Why Won't Your Hip Bursitis Go Away?
Why Won’t Your Hip Bursitis Go Away?
That awful pain in the side of your hip that your doctor said is bursitis, and to just rest it, or have a cortisone still hasn’t gone away? I hate to tell you, but an old fashioned diagnosis and treatment plan could be the reason.
To make hip bursitis go away, firstly we need to know if we have a correct diagnosis and are treating the right thing. Often bursitis comes to the party with it’s friend gluteal tendinopathy.** In addition, while it’s the most popular management strategy I see from well meaning Doctors, complete rest is very rarely a suitable treatment plan for more than 72 hours, and treatment must be directed at the affected tissues without flaring it up. When we have changes in our tissues, we must also look at the whole system, including hormonal changes, other structures (osteoarthritis of the hip can also bring gluteal tendinopathy and bursitis along). We also need to remember that imaging isn’t failsafe and doesn’t tell us what your life looks like.
Is it Bursitis?
Although we thought for many years that hip bursitis is the cause of hip pain (and plenty of people are still being diagnosed like this), what we now know is that bursitis rarely happens on it’s own and most people have either tendon irritation or a combo. Bursitis has been the go-to diagnosis for hips since forever. But…
A true diagnosis of a bursitis normally includes a red, hot, very swollen area, much as you could imagine a housemaid's knee or the bulge that you get on your elbow when you've banged it (olecranon bursitis). A true hip bursitis is very rare.Bursitis is common with a hip tendon issue and it’s thought that the swelling in the bursa is due to the irritation in the tendon impacting the bursa, rather than the bursa driving the pain (though it can be impactful) –much as if the tendon is a banana in a fruit bowl – as it ripens, everything else is changed as well. Unfortunately, this information has not yet been distributed down to many GP’s (this isn’t their fault, education takes time to sift through from research to real life, and they have to know about migranes and big toes as well).
What is causing the bursa to be swollen?
What we have with “hip bursitis” is that it's more likely to be tendinopathy with a bursitis happening alongside, that is caused by the gluteal tendon being irritated, and by default, due to proximity, the hip bursa swells.) It’s technically a burisitis on imaging, BUT the problem is that the bursa gets blamed when it’s the tendon.
One of my clients came to me with hip pain, stopping her from walking up hills with her friends. She was told she had a bursitis (diagnosed with ultrasound) and she wanted to avoid a cortisone for it. Remembering that tendiopathy can’t always be diagnosed with imaging, we found she had all the symptoms of a gluteal tendinopathy, and we agreed that she would try an 8 week strength training programme, and if there was no progress, or if we couldn’t progress week on week, that we would trial an injection, but that we would try and avoid it.
Her programme progressed pretty well (no one is perfect because life happens) and thankfully she managed to get out walking with her friends again.
On the other hand, I had someone who had almost the same symptoms, and she wasn’t able to tolerate progressing to real life even though she had done the programme really well. She was disappointed that in the end she needed an injection.
However, it was a window of opportunity to
1. See if the strength work worked to see if she could avoid the injection (this is one of my favourite approaches) and then …
2. To allow the bursa to be settled enough to be able to load the tendon and improve function (it worked this time).
Imaging
We need to remember that imaging is only one piece of the puzzle. An MRI or ultrasound can (sometimes) show changes in a tendon or bursa but it can't tell us whether those changes are actually causing your pain, how irritable the tendon is, or what you can and can't do. That's why a thorough assessment is so important – for me the most important thing is “what your life is like” because we can be pain free because we aren’t doing the things that we love any more. We so need to remember that not all imaging shows the changes that are there on a microscopic level, depending on the state of the tissue, the technology used and the technician.
We also have to be careful that we get the diagnosis right when the imaging is showing a gluteal tendon tear. Imaging cannot take a picture of pain or function, which is why I make sure I check on the human in front of me.
An amazing lady came to me with pain in the front of her hip, but an ultrasound of a torn gluteal tendon and she couldn't work out why the strength work isn't working. Her functional assessment showed pain in the front of the hip but not on the side, and her gluteal tendon strength was outstanding. If we had treated the torn gluteal tendon we wouldn’t have gotten anywhere. Of course her programme is progressive loading BUT it’s specific to the issues she has.
What is a tendinopathy?
Is it a tendinopathy as opposed to a bursitis?
Tendinopathy is where there is a mismatch between the load and capacity of the tendon, and the ability of the body to heal from that load.
What we know is that the tendon can change, but unless it has a progressive loading program, it generally doesn't settle and doesn't allow for more function. In addition, for real life, with or without tendinopathy, you have to load the tissues you are using so the body knows what to expect.
I had a client come to me with significant pain in the outside of their hip following a fall. It was so frustrating as she had rested, but every time she tried to do cool stuff, (like hill walking) it got so sore, and in the end she couldn’t even walk on the flat. The tendon had been hit in the fall (this can be the instigating cause) and had not settled after many months of resting (the advice she had been given).
After diagnosis (because we need to treat the right thing) we began a progressive loading program, while addressing the whole system, (which is what we do in the Manage Your Grumpy Hip programme). Their hip pain was significantly improved so that they were able to ride their horse again.
