The gluteus medius tendon is one of the most commonly injured tendons in the hip region, yet it receives far less attention than better-known tendons like the Achilles or patellar tendon. Pain on the outer side of the hip, tenderness over the greater trochanter, and discomfort walking up stairs or lying on the affected side are all classic signs of gluteus medius tendon pathology, a condition that affects a significant proportion of active adults and is particularly common in women over 40 and distance runners.
Understanding the anatomy and function of this tendon, the conditions that affect it, and the approaches that produce genuine recovery is the starting point for anyone dealing with outer hip pain that has not responded to simple rest or stretching.
What the Gluteus Medius Tendon Is
The gluteus medius muscle is one of three gluteal muscles (alongside the gluteus maximus and gluteus minimus) that form the muscular bulk of the buttock and outer hip. As covered in the gluteus medius strengthening exercises article on this site, the gluteus medius is the primary hip abductor and the most important stabiliser of the pelvis during single-leg activities.
The gluteus medius tendon is the fibrous connective tissue structure that connects the gluteus medius muscle to its bony attachment point. The tendon attaches to the greater trochanter of the femur, the prominent bony protrusion on the outer upper thigh that can be felt through the skin. The attachment occurs on the superolateral (upper outer) surface and posterosuperior facets of the greater trochanter.
The tendon structure: Like all tendons, the gluteus medius tendon is composed primarily of type I collagen fibres arranged in parallel bundles that provide exceptional tensile strength. A healthy tendon can withstand loads significantly greater than the maximum force the attached muscle can produce. The tendon also contains a small proportion of elastic fibres that allow it to store and return elastic energy during dynamic loading.
The gluteus minimus tendon: The gluteus minimus, the smaller and deeper of the two muscles, also attaches to the greater trochanter via its own tendon, inserting onto the anterior facet. The two tendons are closely related anatomically and are frequently affected together in tendon pathology, which is why the condition is sometimes called gluteal tendinopathy rather than specifically gluteus medius tendinopathy.
The trochanteric bursa: Adjacent to the gluteus medius tendon attachment is the trochanteric bursa, a fluid-filled sac that reduces friction between the tendon and the bone. Historically, outer hip pain was attributed to trochanteric bursitis (inflammation of this bursa). Research over the past two decades has established that the primary pathological change in most cases is actually within the tendon itself rather than the bursa, leading to the reclassification of most cases as gluteal tendinopathy. The bursa may become secondarily inflamed but is rarely the primary pain generator.
How the Gluteus Medius Tendon Functions
The gluteus medius tendon transmits the force generated by the gluteus medius muscle to the greater trochanter, producing the movements and stabilisation functions that the muscle is responsible for.
Force transmission during hip abduction: When the gluteus medius contracts to move the leg away from the midline (hip abduction), the force is transmitted through the tendon to the greater trochanter, which acts as a lever to rotate the femur outward and away from the body.
Pelvic stabilisation during stance: The most important functional role of the gluteus medius tendon is transmitting the pelvic stabilisation force of the gluteus medius during the single-leg stance phase of walking and running. With every step, the gluteus medius contracts isometrically through its tendon to prevent the pelvis from dropping on the unsupported side. This means the tendon is loaded with every stride, over thousands of repetitions during a typical running session or day of walking.
Compressive loading: Beyond the tensile loading of force transmission, the gluteus medius tendon is also subject to compressive loading when it is compressed between the greater trochanter and the overlying structures. This compressive loading occurs particularly in positions of hip adduction (the leg crossing the midline) and hip flexion combined with adduction. These positions are what make certain activities and postures particularly aggravating for gluteus medius tendon pathology.
Common Conditions Affecting the Gluteus Medius Tendon
Gluteal Tendinopathy (Gluteus Medius Tendinopathy)
The most common gluteus medius tendon condition. Gluteal tendinopathy is a painful degeneration of the tendon structure caused by an imbalance between the loads placed on the tendon and its capacity to adapt to those loads.
What happens within the tendon: Research using imaging and histology has established that tendinopathy involves a disruption of the normal parallel collagen structure of the tendon, replaced by disorganised collagen, increased water content, and changes in the cellular composition of the tissue. This structural change is associated with pain and reduced load capacity but is not simply an inflammatory condition: tendinopathy involves failed healing attempts rather than active inflammation, which is why anti-inflammatory treatments (NSAIDs, corticosteroids) provide only temporary relief without addressing the underlying structural problem.
