What's really causing my hip pain?

23 March 2025 - Health Within Osteopathy

Your hips have a big job to do. You use them to stand upright, walk, balance, and exercise. Even when you’re standing still your hips are making constant adjustments to maintain your posture. They do this while bearing the weight of your whole body.

The hip joints are your largest ball-and-socket joints. They allow your thighs to move forward, backward, and sideways, and to rotate. The only other ball-and-socket joints in your body are the shoulders, and they don’t have to bear your weight—unless you’re walking on your hands!

You won’t be surprised to hear that these flexible, weight-bearing joints are prone to injury. What might surprise you is that it’s not just athletes who are at risk. Woman over the age of 50 have the highest rates of hip pain of all. We’ll get to the reason for that soon. First, let’s talk about the different causes of hip pain.

What causes hip pain?

The causes of hip pain have become a lot clearer in recent years. If you’ve ever been to a health professional with pain in the hip, there’s a high chance you’ve been diagnosed with trochanteric bursitis or hip bursitis. This is an inflammation of the bursa, which are small fluid-filled sacs that help protect your hip joints from friction.

However, these days we know that bursitis has been over-diagnosed. There are often no signs of inflammation accompanying hip pain or gluteal pain and surgery on the bursa is frequently ineffective. So if it’s not the bursa, what is the most likely site of hip pain?

The culprits are the gluteus medius and gluteus minimus tendons, which connect the butt muscles to the top of the thigh bones. These tendons are under all the strain of the dynamic weight-bearing we described, putting them at risk of deterioration. This hip & butt tendon breakdown is known as gluteal tendinopathy.

There are other causes of hip pain or clicking hips, including snapping hip (coxa saltans), labrum tears, osteoarthritis of the hip, and back pain, but we’re going to focus on gluteal tendinopathy because it’s by far the most common.

How do I know if I have gluteal tendinopathy?

You’ll have pain on the outside of the hip, and you may feel it down your thigh. It’s tender to the touch, and there can be pain when walking or going up stairs. As it worsens, gluteal tendinopathy goes through four stages:

Reactive tendinopathy: This early stage involves the tendon’s response to overload, causing pain and mild swelling but no significant structural changes.
Tendon disrepair: The condition worsens as the structure of the tendon begins to change, with increased disorganisation in the tendon cells and further pain.
Degenerative tendinopathy: At this stage, the tendon tissue starts to break down due to ongoing stress and insufficient recovery time, leading to chronic pain.
Tendon tear: The final and most severe stage, where the tendon may partially or fully tear, resulting in debilitating pain and significantly impaired function.

Why is it more common in women over 50?

Anyone can suffer from gluteal tendinopathy, but women over the age of 50 are at the highest risk. To understand that, we first need to consider the role that estrogen playing in protecting the tendons. Estrogen has several effects:

Maintaining the flexibility of tendons and ligaments
Strengthening muscles and tendons
Synthesising collagen which supports tendons structurally

During menopause, women experience a rapid drop in estrogen levels. As the graph shows, between the ages of 50 and 60 women’s estrogen levels usually drop well below that of men of the same age.

A graph of estrogen levels over time, showing levels being much higher in women until about 60 years of age when they drop below the levels in men.

How do older men have higher estrogen than older women? The more testosterone you have, the more estrogen it is converted into by the body. While testosterone lowers in men as they age, it is still maintained at a higher level in men than in women, and it continues to be converted to enough estrogen in men to protect the tendons.

Because hormone replacement therapy maintains higher levels of estrogen in older women, it can be helpful to protecting the tendons in menopausal women.

Women may also be at higher risk of gluteal tendinopathy due to anatomical differences. Wider hips mean that the thigh bone is typically more angled inward towards the knee, which puts additional strain on the gluteus medius and gluteus minimus tendons.

Osteopathy: a holistic approach to management

If you’re struggling with hip and buttock pain there are effective treatments available. Osteopathy offers a holistic treatment approach, focusing on the entire body rather than just the symptoms. Osteopaths will not just focus on your hip, they will also assess and treat the spine, knee and feet.

By employing manual therapy techniques such as soft tissue work, balanced tissue tension, joint mobilisation, and muscle energy techniques, osteopaths aim to reduce muscle tension, increase circulation and improve the alignment of the hips, back, and lower limbs. This not only helps alleviate pain but also enhances the functional mobility of the affected areas.

Exercise as a complement to osteopathy

Exercise is a cornerstone of treating gluteal tendinopathy effectively. Initial treatments often focus on gentle, isometric exercises to activate and strengthen the gluteal muscles without exacerbating symptoms. As patients progress, more dynamic exercises involving resistance bands or weights are introduced to further enhance muscle strength and support the lumbopelvic region, ultimately improving movement patterns and preventing future episodes.

What exercises, treatments & behaviours to avoid?

These should be avoided as they will make this condition worse:

butt stretches
back rotations
massage
sleeping on the affected side
sitting cross legged or on low chairs
swinging your hip out to the side
standing with your weight on one leg
letting your leg cross the midline of your body

Comprehensive care and referral options

For cases where further diagnostic clarity is needed, we can facilitate referrals for X-rays and ultrasound scans, or direct you to a musculoskeletal specialist for an MRI and further assessment. Collaborating closely with these specialists ensures that you receive a comprehensive evaluation and treatment plan, helping you achieve optimal recovery from GTPS.

Recent research

The importance of exercise in managing gluteal tendinopathy has been underscored in a recent systematic review and meta-analysis conducted by Cordeiro et al., published in 2024 in Nature Scientific Reports. The study, titled “Effects of exercise-based interventions on gluteal tendinopathy,” found that exercise interventions were not only superior to minimal interventions in improving function and reducing pain but also outperformed corticosteroid injections in the long term. While corticosteroids may provide quick pain relief, the study emphasises that their long-term effectiveness is limited compared to structured exercise programs that include resistance training tailored to individual needs. Research also suggests that corticosteroids injection can also further damage tendons, and reduce bone density leading to fractures from osteoporosis.

Conclusion

Osteopathy is an effective approach to treating gluteal tendinopathy, providing relief and long-term solutions for sufferers. By integrating manual therapies with personalised exercise regimens and lifestyle changes, osteopathy not only addresses the immediate symptoms but also works to rectify biomechanical imbalances that contribute to the condition.

For those suffering from gluteal tendinopathy, or healthcare providers looking to enhance treatment strategies, embracing osteopathy could be the key to improved health and mobility. As research continues to evolve, the integration of new findings will undoubtedly refine these approaches, offering hope and improved outcomes for individuals affected by this challenging condition.