However, there are also other things to take into consideration.
Perimenopause and Tendons
Perimenopause can wreak havoc through the variation of estrogen, the depletion of progesterone, and the change in testosterone. These can cause discomfort, an inability to recover from load, and significantly losing strength in the muscle, which then decreases the load through the tendon. And because the body is cunning, the body thinks the unloaded tendon is not needed, so it doesn't stay strong.
Another client who had hip pain stopping her from sleeping at nightand getting onto the catwalk in the cattle yards was working on her progressive loading program diligently with slow results.After discussion with me and then seeing her GP, she almost miraculously found that the program started working better after she started menopausal hormonal therapy.
Rest
What we often do as well is we rest. Rest tends to make us feel better. However, when we go back to activity, we feel worse. And when we rest again, we feel better, and we get into a boom-bust cycle.
I see this with many of my clients who say that they are much better. But when I ask them if they can do any of the things that make their life full and exciting, they say no.
Rest does give the body the opportunity to recover in the short term, but in the long term it sends signals to muscles, ligaments and tendons and bone that the requirement is low, so there is no need for the body to create capacity beyond just what it does day on day. In this situation, we become deconditioned. It may not be painful, but we alsodon’t get to do many cool things.
What about hip osteoarthritis?
Recently a client came in with a very grumpy hip and x-ray showing that osteoarthritis was in the hip. However, when I tested it, the pain was in the outside of their hip, their hip range was truly excellent, and we were able to change their symptoms on the day by loading the tendon. We do know that we can have gluteal tendinopathy in association with a hip osteoarthritis, and it is a very common collaboration of symptoms. In this case I like to check what helps most, but often the exercises can overlap which is helpful.
So … now what?
Once we know what's driving your symptoms, treatment becomes much more predictable. The exact exercises and progression are generally individual, but the overarching principles are remarkably consistent.
We settle the pain, (always the first go to) gradually rebuild the tendon's capacity to tolerate load, (often deloading the tendon at the start and asking other muscles to join back in, however reluctantly) and address the factors that may be stopping the cranky tendon from recovering well in the first place while reloading it (so it’s ready for the things you want to do). My philosophy for treatment is always “settle, deload, reload.”
Sometimes that approach is all that's needed and we can happily progress down the pathway.
Will it work?
Sometimes doing the work tells us that another option, such as a cortisone injection, further investigations or (it’s rare but happens) surgery, is appropriate as a way back into strength work (strength is nearly always the answer, it's just not always the first answer). Either way, the information from doing the programme guides the next step rather than relying on guesswork. This format allows us to determine whether the progressive loading programme is what you need, or if it’s not for you – yet.
If you've been told you have hip bursitis or gluteal tendinopathyn —or you've had pain on the outside of your hip for months (or years, don’t worry, I’m not judging) and you are over this smaller life than what you want AND you're wondering whether it's actually your gluteal tendons—I'd love to help.
I'm opening a small beta group for my Manage Your Grumpy Hip programme (I’m taking 10 women only for this in-depth high-touch group).
Over six weeks I'll take you through the same step-by-step process I use with my clients to get them started: helping you understand what's driving your pain, progressively reload your tendon safely, and work out whether you're on the right track or whether you need a more individualised approach – or determine if you need “a leg up” (further referral) to get back to doing the good stuff. I want you to be more able to sleep through the night and walk on the flat by the end of the six weeks.
If you'd like to be one of the first to hear when enrolment opens, join the priority list here. Places will be limited, I will be providing an unprecedented amount of support, and before anyone starts, I'll make sure the programme is likely to be the right fit for them.
Looking forward to seeing you there. X
Some references I’ve used
Grimaldi & Fearon (2015)
Grimaldi, A., & Fearon, A. (2015). Gluteal tendinopathy: Integrating pathomechanics and clinical features in its management. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 910–922. https://doi.org/10.2519/jospt.2015.5829
Grimaldi et al. (2025)
Grimaldi, A., Ganderton, C., & Nasser, A. (2025). Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence. Musculoskeletal Science and Practice.
Long et al. (2013)
Long, S. S., Surrey, D. E., & Nazarian, L. N. (2013). Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. American Journal of Roentgenology, 201(5), 1083–1086. https://doi.org/10.2214/AJR.12.10038
Mellor et al. (2018) – LEAP Trial
Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., Brukner, P., & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. British Journal of Sports Medicine, 52(22), 1464–1472. https://doi.org/10.1136/bjsports-2017-098370
Mellor et al. (2022)
Mellor, R., Kasza, J., Grimaldi, A., Nicolson, P., Wajswelner, H., Hodges, P., Bennell, K., & Vicenzino, B. (2022). Mediators and moderators of the effect of education plus exercise versus corticosteroid injection versus wait and see on perceived improvement in individuals with gluteal tendinopathy. Journal of Orthopaedic & Sports Physical Therapy, 52(4), 211–220.
(I recommend confirming the page range from the published version before using this in a manuscript.)
