Outer hip pain has been traditionally referred to as trochanteric bursitis, however significant signs of bursal swelling or thickening is only present in up to 15% of cases. With the advent of better scanning technologies (ultrasound and MRI) we are finding that the causes of outer hip pain are more likely to be related to the gluteal tendons.
Lateral hip pain typically presents as pain over the outside hip and often occurs after a period of being overloaded. Overload can come in the form of activity such as walking, stairs, cycling and running or compression such as crossing legs and sitting for a long period of time or sitting/lying awkwardly. When a tendon has reacted to load it becomes swollen and can be sensitive to relatively small amounts of compression.
Aggravating Movement
Lying on painful side
>Direct compression form mattress
*Try - Soft mattress topper, egg shell mattress topper
Aggravating Movement
Lying on non painfulside
>Upper leg crosses the midline to rest on mattress causing compression from ITB
*Try -Pillow between legs
Aggravating Movement
Hanging on hip posture ( similar to holding child on hip)
>Increases tension through the ITB and compression, reduces motor output to gluteal muscles
*Try - Correct standing posture and improve strength /capacity/ motor control of gluteal muscles
Aggravating Movement
Cross legged sitting
>Increases compression through ITB
* Try - Don’t sit cross legged? * Try - Pillow between legs, will notice when drops to floor
Aggravating Movement
Sitting on low chair/ stools
>Increased hip flexion leads to increased tension via ITB
* Try - Avoid low chairs when possible
Aggravating Movement
Walking (particularly stairs and up hill or over-striding)
>Can lead to compression via drop of pelvis on leg. This causes overload of the gluteal muscles when fatigued - can lead to thickening and pain of the tendon.
*Try to improve flexibility, strength and control around hip. Manage walking/ running load volume and frequency.
Diagnosis of gluteal tendinopathy can be made by your physio and will include reproduction of pain on touch over the outer hip and pain in that area during hip joint testing. There will be pain during single leg standing tasks as well as strength and motor control deficits.
Outer hip pain can have a profound impact on quality of life, it is more prevalent in peri-menopausal women between 40-60 (there is a possible hormonal link with falling oestrogen levels) and in people who carry more weight around their abdomens. Runners and walkers with poor training habits (too much load too quickly), poor hip control and poor running/walking technique are also at risk of developing this condition. The gluteus medius tendon is often provoked by compressive loading of the tendon such as crossing legs and lying on it at night.
Once your physiotherapist has decided on the causes of your gluteal tendon pain then treatment is aimed at avoiding provocative positions (see table) and a strengthening program. Closely monitoring your training load and activity is also very important. Your doctor may suggest a cortisone injection; evidence suggests that early response to these injections is very good with 70-75% of people reporting significant improvement, however this improvement drops at 3-5 months. The window of opportunity brought on by a CSI is an excellent time to progressively increase strength and load. It is an ideal time to discuss a strengthening program aimed at building resilience of the tendon and encouraging movement .
References:
Grimaldi A, Mellor R, Nicolson P, Hodges P, Bennell K and Vincenzino Utility of clinical tests to diagnose MRI- confirmed gluteal tendinopathy in patients with lateral hip pain Br J Sports Med 2017;51:519–524Mellor R, Grmaldi A , Wajswelner, Hodges P, Haxby-Abbot, Bennell K and Vincenzino B Exercise and load modification versus CSI versus ‘wait and see’ for persistent gluteus medius/minimus tendiniopathy ( LEAP trial)