Differentiating Buttock Pain - Gluteal Tendinopathy
Original Editors - Mariam Hashem
Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Tarina van der Stockt, Lucinda hampton and Ewa Jaraczewska
Introduction
Gluteal tendinopathy is a common cause of lateral hip pain.[1][2] Pain is typically centred over the greater trochanter, but it can radiate down the lateral thigh. It can have a substantial impact on sleep, weight-bearing activities (e.g. walking, climbing stairs), and quality of life.[3][4][5]
The way this condition is described has changed as our understanding has improved. Lateral hip pain was once attributed to inflammation of the trochanteric bursa ('trochanteric bursitis'), but this inflammatory model has largely been refuted, with histological studies showing the bursa is rarely inflamed.[6] The umbrella term 'greater trochanteric pain syndrome (GTPS)' remains in common use, but tendinopathy of the gluteus medius and minimus tendons is recognised as the predominant underlying pathology of GTPS.[1][6][7][2]
Epidemiology and Risk Factors
Gluteal tendinopathy is the most common lower-limb tendinopathy.[1] It was traditionally considered a diagnosis for post-menopausal women, but its reach is broader. It most commonly affects women aged over 40 years, but it also occurs in younger women and in men. It frequently coexists with other conditions, including low back pain, hip osteoarthritis, groin, buttock or anterior thigh pain, and other lower-limb injuries. It is also seen following total hip arthroplasty.[6][8][7][9]
The role of oestrogen in gluteal tendinopathy: Oestrogen appears to play a part in tendon health, which may help explain several features of gluteal tendinopathy. The condition is strongly associated with the peri- and post-menopausal years, when oestrogen levels fall. A similar, temporary drop in oestrogen occurs during breastfeeding, and post-partum women returning to exercise may present with lateral hip pain.[6] Anti-oestrogen therapies used after breast cancer, such as aromatase inhibitors and tamoxifen, are also linked to gluteal tendinopathy.[3][10]
Specific mechanical risk factors include overuse, a sudden increase in activity, insufficient recovery, repetitive movements and poor ergonomics. Combined high tensile and compressive loads are particularly problematic for tendon health. Joint position and bony morphology may also be relevant (e.g. an acute femoral neck-shaft angle potentially contributes to compressive forces). Adducted positions (e.g. sitting with legs crossed) can also increase ITB compression over the greater trochanter.[10]
Other risk factors include genetics, increasing age and certain medications. Age affects tendon metabolism, regenerative capacity, mechanical properties and healing. Several medications, including fluoroquinolones, statins, glucocorticoids and anabolic steroids, in addition to the aromatase inhibitors mentioned above, have also been linked with tendinopathy through different mechanisms, as have metabolic conditions, such as obesity, hypercholesterolaemia and diabetes.[10]
Psychological factors are also part of the clinical picture. People with lower-limb tendinopathy report higher levels of anxiety and depression than those without.[11] In gluteal tendinopathy, more severe symptoms are associated with poorer quality of life, higher pain catastrophising and lower pain self-efficacy.[9] However, the direction of these relationships is uncertain: distress may worsen symptoms, or develop from living with persistent pain.[3]
Clinical Presentation
Gluteal tendinopathy presents as persistent pain over the greater trochanter, which may radiate down the lateral thigh. Onset is often insidious, but it can follow trauma or a clear increase in loading.[9] Pain is commonly aggravated by lying on the affected side (often disturbing sleep), standing, walking, ascending or descending stairs, and sitting.[7] Sustained adduction, such as sitting with the legs crossed or standing with the weight shifted onto one hip, also tends to provoke symptoms.[3]
Assessment
Before focusing on just the hip, it is important to screen for lumbar spine conditions in all patients with hip pain. For more information, see: Overview of Lumbar Spine Assessment.
The diagnosis of gluteal tendinopathy itself is primarily clinical. Tenderness on palpation of the greater trochanter is a useful starting point but is considered insufficient on its own; many people without gluteal tendinopathy are tender on palpation, so a non-tender greater trochanter is more useful for ruling the condition out than tenderness is for ruling it in.[6] Diagnostic accuracy improves when palpation is combined with loading tests, such as resisted hip abduction.[12] The 30-second single-leg stance test and the FADER-R test (flexion, adduction and external rotation with resisted internal rotation) can also support a diagnosis of gluteal tendinopathy.[6] Lateral hip pain during the FABER test (flexion, abduction and external rotation) may indicate gluteal tendinopathy.[6][9] However, painful or restricted hip flexion and rotation, or groin pain on the FABER can indicate hip osteoarthritis.[6][9]
Imaging tends to be reserved for patients who have persistent symptoms, who are not responding as expected to treatment, or where the diagnosis is unclear and there are concerning features, such as severe or non-mechanical symptoms. MRI is the gold standard imaging tool for the gluteal tendons and surrounding soft tissues. Ultrasound is also used, but it requires a skilled practitioner.[10][1][8] X-ray can be used to exclude bony pathology such as hip osteoarthritis, or where serious pathology is suspected.[9]
The VISA-G is a widely used patient-reported outcome measure assessing the severity of disability in gluteal tendinopathy.[13] It includes eight questions on pain and function. Further validation of its measurement properties is needed, but it can be useful for quantifying symptom severity and monitoring change over time. [14]
The following table provides a quick guide to help differentiate gluteal tendinopathy, hip osteoarthritis and lumbar radicular pain.