Who is most commonly affected:
- Women over 40 are the most commonly affected demographic, with hormonal changes at menopause thought to affect tendon collagen metabolism and increase vulnerability
- Distance runners, particularly those who increase mileage rapidly
- People who have recently significantly increased their walking or stair climbing
- People with gluteus medius weakness who overload the tendon through compensatory patterns
Symptoms:
- Pain on the outer side of the hip, typically over or around the greater trochanter
- Tenderness on direct palpation of the greater trochanter
- Pain walking upstairs or uphill
- Pain lying on the affected side
- Pain that worsens with sustained walking or running and may improve briefly with rest before returning
- Discomfort rising from a chair after prolonged sitting
The compressive loading problem: A key characteristic of gluteal tendinopathy is that it is highly sensitive to compressive loading of the tendon. The positions that compress the tendon against the greater trochanter consistently aggravate symptoms:
- Crossing the legs (hip adduction)
- Sitting with the knees together and feet apart
- Standing with the weight shifted to one hip (hip drop position)
- Lying on the affected side with the top knee falling forward
- Stretching into hip adduction (pigeon pose, figure four with extreme external rotation)
This compressive sensitivity is important for both diagnosis and management: if activities that compress the tendon consistently reproduce the symptoms, gluteal tendinopathy is the likely diagnosis.
Gluteus Medius Tendon Tears
Tears of the gluteus medius tendon range from small partial tears that occur within the substance of the tendon to complete full-thickness tears that fully separate the tendon from its attachment on the greater trochanter.
Types of tears:
- Partial thickness tears: Involve only a portion of the tendon fibres. More common than complete tears and often occur within the context of existing tendinopathy where the already-compromised tendon sustains additional damage.
- Full-thickness tears: Complete separation of the tendon from the bone. Less common but associated with significant functional impairment, including hip abductor weakness and a positive Trendelenburg sign.
As covered in the symptoms of gluteus medius tear article on this site, the symptoms of a significant tear include sudden or progressive outer hip pain, weakness in hip abduction, a visible Trendelenburg gait pattern (hip drop to the opposite side when walking), and difficulty climbing stairs.
How tears are diagnosed: MRI is the gold standard for identifying and characterising gluteus medius tendon tears. Ultrasound can also identify tears and has the advantage of allowing dynamic assessment during movement.
Differentiating Gluteal Tendinopathy From a Tear
This distinction has significant implications for treatment and prognosis.
Gluteal tendinopathy:
- Gradual onset typically following an increase in activity
- Pain is activity-related and load-dependent
- Hip abductor strength is typically preserved (though the exercise may be painful)
- Responds well to progressive loading rehabilitation
- No or minimal Trendelenburg sign
Gluteus medius tear:
- May have a more acute onset (though partial tears can develop gradually)
- Weakness in hip abduction is a prominent feature alongside pain
- A positive Trendelenburg sign (hip drop on the opposite side during single-leg stance) suggests significant structural disruption
- May not respond to conservative loading as reliably as tendinopathy
- Requires imaging for accurate characterisation
The clinical overlap: There is significant overlap between the presentations of tendinopathy and partial tears, as they frequently coexist. Many people with gluteal tendinopathy have areas of partial tearing within the affected tendon. This is why imaging is important for any outer hip presentation that is not responding to conservative management within 8 to 12 weeks.
Treatment and Rehabilitation
Conservative Management (Most Appropriate First Approach)
Load management: The first priority is reducing the compressive loads on the tendon while maintaining the tensile loads that stimulate tendon healing. This means:
- Avoiding the compressive positions described above (no crossing legs, no hip drop standing posture, sleeping with a pillow between the knees)
- Reducing the walking and running volume that is aggravating the tendon
- Maintaining and progressively increasing tensile loading through targeted strengthening
Isometric loading for pain management: As covered in the isometric hip exercises article on this site, isometric hip abductor exercises produce immediate pain relief in gluteal tendinopathy through cortical inhibition mechanisms. The protocol involves sustained isometric hip abduction at 70 percent of maximum effort for 45-second holds, performed 5 times with 2-minute rest between each, once daily.
Progressive tendon loading: Once pain is managed to a tolerable level, progressive loading of the gluteus medius tendon through hip strengthening exercises drives the structural adaptation of the tendon toward healthier collagen organisation. The loading must be progressive: too much too soon overloads the already-compromised tendon, while too little provides insufficient stimulus for adaptation.
The exercise progression follows:
- Isometric loading (as above)
- Isotonic loading in non-compressive positions (side-lying hip abduction, standing hip abduction with band)
- Functional loading (lateral band walks, step-ups, single-leg exercises in progressively demanding conditions)
- Sport or activity-specific loading (return to running, return to full activity)
Each stage should be maintained for 4 to 8 weeks before progressing to the next. Full tendon rehabilitation typically takes 3 to 6 months.
