditions, and sorting them out can be tricky. Trochanteric bursitis (inflammation of the bursa over the greater trochanter) can coexist with tendinopathy, and both produce pain in the same location. Hip osteoarthritis causes groin and sometimes lateral hip pain and can weaken the gluteal muscles, creating a secondary tendinopathy. Lumbar degenerative disease can refer pain to the hip region, and the relationship appears to go both ways: some symptoms attributed to low back problems may actually originate from gluteal muscle dysfunction, and hip pathology can mimic or worsen low back pain.8PubMed Central. Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa?
Other conditions that can look similar include referred pain from the lumbar spine (especially L4-L5 nerve root irritation), iliotibial band syndrome, stress fractures of the femoral neck, and sacroiliac joint dysfunction. For hamstring tendinopathy specifically, the differential includes ischial bursitis, sciatic nerve irritation, and piriformis syndrome. A careful clinical examination, sometimes supplemented by imaging or diagnostic injections, is usually needed to pinpoint the right diagnosis.
Exercise-Based Treatment
Structured exercise is the single best-supported treatment for hip tendinopathy, and multiple systematic reviews confirm its effectiveness. A 2024 meta-analysis of exercise-based interventions for gluteal tendinopathy found that various exercise modalities, including isometric holds, isotonic strengthening, progressive loading, functional exercises, and home-based programs, all produced positive effects on pain and function. The researchers could not identify one type of exercise that was clearly superior to others, because all modalities worked.9PubMed Central. Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis
What matters more than the specific exercise format is the principle of progressive loading: starting at a level the tendon can tolerate without flaring up and gradually increasing intensity over weeks to months. For gluteal tendinopathy, this typically begins with isometric exercises (holding a position without moving the joint) to reduce pain, then progresses to slow isotonic movements, and eventually to functional tasks like single-leg squats, step-ups, and walking or running at increasing distances. Load management also means temporarily reducing activities that compress or overstretch the tendon. For gluteal tendinopathy, that includes avoiding crossing the legs, sleeping with a pillow between the knees, and minimizing prolonged standing on the affected leg.
A landmark randomized trial compared an education-plus-exercise program with corticosteroid injections and a “wait and see” approach for gluteal tendinopathy. At eight weeks, the exercise group reported the lowest pain scores, followed by the corticosteroid group, then the wait-and-see group. At one year, roughly 78 percent of the exercise group rated their outcome as successful, compared with about 57 percent of the corticosteroid group and 52 percent of the wait-and-see group. The exercise group’s advantage over corticosteroid injections was statistically significant on global outcome ratings at 52 weeks.10PubMed Central. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy This study is one of the strongest pieces of evidence that exercise should be tried before injections, not after.
Injections and Other Non-Surgical Options
Corticosteroid injections have been a mainstay treatment for lateral hip pain for decades. They can provide meaningful short-term pain relief, and the trial described above showed they were better than doing nothing at eight weeks. But by one year, the corticosteroid group’s pain scores were not significantly different from the exercise group’s, and the exercise group had a higher rate of overall treatment success. Repeated corticosteroid injections also raise concerns about further weakening the already compromised tendon tissue, which is why most guidelines now position them as a second-line option for people who cannot participate in exercise because of severe pain.
Platelet-rich plasma (PRP) injections have generated considerable interest as a regenerative alternative. In a randomized, double-blind trial comparing a single PRP injection with a single corticosteroid injection for gluteal tendinopathy, the two groups had similar pain and function scores at two and six weeks. By 12 weeks, the PRP group showed significantly better outcomes: about 82 percent of PRP recipients achieved a clinically meaningful improvement, compared with roughly 57 percent of the corticosteroid group.11PubMed. The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy A review of comparative studies for gluteal tendinopathy similarly found that PRP showed better pain and function outcomes than corticosteroids between three months and one year post-injection, and one study noted structural improvements in the PRP group that were not seen with steroids, hinting that PRP may help reverse some of the degenerative tendon changes.12Georgetown Medical Review. Evaluating Efficacy of Platelet-Rich Plasma versus Corticosteroids in Management of Tendinopathies PRP is promising, but it is not yet standard practice everywhere, and access and cost remain barriers.
A retrospective study of PRP combined with percutaneous needle tenotomy (using a needle to create small, controlled perforations in the tendon to stimulate healing) for hip tendinopathies reported that about 77 percent of patients achieved at least a 30 percent improvement in pain, and 65 percent achieved at least a 50 percent improvement, with an average follow-up of 14 weeks.13Journal of Orthopaedic Reports. Intratendinous platelet-rich plasma injection and percutaneous needle tenotomy in the treatment of hip tendinopathies These are encouraging numbers, though the study lacked a control group.
