Greater Trochanteric Pain Syndrome (GTPS): Gluteal Tendinopathy, Hip Bursitis & Evidence-Based Treatment

Pain on the outside of the hip is extremely common, and it's still frequently called trochanteric bursitis. But we now understand that persistent lateral hip pain is usually more complicated than inflammation of a bursa alone. In most people the main problem involves the gluteus medius and/or minimus tendons, sometimes with bursal irritation as well, which is why the broader term Greater Trochanteric Pain Syndrome (GTPS) is more accurate. It covers gluteal tendinopathy, bursitis and, in more advanced cases, partial or full tendon tears (Bremer et al., 2025). This matters, because treating a painful degenerative tendon is not the same as treating an inflamed bursa.

What is GTPS?

The greater trochanter is the bony prominence you can feel on the outside of your hip. Several structures attach or pass around it, the gluteus medius and minimus tendons, several trochanteric bursae, and the iliotibial band. GTPS is an umbrella term rather than a single disease, and can involve:

• Gluteus medius or minimus tendinopathy
• Trochanteric or subgluteal bursitis
• Partial gluteal tendon tears
• Full-thickness tears
• Or a combination of these

Contemporary evidence increasingly points to gluteal tendon pathology as the major component of persistent GTPS, with the bursae often becoming involved secondarily, which is exactly why calling all lateral hip pain "bursitis" can be misleading (Bremer et al., 2025).

What does it feel like?

• Pain directly over the outside of the hip
• Difficulty (and pain) lying on the painful side, and night pain
• Pain walking longer distances, or climbing stairs and hills
• Pain standing on one leg, or crossing your legs
• Pain during or after running or lower-limb exercise

Symptoms may spread down the outside of the thigh, but don't usually behave like classic nerve pain. Gluteal tendinopathy is particularly associated with pain when the tendons are both loaded and compressed around the greater trochanter (Bremer et al., 2025). That said, not every outer-hip pain is gluteal, hip osteoarthritis, the lumbar spine and other referred sources can produce similar symptoms, which is why assessment matters.

How I diagnose it, and what ultrasound adds

Diagnosis starts with a careful history and examination. Several clinical tests load or provoke the gluteal tendons, and a 2024 systematic review found that combinations of tests are more useful than any single one (Kinsella et al., 2024). Imaging isn't essential for everyone, but I find it particularly valuable when symptoms persist despite treatment, the diagnosis is uncertain, there's significant weakness, a tear is suspected, or an injection is being considered.

Ultrasound lets me assess the gluteal tendons and surrounding tissues dynamically, looking for tendinopathy, tendon thickening or structural change, partial or full-thickness tears, calcification, and bursal distension. A scan finding always has to be interpreted alongside your symptoms and examination: the aim isn't just to find an abnormality, but to work out whether it actually explains your pain. Where a substantial tear is suspected or surgery is being considered, MRI can add further detail.

The best treatment: exercise & education first

The strongest, most consistent evidence supports education, load management and progressive exercise as the foundation of treatment. A major 2025 systematic review concluded that a combination of graded exercise and education currently has the best evidence for gluteal tendinopathy (Bremer et al., 2025), and a 2024 review of six randomised trials (733 participants) strongly recommended exercise as first-line management (Kjeldsen et al., 2024).

The landmark study here is the LEAP trial (Mellor et al., BMJ 2018), which compared education-plus-exercise, a corticosteroid injection, and wait-and-see. At 8 weeks, 77% of the education-and-exercise group reported meaningful improvement, versus 59% after corticosteroid and 29% with wait-and-see. At 52 weeks it was about 79% vs 58% in favour of education and exercise. The message: the goal isn't just to suppress pain temporarily, it's to progressively rebuild the gluteal tendons' capacity to tolerate load.

Evidence: strong, first-line treatment

What rehabilitation involves

There's no single "GTPS exercise". A programme typically builds progressive strength through the gluteus medius, minimus and maximus, the hip external rotators and the wider lower-limb chain, with loading adjusted to how irritable and capable the tendon is. Early on it also helps to temporarily reduce positions that compress the tendons around the trochanter, sleeping directly on the painful hip, prolonged crossed-leg sitting, "hanging" on one hip when standing, and sudden jumps in walking, hills or running. The aim isn't complete rest; it's finding a tolerable amount of activity and progressively rebuilding capacity.

Corticosteroid injections

Do they work? Yes, but their role needs to be understood correctly. A corticosteroid injection can reduce pain relatively quickly, which is genuinely valuable for someone in severe pain or unable to get going with rehab. But the benefit is mainly short-term, and it isn't superior to a good exercise programme in the longer run. A 2022 review of eight RCTs (764 participants) found steroid could beat usual care or wait-and-see, but the advantage faded when it was compared with exercise, placebo, PRP, dry needling or shockwave, so the overall evidence was equivocal (Wang et al., 2022). The 2025 review found only moderate evidence for a small short-term pain reduction (Bremer et al., 2025), which fits the LEAP trial exactly: steroid helps, but education and exercise did better.

