Hip Pain: Bursitis, Tendinopathy and Arthritis

Hip pain is one of the more commonly misdiagnosed problems we see, because pain felt “in the hip” comes from at least three different places. Pain on the outer side, over the bony point you lie on, is usually the gluteal tendons and their bursa. Pain deep in the groin is more likely the hip joint itself. Pain in the buttock is often referred from the lower back. Treating the wrong one of those wastes months.

Pathophysiology: what is actually happening

Gluteal tendinopathy and trochanteric bursitis

The gluteus medius and minimus tendons attach to the greater trochanter, the bony prominence on the outside of the hip. A bursa sits between tendon and bone to reduce friction.

The older model held that the bursa became inflamed and that this was the problem — hence “bursitis”. Imaging and surgical findings changed that picture. In most cases the tendon is the primary problem: repeated compression of the tendon against the bone, particularly in positions of hip adduction, produces a degenerative change in the tendon rather than a classical inflammatory one. Collagen becomes disorganised, the tissue takes on more ground substance and new blood vessels, and the tendon loses its capacity to tolerate load. Bursal inflammation, where present, is usually secondary.

This matters practically. Degenerative tendon does not respond to rest the way inflamed tissue does. It responds to graded, progressive loading — which is why the treatment that works feels counter-intuitive to most patients.

Hip osteoarthritis

Where the pain is in the groin rather than the outer hip, the joint surface itself may be the source. Articular cartilage thins, the underlying bone remodels and stiffens, the joint lining becomes intermittently inflamed, and osteophytes form at the joint margins. Stiffness after sitting and pain that limits rotation — putting on socks, getting out of a car — are typical.

Symptoms and how we tell them apart

• Outer hip, worse lying on that side at night — gluteal tendinopathy is the strong favourite
• Groin pain, stiffness, restricted rotation — points to the joint
• Buttock pain, sometimes radiating down the leg — consider the lumbar spine
• Pain climbing stairs or standing on one leg — a loading problem, usually tendon

Examination tests each of these in turn. Imaging is used to confirm rather than to lead: an X-ray shows joint space and bone changes, ultrasound and MRI show the tendons and bursa.

First-line treatment

For gluteal tendinopathy the priority is removing the positions that compress the tendon — sitting cross-legged, standing with weight hanging on one hip, lying on the painful side — and then loading the gluteal muscles progressively. This is a programme measured in months. Done properly it works for the large majority of people.

For hip osteoarthritis, strengthening, weight management where relevant and activity modification come first, with the same logic we apply to knee osteoarthritis.

Injection options

Injections are not a treatment on their own. Used well, they reduce pain enough that you can do the rehabilitation that actually changes the outcome. Used as a substitute for that work, they buy time and little else. These are the options we discuss.

Corticosteroid

A strong anti-inflammatory placed directly into the painful structure. Onset is fast — usually within days — and for someone who cannot sleep or cannot work, that speed matters.

The limitation is duration. The effect fades over weeks to months, and repeated injections into the same tendon carry a real risk of weakening the tissue. In tendon problems specifically, the evidence is uncomfortable: corticosteroid outperforms doing nothing in the short term but does worse over a year. We use it deliberately and sparingly, and we will tell you if we think it is the wrong choice for your problem.

Platelet-rich plasma (PRP)

A sample of your own blood is spun in a centrifuge to concentrate the platelets, which carry the growth factors involved in tissue repair. The concentrate is injected into the injured tissue.

PRP works in the opposite direction to corticosteroid: onset is slower, often several weeks, but the effect tends to last longer. Preparation matters — leukocyte-poor systems, which remove most white cells, have performed better than leukocyte-rich ones in comparative studies. We use a leukocyte-reduced system.

PRP is a genuinely promising option and we are honest about where the evidence sits: the trials are smaller and less consistent than we would like, and some professional bodies still recommend against it on those grounds. We think it is reasonable for selected patients, and we will say so if we do not think you are one.

How the injection is given

Accuracy matters more than most people expect. Injections placed by landmark alone miss the intended target a meaningful proportion of the time, particularly in deep joints like the hip and in the small spaces around the shoulder and wrist. Ultrasound guidance lets us see the needle reach the structure we are aiming at, which improves both accuracy and safety.

The injection itself takes a few minutes. Most people feel some soreness for a day or two afterwards. We usually ask you to avoid heavy loading of the area for a short period, then start or resume the rehabilitation programme.

Hyaluronic acid

Where the hip joint itself is arthritic rather than the tendon, hyaluronic acid injections are sometimes used to supplement the joint fluid. The evidence base for viscosupplementation is genuinely contested — across large trials the average benefit is small — so we will give you a straight view on whether it is worth trying in your case rather than presenting it as settled. You can read more on our treatments page.

Hip injections in particular are given under ultrasound or image guidance. The joint is deep, and blind injection into it is unreliable.

When to see a doctor

See someone if hip pain is waking you at night, if it is not improving after a few weeks of modified activity, or if it is limiting how far you can walk. Seek prompt assessment for hip pain following a fall, an inability to bear weight, fever alongside joint pain, or pain that is worsening steadily rather than fluctuating.

Part of the other joints we treat. See also ankle and foot pain, shoulder pain.

Written by Dr Gerard Ee. Last medically reviewed and updated: September 2026.