The Four Worst Pieces of Advice I See for People With Pain on the Outside of Their Hip

Part 1: Let’s Give it a cortisone and see what happens.

If you have pain on the outside of your hip, knowing what to do next can feel confusing. You may have been told you have hip bursitis, have trouble walking up and down stairs or even be woken by your hip pain when you lie on that side (or the other side) at night.

Many people are told different things: wait and see, rest it, try an injection, push harder, or accept that it is just part of getting older.

Doing the wrong thing can mean valuable time passes without progress, leaving people feeling frustrated and unsure about what to try next. The problem is that this approach doesn't address the reason the hip has become painful in the first place. Many people I see are “feeling better” but avoiding doing things that make them actually feel like their life is being lived to keep themselves pain free

For many of my clients, the biggest frustration is not just the pain itself — (though this is significant, and should not be diminished) it is feeling stuck, unsure what the next step should be. They feel like they have “tried everything” and they are still in pain and don’t know what the next best thing could be. Could this be as good as it gets? It can be dispiriting.

The advice can sometimes be “just about” right, but be missing important nuance that could mean that the treatment could actually be valuable. Proper assessment and understanding of the diagnosis and drivers are hugely important. I'm here to provide some evidence and experienced based guidance.

1. Get a cortisone injection and see what happens

Often, people are told that the bursa is causing the problem.

This is because they have pain on the outside of their hip and imaging shows that the bursa is swollen.

However, the bursa is not always the primary cause of the pain. Often, it is a secondary response to irritation of the tendon underneath. When the tendon becomes irritated, the bursa can become irritated as well. (think of a banana in a bowl (this is the tendon) and an avocado (the bursa) – a ripe banana (tendinopathy) can make the avocado change (bursa)). In most cases, the bursa is not an issue on it’s own, and the tendon is what needs treatment.

The only time I think a cortisone is appropriate, (and there is always nuance in person) is when the irritation to the bursa is limiting the amount the tendon can be loaded. How I usually test this is an 8 week programme of progressive strengthening, and if at any stage my clients are unable to progress or remain painful, then I become more curious as to the cause of the problem.

There are three ways this could go.

No need for cortisone: even though it's planned:

One of my clients was unable to walk up and down hills at work (and a few other things) because of her hip pain but “was still doing everything she needed” – but she felt limited and had a cortisone booked. After a progressive strengthening programme was helpful, she didn’t need the cortisone, and she’s progressed amazingly without needing further input.

Cortisone allowed for strength based rehab:

Another lady was really bothered with sleeping, and standing watching her kids play sport. Her hip just wouldn’t settle even with a very carefully curated and stepped progressive strength programme. Between us, we chose to have the cortisone (administered by an orthopaedic registrar under ultrasound guidance) and she was able to progress her exercises.

Cortisone didn't work, but helped direct to other treatment:

Another client, who was having trouble with everything, including going up and down stairs (she would avoid her stairs except for coming down in the morning and going up to bed, carrying a massive load of laundry so she didn’t have to do the stairs again) couldn’t progress with a properly prescribed strength programme, but didn’t get better with a cortisone either, so I referred them off to their surgeon for further investigations.

While the final client's outcome isn’t what we want to have happen, it’s nice to have some certainty that a certain treatment option has been exhaustively trialled before going on to more invasive therapy.

When Cortisone isn't appropriate.

Where I really think that cortisone is inappropriate (outside of the above scenarios), is when a client is given a cortisone, then just told to rest. This is just throwing out the old avocado, replacing it with a fresh one and keeping the old banana in the fruit bowl. Tendons must be loaded to recover. **

TL:DR cortisone can sometimes help someone participate in rehab

How we can use cortisone as a tool, without using it as a first line of defence.

My overall take on a cortisone is that if it does happen, ideally it’s after a progressive strengthening programme has failed, and then the cortisone (after a short 1-2 week break of no load (48 hours) and progressively increasing but no heavy lifting load, then a progressive hip strengthening programme is undertaken in a dedicated manner.

The biggest takeaways for me in hip “bursitis” where a cortisone is an option is to make sure that cortisone is the best option. While it’s not highly recommended, I do occasionally see it help people, but as far as I see it – it’s best to have tried a 6-8 week strengthening programme and failed at that, before moving on to a cortisone and then trial a 6-8 week strengthening programme before being referred on for further investigations. (as a by the by, full thickness tears of the gluteal tendons can be accompanied by full function, and I’ve seen this happen, to the joy of both myself and my client.

Most importantly, it’s important to fully understand what is driving the symptoms for my clients.We need to make sure that the assessment is accurate and then we use my “settle/deload/reload” philosophy, where we calm the system, then try and build it (and other helpful muscles) back up. I’ve created this as a programme for you to access at home, and it will be released soon. If you are keen to find out more, pop your name on the waitlist here.

Also - stay tuned for three of my other least favourite treatment plans for hip bursitis – coming soon. This is my favourite article that has helped me the most with this (though I've read a LOT of them lately.)

Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence - ScienceDirect