Is lateral hip pain coming from the gluteal tendons or the lumbar spine?
Separating greater trochanteric pain syndrome (gluteal tendinopathy) from lumbar referred pain using history, palpation and loading tests.
Subjective triage
- Gluteal tendinopathy: lateral hip pain, worse lying on the affected side or on the opposite side with the top leg dropped across.
- Pain with stairs, standing on one leg, and sitting with legs crossed.
- Most common in women over 40, often after a change in walking, running or weight.
- Lumbar referred pain is more likely with back pain, pain below the knee or changes in sensation.
- Ask about groin pain and morning stiffness to consider hip joint pathology.
Differential dilemma: vs lumbar referred pain
| Feature | Gluteal tendinopathy vs lumbar referred pain | Lumbar referred pain |
|---|---|---|
| Palpation | Focal tenderness over the greater trochanter | Trochanter not specifically tender |
| Loading tests | Single-leg stance for 30 seconds reproduces lateral hip pain | Hip loading tests usually not provocative |
| Spine movement | Lumbar movement does not change hip pain | Lumbar movement or sustained posture reproduces symptoms |
| Neurology | Normal | May show dermatomal or reflex change |
Red flags: recognise, screen, refer
Recognise
- History of cancer with new bone pain
- Fever or a hot, swollen joint
- Unable to weight bear after a fall (possible fracture)
- Night pain unrelated to position with systemic illness
Screen
Ask about falls, bone health, cancer history and systemic symptoms, and screen the lumbar spine and hip joint.
Refer
Suspected hip fracture or infection needs same-day assessment. Suspected malignancy follows urgent cancer pathways.
The clinical reasoning chain
- 1
History
Lateral hip pain for four months, worse lying on that side and climbing stairs.
- 2
Pattern
Position and load-related pain without back symptoms fits gluteal tendinopathy.
- 3
Objective finding
Trochanteric tenderness, pain on 30-second single-leg stance, lumbar screen clear.
- 4
Diagnostic decision
Probable gluteal tendinopathy: education on reducing compression plus progressive loading exercise.
Structures to explore in 3D
In Physivo lessons, tap an anatomical term to focus the 3D model on it. These are the key structures for this presentation.
Gluteus medius and minimus tendons
Insert on the greater trochanter and are the tendons involved in lateral hip pain.
Greater trochanter
The bony landmark where tendon compression occurs in side lying and adduction.
Iliotibial band
Can compress the gluteal tendons against the trochanter when the hip moves into adduction.
L4 and L5 nerve roots
Can refer pain to the lateral hip and thigh, the main mimic to rule out.
Quick diagnostic check
Quick reference FAQ
What is the most useful test for gluteal tendinopathy?
Trochanteric tenderness combined with pain on single-leg stance held for 30 seconds is a useful cluster. A negative palpation makes it less likely.
Why does lying on the side hurt?
Positions that compress the tendons against the trochanter, such as side lying or crossing legs, often provoke pain. Reducing compression is a key part of education.
Do steroid injections help?
They may give short-term relief, but education with exercise has better longer-term outcomes in research comparing the two.