One of the most common ailments that I see in my office is people complaining of pain on the outside of the hip. In the medical world when someone complains of pain in this location they are usually given the diagnosis of Trochanteric Bursitis. For years I would give the same diagnosis but since I started to use an ultrasound machine several years ago to help both diagnose and treat musculoskeletal conditions I have come to appreciate a more likely cause of lateral hip pain, and it’s not from a bursitis. Let’s look at the anatomy of this area to better understand what could be causing the pain.
The gluteal muscles make up the buttocks. There are three muscles, the gluteus maximus, medius and minimus. The maximus is the largest of the three and its tendon attaches just below the large bone on the side of the hip known as the greater trochanter. The next muscle is the gluteus medius and it attaches to the greater trochanter on the most outside part of the bone in an area called the lateral facet. Finally, the deepest and smallest of the three gluteal muscles is the gluteus minimus. The tendon from this muscle inserts just in front of the one from the medius on the anterior facet. The second diagram above shows these attachment points. The main action of these two muscles is to abduct the hip or to raise it to the side. The trochanteric bursa sits in what is called the posterior facet which can also be seen in the diagram above.
As we age the tendons that see the most use during our lifetime wear out the fastest. Two areas where this is the most common is the shoulder and the side of the hip. In the shoulder the rotator cuff tendons get a lot of wear from the millions upon millions of times that we use our arms and thus over time can weaken and tear. Before tearing the tendon goes through an aging process in which it swells and starts to loose some of its tensile strength. In other words, it is not as strong or as springy as it once was. This aging is called tendinosis. Doctors used to say that someone that had pain over a tendon was suffering from a tendinitis; the “itis” meaning inflammation. As our understanding of how a tendon ages has grown we have come to learn that it is much more of an aging or tendinosis issue than inflammation. For a Physical Medicine physician that specializes in musculoskeletal conditions I have learned over the past twenty years of practice that some of these tears can be quite painful while others are not.
Therefore, a careful assessment of each person is necessary to rule other potential causes of pain on the outside of the hip such as a pinched nerve or radiculopathy that emanates from the lower back. Patients that have tendon issues on the outside of the hip usually report discomfort that radiates down the outside of the thigh and into the buttock. The pain can be worse with sitting, walking and lying on the affected side. The greater trochanter is always very tender to the touch and there is pain when the person contract the gluteus medius or raises the hip to the outside against resistance. The MRI of the hip usually reveals the aging or tendinosis of the gluteus medius and/or gluteus minimus tendons. When the condition is severe there can be a complete tear of the tendon away from the bone. Weight bearing can be very painful for such an individual.
Stay tuned for the next blog that will review the different treatments that are available for pain on the outside of the hip.