Extracorporeal shockwave therapy (ESWT) is another option with a growing evidence base. A systematic review found that ESWT significantly improved pain and functional outcomes across gluteal tendinopathy, proximal hamstring tendinopathy, and calcific tendinopathy of the hip in the vast majority of studies examined. Several studies showed ESWT outperforming conservative treatment, sham treatment, ultrasound therapy, and corticosteroid injections, with improvements lasting up to 27 months.14PubMed Central. Extracorporeal Shockwave Therapy for Tendinopathies Around the Hip and Pelvis Shockwave therapy is non-invasive and carries minimal risk, making it an appealing middle ground between exercise alone and injection-based treatments.
When Surgery Becomes an Option
Surgery for hip tendinopathy is reserved for cases that have failed prolonged conservative management, typically at least six to twelve months of structured exercise and other non-surgical treatments. The most common surgical scenario involves a gluteal tendon tear, either partial or full thickness, that has not responded to rehabilitation. Surgical options include repair (reattaching the torn tendon to bone), reconstruction, or tendon transfer. Both open and endoscopic (keyhole) repair techniques demonstrate similar improvements in patient-reported outcomes and have low complication and retear rates.15PubMed Central. Surgical Treatment and Outcomes for Gluteal Tendon Tears
The endoscopic approach is gaining favor. Evidence suggests it carries a lower risk of postoperative complications such as infection and retearing compared with open surgery, with equivalent functional outcomes.16JBJS Essential Surgical Techniques. Gluteal Tendon Repair Using an Endoscopic Transosseous-Equivalent Double-Row Repair Technique For full-thickness tears, a double-row technique that provides broader footprint coverage on the bone may offer greater stability. Studies of endoscopic repair report significant increases in hip abduction strength and resolution of the Trendelenburg sign (a limp caused by weak hip abductors) at two years, along with meaningful improvements across multiple functional and pain scores.
For severely atrophied or retracted tendons that cannot be directly repaired, gluteus maximus transfer is a salvage procedure. Outcomes are generally positive in terms of pain relief, but persistent limitations in hip abduction strength and some degree of gait abnormality are common after this procedure.15PubMed Central. Surgical Treatment and Outcomes for Gluteal Tendon Tears One randomized trial also explored adding radiofrequency microdebridement to arthroscopic surgery for recalcitrant gluteal tendinopathy. Both groups (surgery alone versus surgery plus microdebridement) showed significant functional improvement at one year, but the addition of microdebridement did not produce a meaningful difference over standard arthroscopic treatment.17PubMed Central. Radiofrequency Microdebridement as an Adjunct to Arthroscopic Surgical Treatment for Recalcitrant Gluteal Tendinopathy
The Role of Gait and Movement Patterns
How you walk has a direct relationship with tendon load at the hip. In people with gluteal tendinopathy, researchers have found that contralateral pelvic drop (where the pelvis dips on the opposite side during single-leg stance) is significantly correlated with the peak adduction moments at the hip. Greater hip adduction during walking means more compressive load on the gluteal tendons at the trochanter.18PubMed. Kinematics and kinetics during walking in individuals with gluteal tendinopathy This finding provides a rationale for including frontal-plane pelvic control in rehabilitation: strengthening the hip abductors so they can keep the pelvis level during walking and running, and retraining movement patterns during everyday activities.
In practical terms, this means that treatment is not just about the tendon itself but about the neuromuscular system that controls it. A person with weak gluteus medius muscles may develop a habit of letting the pelvis sway or drop with every step, chronically overloading the very tendon they are trying to heal. Physical therapists often address this with cues like “keep your hips level” during step-ups and single-leg exercises, and by progressing to functional tasks like walking on varied terrain once basic pelvic control is established. For runners, gait retraining to reduce crossover stepping (where the feet land close to or across the midline) can reduce the adduction moment and therefore reduce tendon compression.
Why Confidence in Your Body Matters
Hip tendinopathy is often a long-haul condition: recovery takes months, not weeks, and the persistent pain can erode your confidence in movement. Research on people with chronic hip pain found that pain self-efficacy, essentially how confident you are that you can function despite your pain, explained about 20 percent of the variance in patient-reported hip function all on its own. Fear of movement (kinesiophobia) also played a role, and together with physical activity levels, these psychological factors explained roughly 38 percent of how well people reported functioning.19PubMed Central. Pain Self-efficacy Is Associated With Patient-Reported Function in Individuals With Chronic Hip Pain
This does not mean the pain is “in your head.” It means that the brain’s interpretation of pain signals shapes your behavior and your recovery trajectory. If you believe that loading your hip will damage it further, you will avoid activities that are actually necessary for tendon healing, creating a vicious cycle of deconditioning and increased sensitivity. Good rehabilitation programs address this explicitly: they include education about what tendinopathy is (and is not), reassurance that progressive loading is safe, and gradual exposure to feared activities. Understanding that a tendon showing changes on imaging can still adapt and strengthen with the right stimulus is a genuinely important part of recovery, and it is one reason the education-plus-exercise approach outperformed corticosteroid injections in the trial cited earlier.