Gluteal tendinopathy – Causes, symptoms, and diagnosis
- Maryke Louw
- Feb 19
- 18 min read
Updated: Feb 20
Gluteal tendinopathy is one of the most common causes of pain over the outside of the hip. It often goes together with hip bursitis and usually forms part of a broader condition known as greater trochanteric pain syndrome – a term that describes pain arising from several structures around the outer hip rather than just one specific type of tissue.
In this article, we explain the anatomy involved, what happens inside the tendon, the most common causes and symptoms, and how clinicians diagnose gluteal tendinopathy – including other conditions that can mimic gluteal tendinopathy.
Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call.
In this article:
What is gluteal tendinopathy and where does it occur?
My colleague, Alison, also explains the anatomy in this video:
When you have gluteal tendinopathy, the most painful area is typically around the greater trochanter – the bony prominence on the outside of your thigh bone. Several important muscles attach here, including the gluteus medius and gluteus minimus. These muscles help to stabilise your pelvis when you stand, walk, or run.
Their tendons anchor into the greater trochanter, compressing against and sliding over it as you move. Several small fluid filled sacs, called bursae, sit underneath and between these tendons to reduce friction and allow smooth motion.
💡 It's typically the tendons of the gluteus medius and gluteus minimus muscles (one or both) that are injured when you have gluteal tendinopathy.
Healthy tendons consist of thousands of collagen fibres arranged in parallel in strong, organised bundles. It's this parallel alignment that makes tendons so strong. In gluteal tendinopathy, some of these bundles become injured. Importantly, these changes usually affect only parts of the tendon(s) rather than the entire structure.
The bursae can also sometimes become irritated and inflamed; an injury referred to as bursitis. In the past, outside hip pain was often labelled “trochanteric bursitis”, but we now know that the tendons themselves are frequently involved and that these two types of injuries are often both present, which is why the term “greater trochanteric pain syndrome” is now used more often.
Common causes and risk factors
Gluteal tendinopathy is often linked to how much load (or work) the tendon is exposed to – especially when that load changes suddenly. But sometimes it can develop without any obvious cause, and then it can be useful to look at more subtle factors like hormone levels.
How activity or exercise can overload the tendons
The normal repair cycle
When we exercise or do any type of physical activity (gardening, decorating, cleaning, etc.), all the areas in our body that we use for that activity (muscles, bones, joints, tendons, etc.) sustain micro-injuries.
This is normal and actually very beneficial – those small injuries act as a signal to the brain that it needs to make those tissues stronger. So, in the hours after the physical activity, your brain repairs the micro-injuries and makes sure that those areas are even more robust than before the physical activity. This is how we grow stronger over time 💪.
Where things go wrong
But the repair process can only happen if you allow your body to recover. If you regularly do hard workouts or other physical activities (like gardening) before your body has fully repaired itself, these micro-injuries can accumulate and become overuse injuries, such as tendinopathies.
Rapid changes in activity or lifestyle
Many people develop symptoms after increasing their activity levels, returning to exercise after a break, or starting a new type of movement they are not used to. Even periods of illness or holidays that reduce activity, followed by a rapid return to normal training, can contribute.
At any given time, your body has a certain capacity (strength and endurance) to do a specific amount of physical activity or work. If you suddenly do a lot more than what it has been used to over the last few weeks, it can cause it to get a bit overwhelmed and injured.
No one will expect to be able to run 10 km if they’ve only been walking around the house until then. But we often expect our bodies to be happy to suddenly do three days of hard gardening after not having moved or used it much throughout the winter months.
Some tasks or activities work the gluteal tendons harder than others and are more likely to overwhelm them if you increase the amount you do too quickly. Examples include activities that involve standing on one leg for extended periods of time, walking up or down hills, or climbing stairs.
Other contributing factors
There are other factors that might make you prone to developing gluteal tendinopathy.
Direct trauma: Falling on your hip or getting knocked on the tendons can sometimes trigger a tendinopathy to develop.
