Hip Bursitis: What the Evidence Shows About Lateral Hip Pain, Diagnosis and Treatment

Key Takeaways

“Hip bursitis” usually refers to pain over the greater trochanter on the outside of the hip, a presentation also called greater trochanteric pain syndrome (GTPS).
In an ultrasound series of 877 patients with greater trochanteric pain, 79.8% had no bursitis, while 49.9% had gluteal tendinosis.
The condition is common in people aged 50–79, especially women, and in primary care at least 36% of patients still had symptoms after one year.
Corticosteroid injections have shown short-term benefit over usual care in some trials, but a placebo-controlled trial found no significant advantage over saline, and long-term results are mixed.
In a randomised trial of 204 people with MRI-confirmed gluteal tendinopathy, a physiotherapist-led education and exercise programme produced higher rates of global improvement at 8 weeks than an injection or waiting.
Surgical options have been described for refractory cases, mainly in small case series.
In my clinical experience, a typical patient does standing work and often hopes for a cortisone injection, and many stop active physiotherapy once short-term relief sets in, even though the symptoms often recur.

Introduction: Why the Bursitis Label Is Often Misleading

Trochanteric pain is the second most important diagnosis among hip problems presenting in primary care [1], and it has long been labelled hip bursitis. The pain was previously thought to be caused by inflammation of the bursa over the greater trochanter [2].

Imaging studies have challenged that assumption. In a review of ultrasound examinations of 877 patients with greater trochanteric pain, 700 patients (79.8%) did not have bursitis, while 438 (49.9%) had gluteal tendinosis [3]. The authors concluded that the pain usually reflects some combination of gluteus medius and minimus tendon pathology and iliotibial band changes, with bursitis present in only a minority of patients [3].

This matters because, as the authors of that study note, treatment varies depending on the cause of the pain [3].

This article covers what hip bursitis is, how common it is, what is actually happening in the tissues, how it is diagnosed, and what randomised trials show about treatment.

In clinical practice, we usually still speak of trochanteric “bursitis” in quotation marks, since research suggests that the problem is often a tendinopathy rather than true bursitis. Patients themselves generally describe it simply as hip pain, and in my experience they can usually point to the painful spot quite clearly over the greater trochanter.

What Is Hip Bursitis?

A bursa is a small, fluid-filled sac that reduces friction between tendons, muscles and bone. Several bursae sit around the hip, and “hip bursitis” can refer to any of them, but in everyday use it most often means trochanteric bursitis: pain over the bony prominence on the outside of the upper thigh (the greater trochanter).

Because the bursa is only one of several structures in this area, the umbrella term greater trochanteric pain syndrome (GTPS) is often used instead. In a large community study, GTPS was defined as greater trochanteric tenderness to palpation in people with hip pain, and the authors noted that, unlike the term trochanteric bursitis, this definition does not presuppose inflammation [4].

Less commonly, hip bursitis refers to the iliopsoas bursa at the front of the hip, near the groin. In an imaging study of 18 patients with surgically proven iliopsoas bursitis, MRI showed a communication between the bursa and the hip joint in all 18 cases, a link confirmed at surgery [5]. The authors described ultrasound as the most cost-effective, easy-to-perform and fast option for initially confirming iliopsoas bursitis, and MRI as the most accurate way to assess it for therapy planning [5]. The rest of this article focuses on lateral (trochanteric) hip pain.

How Common Is Trochanteric Pain?

In the Multicenter Osteoarthritis (MOST) Study, which included 3,026 community-dwelling adults aged 50 to 79 years, the prevalence of unilateral and bilateral GTPS was 15.0% and 8.5% in women and 6.6% and 1.9% in men [4]. Women had more than three times the odds of GTPS compared with men [4]. It is worth noting that MOST recruited people who had, or were at high risk of, knee osteoarthritis, so these figures may not apply directly to younger or more active populations.

