Fixing Lateral Hip Pain

Welcome back to Squat University! Today we’re going to discuss the topic of lateral hip pain. This injury is commonly associated with a slow-onset of dull and achy pain centered over your greater trochanter (the most prominent bone of your lateral thigh). You can typically pin-point a painful area when pushing just under this bone.

Pain may present when lifting but is often most severe at night when trying to sleep on your affected hip.³ Females, people with a history of low back pain and anyone over the age of 40 are more likely to have lateral hip pain.^3,5,6,15

Traditionally this injury has been labeled by many in the medical field as trochanteric bursitis. Bursitis refers to inflammation of a bursae sac (a small fluid-filled “bumper pad” that provides cushioning and limits friction between bones and the surrounding muscles/tissues that cover them). However, we’ve come to find that only a small majority of lateral hip pain is actually due to an inflamed bursa sac (~8% of cases according to a 2001 research study).¹⁷

Instead this pain is thought to be an overuse tendon injury of two small muscles in your lateral hip (the gluteus minimus and medius) and is therefore referred to as a tendinopathy.² In fact, there is research that finds gluteal tendinopathy to be the most prevalent tendon injury in the entire lower body.¹⁶

Unfortunately, it’s difficult to tell the difference between trochanteric bursitis and glute tendinopathy. In fact, these two problems can actually occur at the same time and are likely caused by the same issue!^2,3 For this reason you may see lateral hip pain generally described as greater trochanteric pain syndrome or GTPS.¹⁸

Anatomy 101

Let’s quickly go over the anatomy of your lateral hip to help you better understand how this injury occurs. Your glute medius is a large fan shaped muscle that runs from the lateral part of your pelvis (iliac crest) and connects with a single tendon to your femur.¹¹ The glute minimus is a smaller muscle that fits right behind the glute medius attaching also to the femur bone.

In most anatomy classes you will be taught that these two muscles are the main abductors of the hip. When activated, the medius/minimus muscles move the thigh away from the midline of the body. However, this isn’t 100% accurate. This originated from research that dates back to the mid 1900’s in which scientists used simplistic mathematical models to study how the body works.¹¹ During their analysis, these models unfortunately failed to take into account the unique size, shape and action of the lateral glute muscles.

For example, while many people think the glute medius is one big muscle, research shows it is actually composed of 3 distinct parts with unique actions.¹¹ The posterior muscle fibers act with the entire glute minimus muscle to pull the femur into the hip socket (acetabulum) to help stabilize the hip joint (basically keeping the ball in the middle of the socket).¹¹ The middle and anterior portions work together to initiate lateral leg movement (abduction), which is then completed by the TFL (tensor fasciae latae).¹¹ Along with beginning any lateral leg movement, the anterior fibers of the glute medius can also create or limiting pelvis rotation.

However, when you’re standing on your feet these muscles take on a slightly different role. When you run, lunge or squat the glute medius and minimus act together to steady the hip joint (limit knee cave) and keep your pelvis from tipping, rotating or shifting from side to side. This allows the larger muscles around the hip (TFL, glute max, hip flexors, hamstrings, etc) to create movement. For this reason, the glute medius/minimus muscles are similar in function to the rotator cuff muscles of the shoulder. Both muscle groups act as stabilizers for their respective joints.¹¹

Contrary to what you may have learned in anatomy class, your lateral glute muscles are in fact more of a movement stabilizer than a prime mover of the lower body. This understanding will help guide us in creating more efficient training and better corrective exercises for the hip joint.

Testing

Unfortunately, there is no “gold standard” when it comes to testing for GTPS. However, there are a few screens that can be helpful that I want to share with you today.

The Resisted External Derotation Test

Lie on your back and raise your thigh to 90 degrees. Have a friend externally rotate your hip by pushing your foot towards the mid-line of your body (don’t crank on your leg and push it too far into this position as doing so may create pain). Next, try to rotate your lower leg back to a straight position as your friend applies a light resistance to your lateral foot. This test is positive if this motion (resisted internal rotation from an externally rotated position) recreates pain in your lateral hip.¹

 

The Single Leg Stance Hold

Assume a single leg stance with the side that hurts. Try to stand as tall as possible and hold this position for at least 30 seconds. The test is positive if this position is able to recreate your lateral hip pain. Research has shown that this test is very good at detecting GTPS if the person performing it is required to maintain their single leg stance for 30 full seconds.¹

Causes?