Genetics: There are certain genes (e.g. the ones linked to hypermobility syndromes like Ehlers-Danlos syndrome) that can affect the quality of your collagen (the main building block of tendons) and how easily your body produces it, which might increase your risk of tendon injuries.
General health: High cholesterol, diabetes, and thyroid problems can make tendons more vulnerable to injury when not treated properly.
The menopause: Women in any stage of the menopause might be at higher risk, because declining oestrogen levels can slow down collagen production.
Medication: Some antibiotics, particularly fluoroquinolones, have been linked to tendon problems. Statins, often prescribed for high cholesterol, can also cause tendon pain in some people. But please don't stop taking medication without discussing it with your docter.
💡 Often, more than one factor combines to cause your tendons to become overloaded and injured.
Typical symptoms of gluteal tendinopathy
Alison gives a brief overview of the symptoms in this video. For a more detailed discussion, see below.
Symptoms can vary widely between individuals. Some people experience only mild irritation with sport, while others find everyday activities extremely uncomfortable.
Symptom location
Most people report pain and/or stiffness directly over the outside of the hip at or close to the greater trochanter. The pain may sometimes travel down the outside of the thigh. Less commonly, it can spread into the buttock, groin, or below the knee.
Pain during specific activities
Common aggravating activities or positions include:
Standing or walking for lengthy periods – total time on feet during the day matters
Walking up or down hills or climbing stairs
Standing on one leg (for example, while dressing)
Squatting down to the floor
Lying on the affected side
Sleeping with the top leg crossing over the bottom one
Getting up after prolonged sitting
Sitting with legs crossed in front of you.
👉 Not everyone experiences the same pattern. Some people have only a few symptoms, while others report several.
A typical symptom pattern for tendon injuries is that:
The pain and stiffness often feel worse after you've sat or lain still for a long time.
You may feel some discomfort when you start to move or at the beginning of an activity (like a run), but then it warms up and goes away.
If you continue that activity for a long time or at a high intensity, you might find that the pain returns towards the end of the session.
But often everything feels absolutely fine while you're doing it, and then your pain and symptoms increase several hours later – often the next day.
A key part of the advice we give our online patients is how to use this symptom response to guide and adapt their rehab and other activities to reduce flare-ups and support better healing. Feel free to reach out if you want help with your recovery. You can find more information about our Video Consultation service here, or email me (Maryke) with any questions at info@sports-injury-physio.com
The stages of gluteal tendinopathy
If you've had gluteal tendinopathy for a while, you might have noticed that some treatments other people swear by make yours feel awful, or perhaps you've tried something that worked well in the past, but now it doesn't seem to have any effect.
One of the reasons for this is that tendinopathy type injuries go through different stages of healing or injury. Understanding these stages can help you to choose better treatments and help you to understand why some people’s injuries clear up more quickly than those of others.
💡 These stages don’t have clear beginning and end points; they tend to overlap somewhat. And you don’t need scans to know in which stage you are. An experienced physiotherapist can use the information about your injury history, symptoms, and activity levels to judge what combination of treatments are needed.
1. Reactive gluteal tendinopathy
This is usually the stage your tendon is in when it first gets injured – those initial few weeks after you’ve overdone an activity – or in some cases when you experience a flare-up after a symptom-free period.
🔬 What scans show: The tendon becomes temporarily irritated and may thicken slightly as it holds more fluid between the collagen fibres. There are often also more cells between the fibres than normal and a small amount of inflammation, but researchers seem to agree that inflammation is not the main cause of the pain. Importantly, the overall structure of the tendon remains largely intact, and there is no significant damage to the collagen fibres.
🏃♂️➡️ What this means for recovery: At this point, the tendon is still highly adaptable and can recover relatively quickly if you allow it time to do so.
👍 Best treatments during this time: Reducing excessive load (work) and allowing symptoms to settle can help the tissue return to normal without long-term changes.