In Dutch primary care, the incidence of trochanteric pain was 1.8 patients per 1,000 per year [1]. The condition was frequently persistent: among patients who answered the follow-up questionnaire, 76% still had trochanteric pain at one year and 63% at five years. Even under the most optimistic assumption, that all non-responders had recovered, at least 36% and 29% still had pain at these time points [1].

The burden is substantial. In a case-control study comparing 42 people with GTPS, 20 with severe hip osteoarthritis and 23 asymptomatic controls, people with GTPS were the least likely to be in full-time work (probability 0.29 vs 0.52 for hip osteoarthritis and 0.68 for controls), and GTPS appeared to carry levels of disability and quality of life similar to severe hip osteoarthritis [6].

In my clinical experience, trochanteric “bursitis” is a fairly common reason for a visit, particularly among women, although I also see men with it from time to time. Many of the patients I see do standing work that places sustained load on the trochanteric region, and a fairly typical patient might be a flight attendant or a nurse past middle age. The symptoms are often recurrent, and many patients have become used to receiving an injection into the bursa or trochanteric region. Some have had a little physiotherapy, but more often the treatment they have received so far has been anti-inflammatory medication and injections.

Is Hip Bursitis Really Bursitis?

Three lines of evidence suggest that primary bursitis is uncommon.

Imaging. Beyond the 877-patient ultrasound series above, where only 177 patients (20.2%) had trochanteric bursitis [3], an MRI study of 24 patients with clinical GTPS found a gluteus medius tear in 11 (45.8%) and gluteus medius tendinitis in 15 (62.5%), whereas only 2 patients had trochanteric bursal distension [7]. In that series, trochanteric bursal distension was uncommon and did not occur in the absence of gluteus medius pathology [7].

Histology. In a small study examining bursal tissue removed during hip surgery, six specimens consisted mainly of fibroadipose tissue with no signs of acute or chronic inflammation, and there were no significant differences between patients who met clinical criteria for trochanteric bursitis and controls [2].

Tendon research. A review in Sports Medicine states that tendinopathy of the gluteus medius and minimus tendons is now recognised as a primary local source of lateral hip pain, and that the condition mostly occurs in mid-life, in athletes and in people who do not exercise regularly [8].

That does not mean the bursa is irrelevant. A histological study comparing tissue from people with GTPS and controls found that tendon specimens from the GTPS group showed more pathology (Bonar score 12.65 vs 10.43, p = 0.04), bursal stroma scores tended to be higher without reaching statistical significance (4.18 vs 2.53, p = 0.051), and the authors suggested that increased substance P in the trochanteric bursa may be related to the pain of GTPS [9]. Taken together, these findings suggest that the bursa can be involved, often alongside tendon changes, rather than usually being an isolated inflammatory condition.

Hip Bursitis Symptoms and Risk Factors

GTPS is characterised by chronic pain and tenderness around the greater trochanter, often aggravated by standing, walking or lying on the affected side [10]. In a primary care trial, the pain was described as chronic intermittent or continuous pain at and around the greater trochanter, sometimes radiating to the lateral hip or thigh and increasing with physical activity, with palpation of the greater trochanter reproducing the patient’s pain [11].

In the MOST Study, several factors were independently associated with GTPS after adjustment for age, sex and other variables [4]:

Knee osteoarthritis on the same side (OR 3.47) and on the opposite side (OR 1.74)
Low back pain (OR 2.79)
Iliotibial band tenderness (OR 1.72)

Body mass index was not associated with GTPS in this fully adjusted model (OR 1.10 comparing BMI ≥30 with <25 kg/m²) [4]. From a mechanical perspective, the Sports Medicine review identified joint position, particularly excessive hip adduction, together with muscle and bone factors as key elements in gluteal tendinopathy [8]. Hip adduction means the thigh moving toward or across the midline, as when crossing the legs or standing with the weight shifted onto one hip.

