Pain on the outside of the hip, worse lying on that side at night? Why it is often a tendon, not bursitis, and the exercise plan that helps most.
It starts as an ache on the outside of your hip. Then it begins to wake you when you roll onto that side. Climbing stairs, getting out of the car and standing on one leg to put on your jeans all hurt. Someone tells you it is "hip bursitis" and suggests an injection.
For many people, the real problem is gluteal tendinopathy — irritation of the tendons of the buttock muscles where they attach to the bony point on the side of the hip. It is particularly common in women in their 40s, 50s and 60s, and it can be stubborn. The good news is that an Australian-led trial published in the BMJ showed a clear, effective way to treat it. This guide explains what is going on, the everyday habits that keep it irritated, and how physiotherapy helps.
At a glance
- What it is: irritation of the gluteus medius and minimus tendons where they attach to the outer hip bone
- Also called: greater trochanteric pain syndrome (GTPS); often labelled "hip bursitis"
- Who: most common in women aged 40–70, and in people with knee osteoarthritis or low back pain
- Classic signs: pain lying on the side, on stairs, standing on one leg, and after sitting with legs crossed
- Best evidence: education plus a specific exercise programme beat both a steroid injection and "wait and see"
- Key tip: avoid positions that squash the tendon — crossing your legs, hanging on one hip, lying on the sore side
What is gluteal tendinopathy?
On the outside of each hip is a bony bump called the greater trochanter. Two important buttock muscles, gluteus medius and gluteus minimus, attach there by their tendons. Their main job is to keep your pelvis level when you stand on one leg — which you do with every step you take, every stair you climb, and every time you put on a shoe.
In gluteal tendinopathy the tendons become painful and less able to tolerate load. Under the microscope, they show changes in structure rather than classic inflammation. There are also small fluid-filled sacs, called bursae, near the tendons, and these can be thickened too — which is why the condition was long called "trochanteric bursitis". We now know the tendon is usually the main source of the problem, and the name greater trochanteric pain syndrome is used to cover the whole picture.
Why it happens: load and compression
A review led by Australian physiotherapy researchers explained that tendons dislike two things in particular: sudden increases in load, and compression — being squashed against bone. At the hip, the tendon is pressed against the trochanter whenever the thigh moves across the body. That happens when you:
- Sit with your legs crossed or knees together
- Stand "hanging" on one hip with the other hip dropped
- Lie on your side with the top knee dropped across the body
- Lie directly on the painful side on a firm mattress
- Stretch the outside of the hip by pulling the leg across
Common triggers include a sudden increase in walking, hill or stair walking, a new exercise class, a change in work, weight change, menopause-related hormonal changes, and weakness of the hip muscles.
How common is it?
A large US study of middle-aged and older adults found greater trochanteric pain was noticeably more common in women than men, and more common in people who also had knee osteoarthritis or low back pain. It is not a minor nuisance: an Australian study found that people with this condition had levels of disability, time off work and reduced quality of life comparable with people waiting for a hip replacement for severe hip arthritis.
Symptoms
- Pain on the outside of the hip, sometimes spreading down the outside of the thigh towards the knee
- Pain lying on the affected side — and often on the other side too, as the top leg drops across
- Pain climbing stairs or walking uphill
- Pain standing on one leg — dressing, getting in and out of the car or bath
- Stiffness and pain getting up after sitting, especially after sitting with legs crossed
- Tenderness when pressing on the bony point at the side of the hip
How is it different from hip arthritis or back pain?
- Hip joint arthritis usually causes pain in the groin and stiffness turning the hip, such as putting on socks. The two can occur together.
- Back problems can refer pain to the buttock and outer thigh, often with back pain and sometimes with pins and needles.
A physiotherapist will check all three, because the treatment differs.
“Sleeping on the sore side, sitting cross-legged and standing on one hip are the three habits we ask about first. Changing them often makes a difference within a couple of weeks.”
— UpPlus Physiotherapy team
What the research says: the LEAP trial
In 2018 the BMJ published the LEAP trial, run in Australia, which compared three approaches for people with gluteal tendinopathy:
- Education plus exercise — advice on reducing tendon compression and overload, plus a progressive hip strengthening programme supervised by a physiotherapist over eight weeks
- A single corticosteroid injection
- Wait and see
At eight weeks, around three in four people in the education-and-exercise group reported success, compared with fewer than six in ten after an injection and fewer than a third with wait-and-see. At one year, education and exercise was still better than the injection. The injection helped pain in the short term, but the benefit faded.
An earlier trial in the American Journal of Sports Medicine found a similar pattern: a steroid injection gave the quickest relief at one month, but by four months a home exercise programme and shockwave therapy both gave better results.
It is worth being honest that not every exercise programme works equally well. A trial of a gluteal strengthening programme in postmenopausal women found no clear advantage over a sham exercise programme — a reminder that the type of exercise, how it is progressed, and the education about avoiding compression all matter.
