Gluteal Tendinopathy

Lower Limb

Overview

Gluteal tendinopathy is an overuse injury affecting the tendons of the gluteus medius and minimus, commonly presenting with lateral hip pain. This condition results from repetitive loading, muscle imbalance, or sudden increases in activity, leading to degenerative changes within the tendon structure. It is a frequent cause of lateral hip pain, particularly in middle-aged and older adults, and can significantly impact functional activities such as walking and climbing stairs.

Pathophysiology

Gluteal tendinopathy develops through cumulative microtrauma to the gluteus medius and minimus tendons at their insertion on the greater trochanter. Repetitive tensile loading, inadequate rest periods, and biomechanical dysfunction (particularly hip weakness and altered neuromuscular control) create conditions for tendon degeneration. Histopathological changes include collagen disorganization, increased neovascularization, and inflammatory infiltration. Excessive hip adduction during weight-bearing activities (such as single-leg stance) increases compressive load on the greater trochanter and irritates the underlying tendon. Additional factors include gluteal muscle weakness, core instability, altered pelvic mechanics, and previous hip pathology.

Patient Education

Gluteal tendinopathy improves with gradual, progressive loading and strengthening of the gluteal muscles, and avoiding painful positions of hip adduction during daily activities.

Typical Presentation

Site

Lateral hip and greater trochanter region, may refer to lateral thigh or buttock; pain typically unilateral

Quality

Sharp, aching, or burning pain; may feel like tenderness over the lateral hip

Intensity

Mild to moderate (typically 3-7/10); fluctuates with activity levels

Aggravating

Prolonged standing or walking, climbing stairs, crossing legs, side-lying on affected hip, single-leg stance, narrow gait base, hill walking, repetitive jumping or running

Relieving

Rest, anti-inflammatory medication, side-lying on unaffected side, gluteal strengthening, activity modification, ice application

Associated

Hip weakness (especially gluteus medius), reduced hip abduction strength, increased hip adduction during gait, core instability, reduced proprioception, possible history of hip pain or lower back pain, difficulty with stairs and rising from seated position

Orthopaedic Tests

Single Leg Stance (SLS) Test

Procedure

Patient stands on the affected leg with hip and knee extended, arms folded across chest, for up to 30 seconds. Observe for pelvic drop or Trendelenburg sign on the contralateral side.

Positive Finding

Pelvic drop >5 cm on the contralateral side, or inability to maintain level pelvis, or pain in the gluteal region

Sensitivity / Specificity

72% / 60%

Reiman MP, Bolgla LA, Lorenz D. Hip functions influence on knee dysfunction: a systematic review. J Athl Train. 2009;44(2):165–174

Interpretation

Suggests gluteal muscle weakness or pain inhibition; helps differentiate gluteal tendinopathy from other hip pathologies. Not highly specific but clinically useful as a functional screening test.

Single Leg Squat (SLS) Test

Procedure

Patient stands on affected leg and performs a controlled squat to approximately 60° knee flexion, maintaining arms outstretched for balance. Observe lower extremity mechanics and patient symptoms.

Positive Finding

Dynamic knee valgus, pelvic drop >5 cm, or pain in gluteal/lateral hip region; patient unable to perform or compensates significantly

Sensitivity / Specificity

68% / 65%

Lack S, Barton C, Sohan O, Crossley K. Proximal muscle rehabilitation is effective for distal joint symptoms: a systematic review and meta-analysis. Br J Sports Med. 2015;49(21):1373–1380

Interpretation

Assesses hip abductor and external rotator function under load. Positive result suggests gluteal weakness or pain-related motor control deficit, consistent with gluteal tendinopathy.

Side-Lying Hip Abduction (SLHA) Test

Procedure

Patient lies on unaffected side with hips flexed 45° and knees extended. Patient abducts the affected leg against gravity (or clinician resistance). Note pain and weakness.

Positive Finding

Pain in gluteal/lateral hip region, or decreased strength compared to contralateral side, or inability to complete 15–20 repetitions

Sensitivity / Specificity

See current literature / See current literature

Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–416

Interpretation

Isolates gluteus medius function. Pain or weakness supports gluteal tendinopathy diagnosis. Strength testing helps quantify abductor deficits.