In my experience, the pain is typically provoked by standing and walking, when load and pressure are placed on the trochanteric region. Patients may describe severe pain after a working day that eases somewhat in the evening, although in more advanced cases it may not settle even at rest. A particularly common complaint in my practice is difficulty sleeping: lying on the painful side compresses the hip, while lying on the other side can also be uncomfortable, because the upper leg drops down and puts tension on the lateral hip. Many patients use a pillow, a folded blanket or a purpose-made cushion between the knees, which in my experience may ease the pain for some of them and make sleep possible.

In my experience, the painful spot over the trochanter often differs from pain at the origins of the gluteal muscles, which is felt somewhat higher and more toward the back. Even so, patients with trochanteric “bursitis” often also have pain, or at least tightness, in the gluteal region, so the symptoms can form something of a continuum. The tensor fasciae latae and iliotibial band region may also be very tight, and I sometimes see patients who have iliotibial band syndrome at the same time.

Diagnosis: Telling Lateral Hip Pain Apart

In research, GTPS has typically been defined clinically, by lateral hip pain with tenderness over the greater trochanter [4][11], and some bedside tests perform better than others. In a study of 65 people with lateral hip pain, using MRI-detected gluteal tendinopathy as the reference standard, pain reported within 30 seconds of standing on the affected leg moved a nominal 50% pre-test probability of tendinopathy to a post-test probability of 98% (specificity 100%) [12]. Conversely, absence of pain on palpation of the greater trochanter (80% sensitivity) made MRI-detected tendinopathy unlikely [12]. The authors cautioned that the sample was small, so these estimates may not apply directly to other clinical populations, and 20 participants (31%) had tendinopathy on MRI despite being clinically negative [12].

The associations with low back pain and knee osteoarthritis in the MOST Study [4] mean that many patients may have more than one potential pain source at the same time.

Imaging is sometimes used when the picture is unclear. In the MRI series described above, the two cases of bursal distension both occurred together with gluteus medius pathology [7], and in the larger ultrasound series most patients had no bursitis at all [3].

From a clinical perspective, differential diagnosis matters, and hip osteoarthritis and radicular pain are among the important conditions to consider. In my experience this is often fairly straightforward, because trochanteric “bursitis” typically presents as clear pain on the lateral side of the hip that is tender to pressure, although overlapping conditions are common. Hip osteoarthritis, in my practice, tends to cause pain more in the groin, and pain on hip rotation is felt deeper. Some patients do have hip osteoarthritis as well, yet their lateral hip pain remains distinct.

Radicular pain, in my experience, is often not as painful on direct palpation of the trochanter, and it tends to be a more diffuse buttock pain that radiates down the leg. Radicular pain may be accompanied by distal weakness or sensory loss, and the Lasègue (straight leg raise) test may be positive, reproducing radiating leg pain or tingling, while sensory loss or weakness is assessed separately in the neurological examination. Sometimes the test produces mainly a feeling of a very tight hamstring, which does not by itself establish or exclude radicular pain, although a tight hamstring can also have other causes. In my view, radicular symptoms can often be distinguished clinically, with imaging or further assessment considered when the picture is unclear. Other hip joint or bone conditions also need to be considered, particularly when the presentation is atypical; from what I have seen, they tend to cause symptoms more in the hip joint and groin area.

Hip Bursitis Treatment: What the Trials Show

Corticosteroid Injections

Corticosteroid injections have been used to treat GTPS for many years [13], and the trial evidence is mixed.

In a pragmatic, open-label trial in Dutch general practice, 120 patients were randomised to a local corticosteroid injection or usual care consisting of analgesics as needed; patients in both groups were allowed additional physiotherapy, and a second injection was permitted in the injection group [11]. At 3 months, 55% of the injection group had recovered compared with 34% of the usual care group (adjusted OR 2.38; number needed to treat 5). At 12 months the difference had disappeared: 61% vs 60% [11].