As I explained earlier, most people with symptoms of lateral hip pain have a gluteal tendinopathy injury. If you remember back to our blog on patellar and quad tendon pain, tendon injuries occur due to relative overuse or overload of these tissues. They can occur in an untrained individual that starts a high intensity program or even in an elite athlete if they decondition their body while on a vacation and jump directly back into their “normal” training. If the body is not allowed to recover after a rapid increase in the intensity and/or frequency of their training, the tendon becomes “reactive” and the injury process begins.

Gluteal tendinopathy occurs due to two main types of overloading: excessive stretching to the tendon fibers (much like stretching a rubber band) and/or too much compressive force (from the tendon being smashed into the tissues/bone underneath).³ These forces (called tensile and transverse loads) likely occur at the same time and reduce the overall strength of the tendons, making them susceptible to injury.³

One of the factors that can lead to overloaded tendons is your anatomy. Some researchers believe that a wider set and/or more angled alignment of the pelvis (often seen in women) can lead to greater compressive forces on the tendons of the lateral glute muscles and predispose them to injury.^3,7,8

Besides anatomy, what else can cause this injury?

The second most common factor is movement or positional faults. I’ll use the common technique fault of the hip shift on the squat as an example. As someone shifts to the right side on the way up from a squat, the right thigh shifts towards the midline of the body (the movement of hip adduction). This causes the right side IT Band to wrap more firmly around the lateral thigh in an effort to keep your pelvis stable, which then compresses the underlying glute tendons and the associated bursae against the femur.³

So what other movement issues should we look for as risk factors?

Basically any time the thigh is pulled in towards the midline of the body (either with a hip shift or with the dreaded knee cave) the glute medius and minimus tendons are placed in a very bad position and exposed to a ton of compressive and tensile forces that can lead to injury.

When analyzing athletes who have GTPS, make sure to observe their lifting technique with light and heavy weight. These athletes are adept at covering up these movement faults with light weight but begin to show movement errors (knee valgus or hip shift) with heavier loads.

So how do we fix it?

Unfortunately, there isn’t a ton of research out there to back up any one specific protocol on treating gluteal tendon pain. However, based on our understanding of tendon injuries and how this injury likely occurred we can come up with a good starting point. First, we want to minimize any compressive loading on the tendons.

This means we want to obviously cut back on performing movements with poor technique (heavy squats for example). We also want to avoid stretches that pull your thigh across your body. The classic glute stretch of pulling your knee to your opposite shoulder may feel okay while performing, but if you have this injury it’s not going to give you any lasting results because you’re only placing more compression on the already injured tendons.

Outside of your workout, think about how you’re standing or sitting throughout the day. Positions such as standing while “hanging on one hip,” standing/sitting with your legs crossed, or sitting with your knees together can place increased compression on the lateral glute tendons.

You may also need to think about the positions you sleep in (as one of the main complaints for many with this injury is pain when trying to lay on their side). To completely remove any tension/compression from the lateral hip, lying on your back with a pillow under your knees is thought to be the best position.³ For those that cannot eliminate sleeping on your side, using a pillow between the knees may help reduce a small amount of compression to improve your sleep quality.

Rehab Exercises

While controlling for movements and positions that may place excessive compression force on the tendons is a great start to early recovery, eventually we need to start re-introducing some force on the injured tendons in order to facilitate healing and improve their load-bearing capacity.

This will come with a basic 3 step process:

1. Isometrics to decrease pain and improve muscular control
2. Strength exercises (called isotonics) to improve tendon capacity to handle load
3. Movement re-education and technique fixes for barbell training.

The first stop is isometrics. Just like with patellar and quad tendon pain, isometrics can be amazing at helping decrease pain when it comes to tendon injuries (called an analgesic effect).¹⁰ There are 2 ways we can perform an isometric for the lateral glutes.