Does it heal the tendon? No, a steroid injection controls pain and inflammation; it doesn't regenerate a degenerative tendon. So I treat it as an adjunct to rehabilitation, not a standalone fix. I'd consider one particularly when pain is severe, night pain is wrecking your sleep, symptoms are blocking meaningful rehab, conservative care hasn't controlled things, or assessment suggests a significant bursal component. What I'm cautious about is repeatedly injecting steroid around a structurally abnormal tendon. The sensible sequence is reduce pain → restore loading → progressively strengthen, not inject, wait for the pain to return, inject again.

Why ultrasound first? The real value isn't just putting a needle in the sore spot, it's assessing the structures beforehand. Two people with identical-seeming outer-hip pain might have very different findings: one mainly bursal inflammation, another insertional tendinopathy, another calcific tendinopathy, another a significant tear. They shouldn't all be treated the same way. If an injection is appropriate, ultrasound also lets me target the right structure and watch the needle throughout, though I wouldn't claim guidance guarantees better long-term outcomes for everyone. The value is combining accurate diagnosis with precise treatment selection.

Evidence: moderate, short-term pain relief, adjunct to rehab

Shockwave therapy (ESWT)

Extracorporeal shockwave therapy is a reasonable option for persistent gluteal tendinopathy, particularly when appropriate rehab hasn't given enough improvement. A 2024 review found short-term pain improvements, with focused shockwave looking more favourable than radial, but seven of eight trials were at high risk of bias, so certainty is limited (Rhim et al., 2024). The 2025 review was a little more supportive, suggesting focused shockwave may add longer-term pain benefit compared with steroid, while still calling for better trials (Bremer et al., 2025). My take: a reasonable second-line option that should complement, not replace, progressive rehabilitation.

Evidence: reasonable second-line, complements rehab

PRP and hyaluronic acid

This is where the evidence has genuinely shifted. An early well-known RCT (Fitzpatrick et al., 2018) found a single leukocyte-rich PRP injection outperformed corticosteroid at 12 weeks, with follow-up suggesting benefit up to two years (Fitzpatrick et al., 2019), which generated a lot of enthusiasm. But in 2025, a double-blinded, placebo-controlled Level-I trial (Atchia et al., JBJS) randomised 79 patients with chronic, conservative-resistant GTPS to leukocyte-rich PRP or saline placebo, both followed by standardised physio, and found no significant difference between PRP and placebo. That's the more fundamental question: comparing PRP with placebo tests whether PRP itself adds a real effect. Here it didn't. So on current evidence I would not recommend routine PRP for GTPS; it could be discussed in selected refractory cases, but only with a clear understanding of this uncertainty.

PRP: conflicting, no advantage over placebo in the newest high-quality trial

For hyaluronic acid, unlike osteoarthritis, there's currently insufficient high-quality evidence to recommend it routinely for gluteal tendinopathy (Wang SQ et al., 2025), so I don't consider it a standard treatment here.

Hyaluronic acid: insufficient evidence for GTPS

Gluteal tendon tears & surgery

Gluteal tendon disease sits on a spectrum: tendinopathy → partial tearing → full-thickness tear. Not every tear needs surgery, but significant tears become important when they come with persistent lateral hip pain, substantial abductor weakness, difficulty walking, a Trendelenburg gait (a dropping/lurching gait from weak abductors), progressive loss of function, or failure of appropriate rehabilitation. A 2026 systematic review of 38 studies (1,584 patients) found surgery improved pain, function and quality of life, but there were no randomised trials and the certainty of evidence was rated very low (Spencer et al., 2026). So repair can do well in the right patient, but we shouldn't overstate the evidence. I'd consider referral to a specialist hip surgeon for a significant partial or full-thickness tear, persistent pain despite prolonged rehab, marked weakness, a Trendelenburg gait or progressive deterioration, usually with an MRI to plan. Surgery is generally reserved for structurally significant, persistently symptomatic tendon disease rather than uncomplicated GTPS.

My stepwise approach

1. Establish the diagnosis, is this gluteal tendinopathy, bursitis, a tendon tear, calcific disease, the hip joint, or referred pain? Ultrasound helps tell these apart.
2. First-line: education + load modification + progressive exercise, the strongest evidence, and the foundation of treatment (Kjeldsen et al., 2024; Bremer et al., 2025).
3. If pain is blocking rehab, an ultrasound-guided corticosteroid injection can reduce symptoms so you can get moving, viewed as short-term relief rather than tendon healing.
4. Persistent tendinopathy, reassess the diagnosis, loading, strength and progression; consider whether imaging is needed. Focused shockwave is a reasonable second-line option.
5. PRP, conflicting evidence, no advantage over placebo in the newest high-quality trial, so not a routine treatment.
6. Suspected significant tear, MRI and a specialist surgical opinion where substantial weakness or loss of function accompanies the tear.

Frequently asked questions

References