| Feature | Gluteal tendinopathy | Hip osteoarthritis | Lumbar radicular pain |
|---|---|---|---|
| Main pain location and radiation | Over the greater trochanter; may extend into the lateral thigh, usually not below the knee. | Deep, mid-inguinal and/or anterolateral pain. Lateral pain is often proximal to the greater trochanter and below the iliac crest. May generate deep mid-buttock pain and can refer to the anterior thigh and knee. | Pain originates in lumbar or buttock region. Often refers in a dermatomal pattern. Pain can extend to leg and foot. May refer pain to trochanteric region, but will not emanate from greater trochanter. |
| Typical aggravating factors | Lying on side, single-leg loading (stairs, walking), prolonged sitting in deep chair, pain on standing/walking after sitting. | Weight-bearing, deep hip flexion and rotation (e.g. squatting, rising from a car). | Movements and positions that load the lumbar spine (prolonged sitting, standing, bending, lifting). |
| Other distinguishing features | Tenderness over the greater trochanter; no neurological symptoms. Night pain in sidelying (around trochanter). | Restricted hip range, particularly flexion and internal rotation; morning or post-rest stiffness. May have deep, general ache at night. | Paraesthesia or numbness in a dermatomal pattern; possible neurological signs. Night pain tends to be worse in supine or prone. |
Management of Gluteal Tendinopathy
Gluteal tendinopathy management should focus on patient education, load management and progressive exercise. It should also consider a person's general health. This approach is supported by the 2018 LEAP trial, which compared outcomes across three groups: physiotherapy-led exercise and education, corticosteroid injection, and wait-and-see. Outcomes were better for those in the exercise and education group.[15]
Education and Load Modification
Education aims to help the person with gluteal tendinopathy understand their condition and take an active role in recovery. Provoking and contributing factors (e.g. load, sleep position, hormonal influences (where relevant), and other comorbidities) should be discussed. While some are modifiable and some are not, awareness supports self-management. Promoting healthy lifestyle changes, such as stopping smoking and weight management, is also an integral part of care.[3]
Because the gluteal tendons are aggravated by compression, much of the early advice focuses on reducing sustained or repeated hip adduction. People should be advised to avoid sitting with the legs crossed, standing with the weight shifted onto one hip, and lying on the affected side. Note that lying on the unaffected side without a pillow between the knees also draws the upper leg into adduction. Stretches that compress the tendons, particularly of the tensor fascia lata and iliotibial band, are not recommended, and during functional activities the person should be helped to avoid dynamic valgus (hip adduction with internal rotation), which increases load on the tendon.[3][9]
Download this patient infographic from Groovi Movements here.
Exercise
Progressive loading is a key aspect of management. Load is increased gradually by adjusting frequency, repetitions and resistance. Progressions should be guided by the person's response rather than a fixed timeline. A useful rule is to keep pain to no more than 4/10 during exercise, with no worsening over the following 24 hours; this allows loading to be progressed safely and signals when the tendon has been overloaded.[3]
Rehabilitation is often started with isometric exercises, which can have an analgesic effect on tendon pain and provide a manageable entry point.[16] Because compression aggravates tendons, high-compression exercises are avoided early on. For example, the traditional clam should be avoided as it generates high compressive load and can be provocative. However, a modified version can be used (see image). Exercises are best performed slowly and with control, from a neutral lumbar spine, with attention to avoiding dynamic valgus during loading. An exercise that flares symptoms does not necessarily need to be abandoned; the load can be reduced and the exercise reintroduced later in the programme.[3]
It is worth noting that hip abductor strength is not associated with the severity of gluteal tendinopathy, so rehabilitation is not simply a matter of correcting a strength deficit. Even so, progressive abductor and lower-limb loading remains central to rehabilitation.[15]
The following table includes example exercises for different stages of gluteal tendinopathy rehabilitation. Note that exercise selection and progression should be guided by clinical reasoning and the individual's presentation, irritability and goals.
| Focus | Example exercises |
|---|---|
| Pain relief and entry-level loading | Isometric hip abduction (supine or standing) |
| Low-compression abduction loading | Modified clam, bridging progression (double leg, off-set, single leg) |
| Functional loading | Squats (double leg, split squats, single leg), single leg stance |
| Frontal plane loading | Side steps, abduction slides, banded walks (monster and sumo walks) |
To learn more about the LEAP exercises, see: Exercise and load modification versus corticosteroid injection versus ‘wait and see’ for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomised clinical trial.