A double-blind trial comparing an injection of local anaesthetic plus glucocorticoid with an injection of saline in 46 patients found no significant difference in pain reduction at 1 month (p = 0.23), only a non-significant trend in favour of the steroid over the first 4 weeks (p = 0.08), and no differences at 3 and 6 months [14]. The authors concluded that local glucocorticoid injections were no more effective than saline [14].

Image guidance did not clearly improve results in one trial. In a multicentre randomised trial of 65 patients, fluoroscopically guided and “blind” landmark-guided injections produced no differences in outcomes; at 3 months, 47% of the blind group and 41% of the fluoroscopy group still had a positive outcome, and overall success did not differ between injections that reached the bursa and those that did not [15].

A 2022 meta-analysis of 8 randomised trials (764 patients) concluded that injection may be superior to usual care, a wait-and-see approach and shockwave therapy for short-term pain, but may not be superior to exercise, platelet-rich plasma (PRP), dry needling or a sham injection, and that the overall evidence remains equivocal [13]. In its pooled short-term analysis that included the sham-controlled trial, the difference was not statistically significant; a significant short-term benefit over usual care and wait-and-see appeared only after that trial was removed in a sensitivity analysis [13].

In my clinical experience, many patients come specifically to ask for a cortisone injection, and I do give injections, as many patients hope for one. Many of them seem to benefit, at least in the short term. Short-term relief often appears to be enough for patients, in the sense that they are satisfied once the acute pain eases, and the next pain episode is often far enough away that they can return for another injection. How much of this short-term benefit is specific to the corticosteroid is less clear, given the placebo-controlled trial described above [14]. I often tell patients that an injection alone may not resolve the problem and that physiotherapy may be worth considering as well. Many patients in my practice also report at least short-term relief from NSAIDs, and etoricoxib is an option I fairly often prescribe.

In the Dutch primary care cohort, 52% of patients treated with medication such as paracetamol or NSAIDs reported a temporary improvement; in the study’s one-year prognosis analysis, use of analgesics showed no significant relationship with prognosis [1].

Education and Exercise

The LEAP trial randomised 204 people aged 35–70 with lateral hip pain for more than 3 months and MRI-confirmed gluteal tendinopathy to a physiotherapist-led programme of education plus exercise (14 sessions over 8 weeks), a single corticosteroid injection, or a wait-and-see approach [16]. At 8 weeks, success on the global rating of change was reported by 51 of 66 in the education plus exercise group, 38 of 65 in the injection group and 20 of 68 in the wait-and-see group [16]. At 52 weeks, education plus exercise still produced better global improvement than the injection, although pain intensity no longer differed between those two groups [16].

The approach combined education to reduce load on the tendon during sustained postures and daily function (load management) with exercise [16]. Because LEAP required MRI-confirmed tendinopathy, its findings apply most directly to the tendon-related form of hip bursitis, which the imaging data above show to be common.

Because research suggests the problem is often a tendinopathy rather than true bursitis, in my view this is all the more reason to focus treatment on physiotherapy. Pointing to the long-term, recurrent nature of the symptoms, I usually try to encourage patients toward active physiotherapy and often write the referral myself. For patients whose symptoms are aggravated by prolonged static standing, I consider load management and active physiotherapy a sensible part of the overall approach. In my practice, I generally encourage patients to stay active and continue their sport, adjusting activities that clearly aggravate the pain, and in my clinical experience active, physiotherapy-led rehabilitation is a central part of treatment.

Adherence is a recurring challenge in my practice. In my experience, once the pain eases, many patients stop doing active physiotherapy because the perceived need disappears, and short-term treatments may carry them far enough that they do not see a need for it. When the symptoms recur frequently, however, patients often recognise the need, because, in their experience, the pain tends to return.