Treatment: what helps
1. Reduce compression in everyday life
- Do not cross your legs, and sit with knees slightly apart and hips higher than knees.
- Stand evenly on both feet rather than hanging on one hip.
- Sleep with a pillow between your knees when lying on your side, and consider a soft mattress topper. Avoid lying directly on the sore side for now.
- Avoid stretching the outer hip by pulling the leg across your body — it often feels good briefly but compresses the tendon.
2. Manage load
- Break long walks into shorter ones, and avoid steep hills and lots of stairs for a while.
- Use a handrail on stairs and lead with the stronger leg going up.
- Do not stop activity altogether — tendons need load to recover.
3. Progressive strengthening
Exercise is the core of treatment. A typical programme moves through stages:
- Isometric holds: for example, lying on your back with a band around the knees and gently pressing outwards, held for 30–45 seconds. These can ease pain early on.
- Bridges and sit-to-stands, building basic hip and leg strength.
- Standing work: side steps, step-ups and single-leg balance, keeping the pelvis level.
- Functional and heavier strength: squats, lunges, step-downs and, later, hopping or running drills for active people.
Expect improvement over 8 to 12 weeks, with continued gains after that. A primary care study found that many people still had pain a year later without specific treatment, so starting a structured programme early is worthwhile.
4. Shockwave therapy
For persistent symptoms, shockwave therapy has evidence of benefit and can be combined with an exercise programme.
5. Injections
A steroid injection can give short-term relief and may help someone start exercising, but on its own it is less effective than education and exercise over time, and repeated injections are not recommended for tendons.
Exercises to start with
These should feel like effort, with no more than mild discomfort that settles within 24 hours.
- Isometric hip press: lie on your back, knees bent, a band just above the knees. Gently press the knees apart and hold 30 seconds. Repeat 5 times.
- Bridge: lie on your back, knees bent, squeeze your buttocks and lift your hips. Hold 3 seconds. 3 sets of 10.
- Sit to stand: from a chair, with knees apart and level, stand up and sit down slowly. 3 sets of 10.
- Side step with band: band around the thighs, small steps sideways keeping knees apart. 10 steps each way, 3 times.
- Single-leg stand: stand on one leg, keeping the pelvis level, near a bench. Hold 30 seconds, 3 times each side.
Side-lying leg lifts are often prescribed, but in a painful tendon they can be aggravating early on, because lying on your side and lifting the leg compresses and loads the tendon at the same time. A physio will decide when to add them.
Myths about outer hip pain
- "It's bursitis, so it needs an injection." The tendon is usually the main problem, and exercise does better over time.
- "Stretch the ITB and outer hip." Stretching across the body often compresses the tendon and can keep it irritated.
- "Rest until it settles." Rest reduces pain briefly, but tendons need graded load to recover.
- "Foam rolling the outside of the hip fixes it." Rolling hard over the painful area can add compression.
- "It's just my age." It is more common in middle age, but it responds well to the right treatment.
When to see a physio
- Outer hip pain lasting more than a couple of weeks
- Pain waking you at night when lying on your side
- Pain limiting walking, stairs, work or exercise
- You have had an injection and the pain has returned
See a doctor promptly if the hip is hot, red and swollen, if you feel unwell or feverish, or if you cannot bear weight after a fall.
How UpPlus Physiotherapy helps
- An assessment of your hip, back and walking to confirm where the pain is coming from
- Clear advice on sleeping, sitting and standing positions that take compression off the tendon
- A staged strengthening programme, progressed regularly — in the clinic, our gym-based rehab, hydrotherapy or at home
- Shockwave therapy for persistent cases
Read more about gluteal tendinopathy and hip bursitis. If you also have knee pain, see our guide to knee osteoarthritis.
Finding a physio near me for hip pain
When searching for the best physio for gluteal tendinopathy or hip bursitis, look for someone who checks your hip, back and walking, gives you specific advice on reducing tendon compression, and builds a progressive strengthening programme over at least eight weeks.
Our clinic is at 177 Trimmer Parade, Seaton, a short drive from Grange, Henley Beach, Woodville, West Lakes and Tennyson. No referral is needed, and you can claim on the spot with private health cover.
Physio take-home message
- Outer hip pain is often a tendon problem, not just bursitis.
- Avoid squashing the tendon: no crossed legs, no hanging on one hip, pillow between the knees at night.
- Education plus progressive exercise works better than an injection or waiting.
- Give it 8–12 weeks of consistent strengthening.
- Persistent cases may benefit from shockwave therapy alongside exercise.
If outer hip pain is keeping you up at night, our physiotherapists can assess it and build you a clear plan. Book online or call 0403 907 587.
This article is general information, not a diagnosis or a substitute for an individual assessment. If you are unsure about your symptoms, see a health professional.