1. Squat Stance Holds
2. Wall Sits

Squat Stance Holds

Assume the same stance you would take during a squat with the belt across your knees (you can use the same belt you would regularly use across your waist during barbell training). Perform a small mini squat and hold that position. While keeping your feet glued to the ground, drive your knees out to the side against the belt to turn on your lateral glutes (don’t lose your tripod foot and let it roll onto the side!)

This does not need to be a very intense contraction! In fact, research has shown that low-intensity isometrics (~25% of your max ability to contract the muscle) can be more efficient at decreasing pain compared to high-intensity isometrics (>80%).⁹

Recommended sets/reps: 5 sets of 10-30 second holds

Wall Sits

Just like with patellar or quad tendinopathy, we can use the isometric activation of a simple wall sit to decrease pain and return control of your muscles. The only difference this time is we’re going to be performing this wall sit with an emphasis on the lateral glutes.

The first way to engage these muscles correctly is to add a band across your knees with the classic wall sit.

Step 1: Start with a small resistance band across your knees. With your back against a wall and feet in front of you, slide down into a wall sit position.

Step 2: Drive your knees out to the side as far as they will go while still maintaining a flat stable foot (don’t let your foot roll on it’s side).

An alternative to this wall sit is to perform a single leg version while pushing laterally into the wall.

Step 1: Stand next to a wall with your outermost foot at least 1 foot from the edge (this gives you some room to lean into the wall). Bring your inner thigh up to 90° and lean your body into the wall.

Step 2: Push with your outermost leg and jam your hip into the wall. This action should turn on the lateral glute muscles of your pushing leg. Make sure the knee of the leg you’re pushing with is in line with your foot and not caving inwards.

Recommended sets/reps: 5 sets of 10-30 second holds

Lateral Band Walks

Next we need to transition to higher level strength exercises with movement (called an isotonic exercise) to improve the load bearing capacity of the injured tendons. Research has shown that heavy resistance exercises with a slow tempo (typical of muscle hypertrophy programs) can be more efficient at improving symptoms and facilitating the healing process when compared to classic eccentric exercises.¹²

During this time, exercises performed while standing will activate the glutes (glute medius specifically) more than a non-weight bearing exercise (such as your classic side lying leg lift). Once, we’re standing, it then comes down to choosing the right exercise.

Early in the rehab process of this injury we don’t want to perform a ton of single leg squats as the injured leg naturally moves into slight adduction in order to stay balanced (meaning a small amount of tendon compression cannot be avoided). This normal increase in compression with single leg stance is why the position is used as a provocation test for this injury in the first place!

One of the best ways to activate your lateral glute muscles while standing is with lateral band walks.³ Here’s how you perform them.

Step 1: Stand with a small resistance band across your ankles. Perform a small mini-squat and hold this position.

Step 2: Start walking sideways with the emphasis placed on pushing into the ground with your trail leg. If you only reach out in a stepping motion, you will be emphasizing your TFL in your forward leg (a muscle that is likely already overworked in the presence of underutilized or injured glute medius and minimus muscles). As you drive yourself laterally with your trail leg, make sure to keep your knees in line with your feet and your pelvis flat.

Recommended sets/reps: 3 sets of 30 feet. If done correctly, your lateral glutes should be on fire.

Within the next 24 hours after performing this exercise, assess whether your symptoms are getting better or worse.³ For this injury, a change in night time pain is a good indicator of your tolerance to the program. If your pain gets worse at night, it may be an indication that your corrective exercises or training program is too intense and need to be adjusted.

Movement Re-Education

The last step in the rehab process is to retrain any broken movement patterns and start loading barbell lifts again. A great tool for this task is RNT (reactive neuromuscular training). First introduced by physical therapists Michael Voight and Gray Cook, RNT exercises are designed to help improve movement quality by teaching the athlete to feel for how it is moving (also known as proprioception).¹⁴

To perform these exercises, we will use a resistance band to pull the body into an exaggerated movement fault (knee cave or hip shift). By “feeding” the movement problem, the body should reflexively realize the error and learn how to correct itself by pushing in the opposite direction.