👎 Worst treatments during this time: Trying to just ignore the pain and carry on as normal while also adding strength training exercises and/or stretches.
👉 In our gluteal tendinopathy treatment article (coming soon), we explain in detail which treatments work best at each stage and why.
2. Tendon dysrepair
If the tendon continues to be overworked (either through too much physical activity or perhaps by applying the wrong treatments), it might move into a stage where the tissue starts to lose some of its organised structure. Instead of healing, the injury gets a bit worse.
🔬 What scans show: The collagen fibres begin to move away from each other slightly, losing some of their nice, strong, parallel structure. Small blood vessels might also grow into these areas. Usually, only a portion of the tendon is affected – much of the structure remains healthy and strong.
🏃♂️➡️ What this means for recovery: Progress tends to be slower than in the reactive phase, because the tendon now has to create new, healthy collagen fibres, and this is a slow process. There's evidence that the injured area can still fully recover and regain its previous strength as long as you give it the correct mix of rest and exercise. (Keep an eye out for our treatment article – we’ll discuss it there.)
3. Degenerative stage
I really hate this name because it makes it sound a lot more serious than what it actually is. In general I try to avoid using the word "degenerative" because it makes people think of permanent damage and something that won't heal, which is NOT THE CASE.
👉 You can still get back to full, pain-free activity even if you think you've entered this stage.
The injured part of your tendon might have entered this stage if the injury has been allowed to drag on for several months.
🔬 What scans show: In some areas in the tendon the collagen fibres have now totally lost their strong, parallel structure. Even so, this usually affects only a small area rather than the entire tendon. You also see many blood vessels growing into the area. There is no inflammation.
🏃♂️➡️ What this means for recovery: Although the injured section might not fully return to its original structure, people can still regain strong, pain-free function. In other words, when you look at the tendon on a scan, you might see signs that a part of it doesn’t look 100% normal, despite the fact that you have no pain and can do all the sports and activities you want to do.
The treatment during this stage is very similar to that of the dysrepair stage, but it just takes longer to see results. Rehabilitation focuses on strengthening the healthier portions of the tendon so they can compensate for the part of the tendon that has lost its structure.
Why pain levels don’t reflect how serious your gluteal tendinopathy is
One of the most confusing aspects of tendon injuries is that how much something hurts doesn’t necessarily tell us how damaged the tissue is.
Research and clinical experience show that many people have structural tendon changes on scans without any pain at all. At the same time, someone else may experience significant pain even though imaging shows only minor changes.
This mismatch happens because pain is influenced by many factors – including how sensitive the nervous system is, how the tendon is being loaded, and how irritated the surrounding tissues have become.
With gluteal tendinopathy, it’s common for symptoms to fluctuate. A sudden increase in pain doesn’t automatically mean that you’ve caused new harm, and lower pain levels don’t always mean the tendon has fully healed.
For this reason, physiotherapists don’t rely on pain intensity alone when assessing progress. Instead, we look at patterns such as how symptoms respond to activity, whether function is improving, and how well the tendon tolerates gradual increases in load.
💡 Understanding this can be reassuring: strong pain does not necessarily mean severe injury, and in other cases people can get back to doing what they want, pain-free, even when scans continue to show tendon changes.
How gluteal tendinopathy is diagnosed
Most cases of gluteal tendinopathy can be diagnosed through combining information from an in-depth conversation and some movement tests. In some cases, scans might be needed to rule out other injuries.
1. The conversation
Your physiotherapist will ask detailed questions about how your injury started, how your symptoms react to different activities, your general health, habits, and goals.
The aim of this conversation is to identify the factors that might have contributed to your injury – these need to be addressed in your treatment plan to ensure the injury doesn’t recur – and also check whether your symptoms and history fits the typical picture we would expect someone with gluteal tendinopathy to have. It can help us understand if there are more than one injury that might be at play or something totally different we should test for.