Grimaldi et al. also share an example exercise programme here: Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence.
Other Conservative Options
Where education and exercise do not achieve the person's goals, additional options may be considered, but these are not considered first-line management options.
Shockwave therapy and injection therapies such as platelet-rich plasma are sometimes used when rehabilitation has not produced adequate progress. Their use is growing, but there is currently no high-quality evidence to support them and further research is needed on these treatments.[6]
Corticosteroid injection is also not recommended as a first-line treatment. While it can provide rapid short-term pain relief, its effect diminishes within a few weeks. It also has adverse effects on tendon health, reducing cell viability and collagen synthesis and altering the tendon's mechanical properties. And given its quick pain-relieving qualities, it has been argued that patients may seek repeat injections rather than continuing with active management.[10]
Surgery
Surgical management is generally a last resort, considered only once non-surgical approaches have been exhausted. In lower-limb tendinopathy, it is usually recommended that conservative management be trialled for at least one year before surgery is considered.[6] Open and endoscopic repairs generally produce similar results, but there are fewer complications associated with endoscopic approaches.[10] It is also important to note that patients often have multiple corticosteroid injections before having surgery. This can have an effect on outcomes, as higher numbers of previous corticosteroid injections are considered a prognostic indicator for poorer clinical outcomes following endoscopic gluteal tendinopathy surgery.[10]
References
- ↑ 1.0 1.1 1.2 1.3 Ladurner A, Fitzpatrick J, O’Donnell JM. Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthopaedic Journal of Sports Medicine. 2021 Jul 29;9(7):23259671211016850.
- ↑ 2.0 2.1 Patricio Cordeiro TT, Rocha EAB, Scattone Silva R. Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis. Sci Rep. 2024 Feb 9;14(1):3343.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Bell-Jenje T. Differentiating Gluteal Tendinopathy Course. Physiopedia Plus, 2020.
- ↑ Fearon AM, et al. Greater Trochanteric Pain Syndrome Negatively Affects Work, Physical Activity and Quality of Life: A Case Control Study. J Arthroplast. 2014;29(2):383–86.
- ↑ Grimaldi A, Nasser A, Mellor R, Vicenzino B. An examination of imaging findings in patients with clinically diagnosed gluteal tendinopathy: a secondary analysis of a randomised clinical trial. Arch Orthop Trauma Surg. 2025 Jun 19;145(1):347.
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Grimaldi A, Ganderton C, Nasser A. Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence. Musculoskelet Sci Pract. 2025 Apr;76:103253.
- ↑ 7.0 7.1 7.2 Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. J Orthop Sports Phys Ther. 2015 Nov;45(11):910-22.
- ↑ 8.0 8.1 Bremer T, Lack S, Fearon A, Morrissey D. Best practice for patients with gluteal tendinopathy: A qualitative exploration of expert clinical reasoning and management. Physiotherapy. 2025 Dec 17:101871.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Fearon AM. Physiotherapy management of gluteal tendinopathy. J Physiother. 2025 Apr;71(2):81-90.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Grimaldi A, Mellor R, Nasser A, Vicenzino B, Hunter DJ. Current and future advances in practice: tendinopathies of the hip. Rheumatol Adv Pract. 2024 Apr 10;8(2):rkae022.
- ↑ Mest J, Flood A, Toufexis C, Waddington G, Malliaras P, Fearon AM. Differences in psychological factors between people with persistent tendinopathy and those without tendinopathy: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2025 Dec;55(12):1-18.
- ↑ Kinsella R, Semciw AI, Hawke LJ, Stoney J, Choong PFM, Dowsey MM. Diagnostic accuracy of clinical tests for assessing greater trochanteric pain syndrome: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2024 Jan;54(1):26-49.
- ↑ Fearon AM, Ganderton C, Scarvell JM, Smith PN, Neeman T, Nash C, Cook JL. Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G. Manual therapy. 2015 Dec 1;20(6):805-13.
- ↑ Nasser A, Grimaldi A. Clinimetrics: The Victorian Institute of Sport Questionnaire - gluteal tendinopathy (VISA-G). J Physiother. 2024 Apr;70(2):153.
- ↑ 15.0 15.1 Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, et al. 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. 2018 Nov;52(22):1464-1472.
- ↑ Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British journal of sports medicine. 2016 Feb 1;50(4):209-15.