Hip Internal Rotation Range of Motion (IROM) Test

Procedure

Patient supine, hip flexed 90° and knee flexed 90°. Clinician passively internally rotates the femur, noting end-feel and any reproduction of gluteal pain.

Positive Finding

Reduced internal rotation (<30° or asymmetry >10°), or pain in gluteal/posterior hip region at end-range

Sensitivity / Specificity

See current literature / See current literature

Reiman MP, Weisbach PC, Glynn PE. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2015;49(12):811

Interpretation

Reduced hip internal rotation is associated with hip femoroacetabular impingement and altered hip biomechanics, contributing factors to gluteal tendinopathy. Pain may indicate tendon irritation.

Gluteal Tendon Palpation Test

Procedure

Patient side-lying on unaffected side. Clinician palpates the gluteal insertion region (lateral greater trochanter and adjacent gluteal muscle attachments) using firm, direct pressure.

Positive Finding

Reproduction of patient's characteristic gluteal pain, point tenderness, or patient recognition of symptom familiar pain

Sensitivity / Specificity

See current literature / See current literature

Cook JL, Barton C, Purdam CR. The intra-tendon pathology in chronic mid-substance tendon pathology is different from the insertional pathology observed in gluteal tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2887–2889

Interpretation

Direct palpation of gluteal tendon insertions localizes pain to gluteal structures. Positive finding supports diagnosis of gluteal tendinopathy when corroborated with movement dysfunction and imaging.

Modified Thomas Test (Hip Flexor Tightness)

Procedure

Patient supine with contralateral knee pulled to chest. Affected leg hangs over table edge. Observe hip extension angle and external rotation. Note any gluteal pain with hip extension.

Positive Finding

Hip flexor tightness (hip flexion angle >30° from neutral), or gluteal/lateral hip pain with passive hip extension and external rotation

Sensitivity / Specificity

See current literature / See current literature

Moore K, Dalley A, Agur A. Clinically Oriented Anatomy. 8th ed. Wolters Kluwer; 2018

Interpretation

Identifies hip flexor tightness that can alter hip mechanics and increase gluteal tendon load. Pain with hip extension may indicate gluteal tendon irritation.

⚠ Red Flags

  • •Sudden onset severe pain with trauma or fall on hip
  • •Night pain preventing sleep unrelated to position changes
  • •Unexplained weight loss with hip pain
  • •Fever or chills accompanying hip pain
  • •Signs of infection (erythema, warmth, swelling over greater trochanter)
  • •Progressive neurological symptoms (numbness, weakness in leg)
  • •Severe limitation preventing weight-bearing or ambulation
  • •History of cancer with new hip pain

⚡ Yellow Flags

  • •High fear-avoidance beliefs about movement and exercise
  • •Catastrophizing about pain or prognosis
  • •Significant psychosocial stress or depression
  • •Poor pain coping strategies
  • •Multiple pain sites with health anxiety
  • •Passive approach to recovery with low self-efficacy for exercise
  • •Belief that pain means damage is occurring
  • •Secondary gain or litigation involvement

Osteopathic Techniques

Region

Gluteal muscles and greater trochanter

Technique

Soft Tissue

Rationale

Direct soft tissue techniques including myofascial release, sustained pressure, and cross-friction to reduce muscle tension, improve blood flow to the tendon, and address trigger points in gluteus medius and minimus. Evidence supports soft tissue therapy for reducing pain and improving function in tendinopathy.

Region

Hip joint and lumbar-pelvic region

Technique

Articulation

Rationale

Gentle articulation of the hip joint through passive range of motion improves synovial nutrition, reduces stiffness, and helps normalize hip mechanics. This addresses secondary hip stiffness that may contribute to altered biomechanics and increased tendon stress.

Region

Hip and lumbo-pelvic complex

Technique

MET

Rationale

Muscle energy techniques targeting hip abductors, external rotators, and core stabilizers improve neuromuscular control and reduce compensatory patterns. MET allows progressive loading and strengthening while respecting pain thresholds, facilitating active patient participation.