When it comes to creating an effective treatment plan, the devil is in the detail – understanding all these factors and how they affect the specific individual is important to:
form an accurate diagnosis – it can highlight whether you need to further test for other conditions,
judge what movement tests will be most appropriate during the second part of the assessment
start forming an opinion of what types of exercise might be most appropriate to start with and what activities might have to be adapted to allow recovery
understand what level of strength and function the person’s rehab plan should eventually build up to for the activity goals they want to achieve.
This is why we spend a significant part of the first consultation unpacking all of this information and making sure that we’re not misunderstanding or assuming anything.
2. The physical tests
Next, your physio or doctor will check whether they can reproduce any of your symptoms by pressing around the area or getting you to do movements that contract or stretch the gluteal muscles and tendons.
We also guide our online patients through this process. I’ve listed some of the most common tests below, but first, let’s look at how to interpret their results:
Positive test result: If the test causes some pain, it might mean your gluteal tendons are injured.
Negative test result: If you didn’t feel any pain, you might not have gluteal tendinopathy.
However, injured tendons can sometimes have a delayed pain response, meaning they feel absolutely fine during the test, but then your pain flares up several hours later or the next day. If this happens, let your physio know – it might be significant for your diagnosis.
🚨 None of these tests are 100% accurate. They can be painful when it isn’t gluteal tendinopathy and pain-free when it is. That’s why you should use more than one and combine the findings with what you learn from the conversation.
The test we list below have all been shown to have:
good specificity – meaning that if the tests do provoke your symptoms, it is likely to be gluteal tendinopathy
varied sensitivity – meaning that they are not consistently good at picking up cases; in other words, if they don’t provoke your symptoms, you might still have gluteal tendinopathy.
The research shows that combining the information from the in-depth conversation with more than one physical test usually provides the most accurate diagnosis.
For example, a recent review of all physical tests for gluteal tendinopathy found that if a patient was thought to likely have gluteal tendinopathy after the conversation, the likelihood of them having it when scanned increased to 96% if the Pressing Test as well as the Resisted Abduction Test (see below) were positive. If both those tests were negative, it decreased the likelihood to 14%.
👉 Your physio may have very good reasons for using totally different tests or leaving them out initially – these are just examples of tests that could be used.
Pressing around the greater trochanter
If you’re consulting a clinician in a practice, they will do this for you. In a video consultation, we show you where to press and ask you to do it yourself. The aim is to apply firm pressure over the gluteal tendons to see whether it hurts. You can also use a ball against a wall if you’re struggling to apply enough pressure with your hands.
👉It’s important to repeat this on the uninjured side as well – the outer hip can be tender to press on even when it isn’t injured, so this helps you judge whether it feels different from the other side.
Resisted abduction
Abduction is the medical term for when you move your leg or arm out to the side. Your gluteus medius and minimus muscles (the ones most involved with gluteal tendinopathy) work hard during that movement. If the tendons connected to them are injured, it usually causes some pain when you do that movement against resistance.
This test can be performed in many positions, but you can perform it yourself as follows:
Stand sideways next to a wall with your injured leg on the wall side.
Stand a little away from the wall so that your hip will form a 30–45-degree angle when you lift your leg out to the side.
Have a chair or something sturdy in front of you to hold on to – this is not a balance test.
Now, lift your injured leg straight out to the side and press the outside of your foot into the wall.
Press gently at first – if it doesn’t cause pain, press harder until you are pressing with your full force.
Stop if you feel discomfort.
The 30-second balance test
The gluteal muscles have to contract and work to keep your pelvis level when you balance on one leg.
Perform this test as follows:
Stand next to a wall, chair, or kitchen counter so you can lightly correct yourself if you lose your balance.
Stand tall, with your feet hip-width apart and your weight evenly distributed.
Shift your weight onto the leg you want to test.
Lift your other foot off the floor by bending your knee so your foot is hovering behind you.
