Gluteus medius tendinopathy

Gluteus medius tendinopathy is a painful condition of the tendon of the gluteus medius muscle, most often at its insertion on the greater trochanter. It is often part of a broader clinical picture called greater trochanteric pain syndrome (Greater Trochanteric Pain Syndrome, GTPS), which may involve the gluteus medius tendon, the gluteus minimus tendon, both tendons, the trochanteric bursa and the surrounding tissues.

The term “tendinitis” is now considered less precise: in chronic forms, the condition corresponds more to a change in the structure and mechanical capacity of the tendon than to simple inflammation. The term gluteal tendinopathy is therefore preferred; it is one of the main causes of lateral hip pain.

The gluteus medius is a muscle located on the lateral side of the pelvis. It originates from the outer surface of the ilium and inserts mainly on the lateral surface of the greater trochanter, an area under particularly high stress during single-leg stance. It has several bundles of fibres whose orientation allows different functions, and it works in synergy with the gluteus minimus, the gluteus maximus and the deep hip rotators.

🔍 Click on the image to enlarge it

Function of the gluteus medius

The gluteus medius plays several essential roles. It produces hip abduction, i.e. moving the thigh away from the midline of the body. When a person is standing on one leg, it also ensures stabilisation of the pelvis by preventing it from tilting towards the opposite side.

Finally, it contributes to control of the lower limb: hip adduction, rotation of the femur and dynamic alignment of the knee. This function is particularly important when walking, running, climbing stairs, jumping and changing direction.

The gluteus medius in runners

When running, each foot strike places significant stress on the pelvis and hip. The gluteus medius must in particular stabilise the pelvis, control femoral movement and contribute to force transmission between the trunk and the lower limb; its activity increases with running speed.

However, it is important not to reduce running injuries to a simple “weak gluteus medius”: the available data do not show a universal, consistent deficit in activation of this muscle across the various running-related injuries.

Gluteal tendinopathy is particularly common in middle-aged and older adults, and much more common in women: some publications report that it may affect up to one in four women over the age of 50, making it one of the most common tendinopathies of the lower limb.

However, it is by no means limited to postmenopausal women: it also affects men, athletes, runners, young people and people who do little sport.

The gluteal tendon has to withstand tensile, compressive and shear stresses. Compression can be particularly high when the hip is in adduction, in flexion-adduction or in certain crossed positions — a classic example being sleeping for long periods on the painful side, which places the hip in adduction and compresses the tendon against the greater trochanter.

The problem can be summarised as follows: excessive or poorly tolerated tendon load + repeated compression → reduced capacity of the tendon to withstand stress → pain.

Load-related factors

Increased mileage, increased intensity, returning after a break, significant elevation gain, hill running, an increased number of sessions.

Mechanical factors

Marked hip adduction, prolonged single-leg stance, poor tolerance of certain positions, a sudden increase in lateral load.

Individual factors

The following are found more frequently: middle or older age, female sex, a history of low back pain, knee or hip osteoarthritis, and excess body weight in some populations. However, these epidemiological associations remain complex and should not be interpreted as direct causes.

Patients often say: “My hip hurts on the side”, then “when I sleep on that side, it wakes me up”, or “it hurts when I go up stairs or when I run”. In runners, the typical scenario combines an increase in training volume, lateral hip pain, pain during and then after running, and discomfort on stairs or when lying down.

The pain is usually located on the outer side of the hip, around the greater trochanter. It can sometimes radiate down the lateral side of the thigh to the knee, or be felt further back, in the buttock region. It is described as dull, burning, throbbing, deep or, on the contrary, very localised.

Night pain

Night pain is highly characteristic: the patient may feel pain when sleeping on the painful side, when turning over in bed, or sometimes even when sleeping on the opposite side — because the painful leg can then drop into adduction and compress the tendon against the greater trochanter. A pillow between the knees can sometimes reduce this compression.

Pain when walking and running

Single-leg weight-bearing activities place heavy demands on the hip abductors: symptoms may therefore appear during prolonged walking, running, on stairs, going uphill or downhill, or when changing direction. In runners, pain may appear during the run, after the run, several hours later, or sometimes only the following morning.

Clinical examination

The examination starts by determining the exact location of the pain and looking for night pain, pain when walking, running, standing on one leg or using stairs, as well as a history of lumbar problems or intra-articular hip symptoms. Hip mobility, abductor and rotator strength, and control of the pelvis and lower limb are then examined.

Palpation of the greater trochanter is a very important element: pain that precisely reproduces the usual pain greatly increases the likelihood of gluteal involvement, while the absence of tenderness on palpation makes the diagnosis less likely.

The single-leg stance test (about 30 seconds) looks for the onset of pain, pelvic stability, hip adduction and any trunk compensation; reproduction of pain within the first few seconds is highly suggestive. Resisted hip abduction looks for pain, weakness and asymmetry. The combination of pain on palpation of the greater trochanter + pain on resisted abduction is particularly useful for confirming the diagnosis clinically.

The examination can be completed with functional tests: single-leg squat (pain, pelvic control, hip adduction, knee stability), step-down (frontal-plane control of the lower limb), walking (looking for a limp) and running (pelvis, cadence, step width, foot-contact control, onset of pain).

A drop of the pelvis on the opposite side may reflect abductor insufficiency, but does not automatically mean that “the gluteus medius is weak and simply needs strengthening”: strength, pain, coordination, fatigue and individual strategies interact, which calls for individualised management.

Surgery is rarely needed for simple gluteal tendinopathy. It may be considered in cases of a large partial tear or a complete tear, major functional weakness, prolonged failure of conservative treatment or significant limitation of daily life or sport. Possible techniques include endoscopic repair, open repair, debridement, tendon reattachment or augmentation for some large tears — although the surgical data remain much less robust than those for conservative treatment.

Certain characteristics can complicate recovery: long duration, a large tear, retraction, muscle atrophy, fatty infiltration, marked weakness or late diagnosis — the quality of the muscle and tendon being particularly important when surgical repair is being considered.

Rehabilitation after surgery is generally progressive: protecting the repair and reducing weight-bearing according to the surgeon’s instructions (phase 1), muscle contractions and trunk work (phase 2), strengthening of the abductors, gluteus maximus, quadriceps and posterior chain (phase 3), single-leg work — balance, step-ups, step-downs (phase 4), then reintroduction of impact — jumps, running, accelerations, sport-specific work (phase 5). The timeline depends heavily on the type of injury and the surgical technique.

Improvement may be seen within a few weeks, but chronic forms often require several months to regain full capacity. The return to running should never be guided solely by the disappearance of pain, but by the tissues’ progressive ability to tolerate the stresses of daily life and sport.

Prevention is based mainly on load management. Runners should avoid increasing mileage, speed, elevation gain and session frequency at the same time.

It is also helpful to maintain hip strengthening, general strength, regular single-leg work and sufficient recovery.

Night pain, pain in daily life and pain after sessions should be monitored particularly closely: night pain in particular is an excellent indicator of tendon irritability.