Shockwave Therapy

In a trial of 229 patients with refractory unilateral GTPS, patients were assigned sequentially to home training, a single corticosteroid injection or radial shockwave therapy [17]. At 1 month, the injection group did best (success rate 75% vs 7% for home training and 13% for shockwave). At 4 months, shockwave led (68% vs 41% for home training and 51% for injection). At 15 months, shockwave (74%) and home training (80%) were both significantly more successful than injection (48%) [17]. Because allocation was sequential rather than truly random and outcomes were not blinded, these results may carry a higher risk of bias than those of the trials above.

Comparing the Options

A 2022 network meta-analysis of 13 randomised trials (1,034 patients) compared non-operative treatments for GTPS [18]. For pain at 1–3 months, PRP and shockwave therapy were both significantly better than no treatment, but no therapy significantly outperformed no treatment for pain at 6–12 months. Structured exercise was the only treatment that significantly improved function compared with no treatment at 1–3 months [18].

A larger 2025 network meta-analysis included 19 randomised trials (1,701 participants), although each outcome analysis used a smaller subset, and it grouped treatments into broad categories. Exercise therapy ranked highest for pain measured with the NRS (6 trials, 796 patients) and for function measured with the VISA-G (3 trials, 418 patients), while injection therapy, a category that combined corticosteroid, platelet-rich plasma and other injections, ranked highest for function measured with the Harris Hip Score (4 trials, 370 patients) [10]. The authors concluded that exercise therapy was superior overall, while noting that the limited number of trials made comparisons between treatments challenging [10].

Surgery

In the literature, surgery is described for refractory cases. A systematic review of 24 articles on the treatment of trochanteric bursitis identified several surgical options for refractory cases, including bursectomy, iliotibial band release or lengthening, osteotomy and repair of gluteus medius tears, and concluded that most patients improved with non-operative treatment and surgery was effective in refractory cases [19]. The review noted that surgical options for severe refractory cases have been described mainly in small case series, so the true benefit compared with continued conservative care remains uncertain [19].

What This Means in Practice

Taken together, the evidence describes hip bursitis as a condition that is common, often persistent and frequently associated with gluteal tendon changes rather than with isolated bursal inflammation.

The label matters less than the mechanism. In imaging studies of trochanteric pain, bursitis was the minority finding, while gluteal tendon changes were common [3][7].
In these trials, injection benefits were mainly short-term. Trials show the clearest injection effects within the first weeks to months, with the advantage over usual care disappearing at 12 months in one trial [11], and with injection less successful than home training or shockwave at 15 months in another [17]. One small placebo-controlled trial found no significant advantage over saline [14].
Exercise-based care has shown benefits for global improvement and some measures of function. The LEAP trial and the network meta-analysis both point in this direction [16][18].
Recovery from hip bursitis is often slow. Persistent symptoms at one and five years are common in primary care [1], which may be worth knowing when setting expectations.
Co-existing problems need consideration. Low back pain and knee osteoarthritis are associated with GTPS [4], so assessment often has to consider more than one source of pain.

Conclusion: Hip Bursitis Is Often a Tendon Problem

Hip bursitis is a common label for lateral hip pain, but the name is often inaccurate. In 877 patients examined with ultrasound, 79.8% had no bursitis while 49.9% had gluteal tendinosis [3], and a small histological study found no signs of bursal inflammation [2].

Among adults aged 50–79, unilateral GTPS was found in 15.0% of women and bilateral GTPS in 8.5% [4], and in one case-control study it was associated with disability and quality of life similar to severe hip osteoarthritis, with lower full-time work participation [6]. Corticosteroid injections can provide short-term relief for some patients, but their results beyond the short term are inconsistent, while in the LEAP trial education plus exercise produced higher rates of global improvement than an injection or a wait-and-see approach at 8 weeks [16].

This matches what I see in practice: most often, it is a patient in standing work whose symptoms keep returning and who has come to rely on repeated injections. For that reason, I try to encourage active physiotherapy, especially when the symptoms recur.

In my view, understanding hip bursitis as often a load-related tendon condition, rather than a simple inflammation of a fluid sac, may help patients and clinicians set realistic expectations.