RNT Squat

Step 1: Assume your normal squat stance with a small resistance band across your knees.

Step 2: As you squat, keep your knees in alignment with your feet. In order to keep the tension of the band from pulling your knees together, your lateral glutes must kick on to stabilize the femur and pelvis. As you drive your knees wide against the band resistance, make sure your feet stay glued to the ground. A good cue to limit your foot from rolling on its side is to keep your big toe jammed into the ground.

Recommended sets/reps: start with 2 sets of 20 reps of bodyweight squats

As your movement quality improves and your pain lessens, you can start using a band with a lightly loaded barbell as part of your warm ups before attempting heavier weights.

RNT Split Squat

Step 1: Assume a lunge position (one leg in front of the other) with the heel of your back foot elevated off the ground. Place a resistance band around your forward leg and have your friend pull the band inwards in an effort to collapse the knee.

Step 2: As you perform the split squat, work to maintain your knee in alignment with your foot. The resistance from the band should stimulate the lateral glutes to kick on at the appropriate time and keep the knee in a good stable position.

Recommended sets/reps: 2 sets of 20 reps of bodyweight lunges

Again as the quality of your movement progresses and your pain decreases, you can start using a loaded barbell on your back or holding dumbbells in your hands to increase the challenge of this exercise and ease back into your normal training routine.

Final Thoughts

As you now know, lateral hip pain is no simple injury. I hope this article was able to help you better understand this injury and equip you with a few tools to manage it.

If you are unable to find relief with your lateral hip pain after performing these exercises, I recommend going to a medical professional (doctor or physical therapist) to assist in your recovery.

Until next time,

With

 

References

1. Lequesne M, Mathieu P, Vuillemin-Bodaghi V, et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis & Rheumatism. 2008; 59(2):241-246
2. Klauser AS, Martinoli C, Tagliafico A, et al. Greater trochanteric pain syndrome. Semin Musculoskelet Radio. 2013;17:43-48
3. Grimaldi A & Rearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. Clinical commentary. JOSPT. 2015;45(11):910-922
4. Little H. Trochanteric bursitis: a common cause of pelvic girdle pain. Can Med Assoc J. 1979;120:456-458
5. Collee G, Dijkmans BA, Vandenbroucke JP, et al. Greater trochanteric pain syndrome (trochanteric bursitis) in low back pain. Scan J Rheumatol. 1991;20:262-266
6. Tortolani PJ, Carbone JJ, Quartararo LG. Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists. Spine J. 2002;2:251-254
7. Viradia NK, ZBerger AA, Dahners LE. Relationship between width of greater trochanters and width of iliac wings in trochanteric bursitis. Am J Orthop (Belle Mead NK). 2011;40:E159-E162
8. Woyski D, Olinger A, Wright B. Smaller insertion area and inefficient mechanics of the gluteus medius in females. Surg Radiol Anat. 2013;35:713-719
9. Hoeger Bement MK, Dicapo J, Rasiarmos R, et al. Dose response of isometric contractions on pain perception in healthy adults. Med Sci Sports Exerc. 2008;40:1880-1889.
10. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49:1277-1283
11. Gottschalk G, Kourosh S, Leveau B. The functional anatomy of the tensor fasciae latae and gluteus medius and minimus. J Anat. 1989;166:179-189.
12. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19:790-802
13. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35:487-494
14. Cook G, Burton L, Fields K. Reactive neuromuscular training for the anterior cruciate ligament-deficient knee: a case report. J Athl Train. Apr – Jun 1999; 34(2): 194-201
15. Segal NA, Felson DT, Torner JC et al. Greater trochanteric pain syndrome: Epidemiology and associated factors. Arch Phys Med Rehabil. 2007;88(8):988-92
16. Albers IS, Zwerver J, Diercks RL, et al. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC Musculoskeletal Disorders. 2016;17(1)
17. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138-45
18. Williams BS & Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-70

^{**Pelvis Images were used with permission from Paul Grilley} 

** Thank you to 3D4Anatomy and their app “Complete Anatomy” for the other anatomical images.