Region

Lumbar spine and sacroiliac joints

Technique

Articulation

Rationale

Addressing segmental dysfunction in the lumbar spine and sacroiliac joints improves pelvic stability and hip mechanics. Lumbar or sacroiliac restriction contributes to altered hip biomechanics and increased load on gluteal tendons.

Region

Hip and greater trochanter

Technique

Functional

Rationale

Functional technique positions the hip to reduce tension on the affected gluteal tendons, promoting comfort and proprioceptive retraining. This technique is particularly useful in acute phases to facilitate pain-free movement patterns.

Region

Fascial systems connecting hip, pelvis, and thorax

Technique

Soft Tissue

Rationale

Release of iliotibial band, tensor fasciae latae, and associated fascia reduces compressive forces on the greater trochanter and improves force distribution through the hip complex. Addressing these related structures reduces compensatory stress on gluteal tendons.

Add-On Approaches

Chinese Medicine

Acupuncture and moxibustion to acupoints GB29 (Kuanfu), GB30 (Huantiao), and GB31 (Fengshi) combined with herbal medicine to promote qi and blood circulation, reduce inflammation, and alleviate lateral hip pain according to TCM principles of addressing stagnation in the Gallbladder meridian.

Chiropractic

Hip joint manipulation and lumbar spine mobilization to address segmental dysfunction, combined with assessment of foot pronation and shoe orthotics to correct lower limb alignment and reduce excessive hip adduction during gait.

Physiotherapy

Progressive hip abduction and external rotation strengthening exercises, core stability training, gait retraining to reduce hip adduction during stance, progressive weight-bearing activities, and neuromuscular re-education with focus on single-leg stability and proprioception.

Remedial Massage

Deep tissue massage to gluteus medius and minimus, myofascial release of tensor fasciae latae and iliotibial band, trigger point therapy to address referred pain patterns, and soft tissue mobilization to reduce muscle guarding and improve circulation to the tendon.

Rehabilitation Exercises

Hip Flexion and Extension in Prone

Range of MotionBeginner

Hip Flexor Stretch (Kneeling Lunge)

StretchingBeginner

Figure Four Stretch (Piriformis and Gluteal Stretch)

StretchingBeginner

Iliotibial Band Stretch (Standing)

StretchingBeginner

Supine Hip Abduction (Both Legs)

StrengtheningBeginner

Gluteal Bridge (Double Leg)

StrengtheningBeginner

Clamshells (Side-Lying Hip Abduction and External Rotation)

StrengtheningBeginner

Quadruped Hip Abduction (Leg Lifts)

StrengtheningIntermediate

Single-Leg Gluteal Bridge

StrengtheningIntermediate

Single-Leg Stance with Hip Stability Focus

BalanceIntermediate

Gait Training: Correcting Hip Adduction During Walking

PosturalIntermediate

Side-Lying Hip Abduction (Lateral Hip Strengthening)

StrengtheningIntermediate

Monster Walks with Resistance Band

StrengtheningIntermediate

Single-Leg Stance on Unstable Surface (Foam Pad)

BalanceAdvanced

Lateral Step-Up with Hip Stability

StrengtheningAdvanced

Referral Criteria

  • •Failure to improve with conservative management after 6-8 weeks of appropriate treatment
  • •Progressive neurological symptoms or signs suggesting nerve compression
  • •Severe functional limitation affecting quality of life despite intervention
  • •Imaging findings suggesting significant tendon pathology or other intra-articular hip pathology
  • •Signs of systemic inflammatory conditions (rheumatoid arthritis, ankylosing spondylitis)
  • •Suspected labral pathology with clicking, catching, or giving way of hip
  • •Recurrent symptoms suggesting need for corticosteroid injection or imaging guidance
  • •Severe night pain or constitutional symptoms requiring medical investigation
  • •Previous hip surgery with recurrent gluteal pain suggesting surgical complication
  • •Patient desire for advanced imaging (MRI) or specialist opinion after initial conservative trial