Keep your pelvis level – try not to let one hip drop or hitch up.
Keep the knee of your standing leg pointing straight ahead and your body upright (avoid leaning sideways).
Once you are steady, start a timer and balance for 30 seconds.
Try not to hold on, but you can place a finger or two against the support if you’re struggling to balance – the important part is to not take any weight off your standing leg.
Stop if you feel any discomfort or pain, or when the 30 seconds are over.
Trendelenburg sign (hip drop)
The Trendelenburg sign is when the pelvis drops on the side of the leg that is lifted off the floor while you are standing on one leg. It usually indicates weakness or poor control of the hip abductor muscles (mainly the gluteus medius and minimus) on the standing leg side.
In a normal response, these muscles keep the pelvis level when you stand on one leg. If they are not working well – which can happen with conditions like gluteal tendinopathy or hip pain – the pelvis tilts downward on the opposite side.
This is something your physio will look out for while you’re performing the balance test.
Stretch test
When the gluteal tendons are injured, they often don’t like to be stretched, so with this test you take the tendons into a stretched position to see if they complain.
There are several positions that can be used – one way to perform it is as follows:
Lie on your back, with your knees bent and feet flat on the floor.
Let’s assume in this example it is your right side that is injured and that you want to test.
Cross your right leg over your left thigh, near the knee.
Place your right hand on your right knee. And your left hand on your right shin.
Pull your leg diagonally towards you with both hands, so that your knee moves towards your left shoulder.
You should feel a stretch in your right buttock.
If you don’t feel any stretch or discomfort, you can increase the stretch by straightening your left leg flat on the floor and pulling a little harder with your left hand on your right ankle (to increase the twist).
The leg can also be angled into different directions.
Re test on the uninjured side to see how it compares.
👉 Your physio might limit the number or types of tests they perform if they identified in the conversation that your symptoms are very easy to flare up and irritate. They might first suggest treatments to allow the pain and sensitivity to settle down and then only perform movement tests in subsequent consultations. And the tests they use might look different from the ones described here.
Scans
If, after having an in-depth conversation and performing the movement tests, your physio feels that it’s not clear what your diagnosis is or that they should rule out a different condition, they might suggest that you get a scan. Scans can also be useful if your recovery is not progressing as expected.
Why not have a scan straight away? Research shows that up to 50% of people with no hip pain show signs of tendinopathy on scans – a false positive. That’s why a diagnosis should never be based on scan results alone; the findings must fit with what the rest of the assessment is pointing to.
The best scans to diagnose gluteal tendinopathy and rule out other causes are MRI scans and ultrasound scans. X-rays can be useful to rule out arthritis or bone injuries, but they don’t pick up soft tissue injuries like tendinopathies.
Conditions that can mimic gluteal tendinopathy
Alison also discusses other causes for lateral hip pain as it relates to gluteal tendinopathy in this video:
Pain on the outside of the hip does not always come from the gluteal tendons or bursae. A thorough assessment aims to rule out other potential sources.
Lower back or nerve-related pain: Problems in the lower back can refer pain down the outside of the leg. Nerve irritation may produce similar symptoms, even without noticeable back pain. Clinicians use specific questions and movement tests to distinguish between these possibilities.
Hip joint pathology: The hip joint itself can cause pain, although this is more commonly felt in the groin rather than the outer hip. Differences in symptom patterns and movement tests help to distinguish joint problems from tendon issues.
Trauma: If a person’s symptoms started after a fall or accident, the clinician might want to rule out fractures, tears, or other trauma-related injuries.
Stress fractures: A history of high volumes of endurance sport, diet restrictions, changes to menstrual cycles, bone density issues, or a previous history of fractures might raise suspicion of a stress fracture.
Medical conditions outside the musculoskeletal system: In rare cases, illnesses unrelated to muscles or joints can refer pain to the lateral hip. Physiotherapists screen for warning signs and refer patients for medical evaluation if necessary.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