See the gluteus medius strengthening exercises article on this site for the complete progressive strengthening programme.
Addressing contributing factors:
- Gluteus medius weakness: the most important contributing factor to address through progressive strengthening
- Hip and pelvic control: improving single-leg stability reduces the compensatory loading patterns that overload the tendon
- Running mechanics: if running is a contributing factor, gait analysis may identify the specific mechanics (excessive contralateral pelvic drop, hip adduction in stance) that increase tendon load
Injection Treatments
Corticosteroid injection: Provides short-term pain relief (typically 4 to 12 weeks) by reducing secondary inflammation but does not address the underlying tendon degeneration and may have negative effects on tendon structure with repeated injections. Most appropriate as a short-term pain management tool to allow engagement with rehabilitation rather than as a standalone treatment.
Platelet-rich plasma (PRP): An emerging treatment where the patient’s own blood is processed to concentrate the growth factors and injected into the tendon. The evidence base for PRP in gluteal tendinopathy is growing but not yet conclusive.
Prolotherapy: Serial injections of an irritant solution to stimulate healing. Used by some practitioners but the evidence base is limited.
Surgical Treatment
Surgery is considered for gluteus medius tendon tears that do not respond to conservative management, particularly full-thickness tears causing significant functional impairment. Surgical options include:
Tendon repair: Reattachment of the torn tendon to the greater trochanter using anchors. Outcomes for surgical repair of full-thickness tears are generally favourable, with most patients recovering good function within 6 to 12 months.
Trochanteric bursectomy: Removal of the inflamed bursa, sometimes combined with tendon debridement for cases where secondary bursitis is a significant contributor.
Positions and Activities to Avoid
As noted above, the compressive sensitivity of the gluteus medius tendon means that certain positions and activities consistently worsen tendinopathy symptoms and should be avoided during rehabilitation:
- Crossing the legs when sitting or standing
- Sitting with the knees together and feet apart (the hip adduction position this creates compresses the tendon)
- Standing with the hip dropped to one side (the habitual posture of leaning on one leg)
- Sleeping on the affected side without a pillow between the knees
- Hip adduction stretches including pigeon pose and the figure four stretch performed with extreme external rotation and adduction
- Running on cambered roads where the downhill leg is forced into adduction
- Sitting on low chairs or soft sofas that create deep hip flexion with adduction
These restrictions are not permanent: as the tendon rehabilitates and its load capacity increases, these positions and activities can be gradually reintroduced.
When to Seek Medical Assessment
Seek assessment from a doctor, sports physician, or physiotherapist if:
- Outer hip pain has not improved after 6 to 8 weeks of activity modification and targeted exercise
- Significant hip abductor weakness is present
- A Trendelenburg gait pattern (visible hip drop when walking) is present
- Pain is severe and limiting daily function
- There was a specific injury or fall that preceded the onset of symptoms
- Imaging has not been performed to characterise the extent of tendon pathology
Frequently Asked Questions
Is gluteus medius tendinopathy the same as trochanteric bursitis?
They produce similar symptoms and were historically considered the same condition under the name trochanteric bursitis. Research over the past two decades has established that the primary pathology in most cases is within the gluteus medius tendon itself rather than the trochanteric bursa. The condition is now more accurately called gluteal tendinopathy or greater trochanteric pain syndrome. The trochanteric bursa may become secondarily inflamed but is rarely the primary pain generator.
Can gluteal tendinopathy heal without treatment?
Mild gluteal tendinopathy may resolve spontaneously with rest, but moderate to severe tendinopathy rarely heals without targeted progressive loading rehabilitation. The structural changes within the tendon that produce the pain require a specific mechanical stimulus (progressive loading) to drive the collagen remodelling needed for recovery. Rest alone provides symptomatic relief but does not address the underlying structural problem.
Is stretching the hip helpful for gluteus medius tendinopathy?
Stretching the hip into adduction (positions that bring the leg across the body) should be avoided during gluteal tendinopathy because these positions compress the tendon. Hip flexor stretching in non-compressive positions (kneeling hip flexor stretch, standing hip flexor stretch) is generally safe and can help address contributing hip imbalances.
How do I know if I have a tear or tendinopathy?
The symptoms overlap significantly and clinical examination alone cannot reliably distinguish between the two. MRI or high-quality ultrasound examination is needed to characterise the extent and nature of the tendon pathology. If conservative management is not producing adequate improvement within 8 to 12 weeks, imaging is warranted to determine whether a tear is present and guide further management.
Can I continue running with gluteal tendinopathy?
Modified running is often possible during rehabilitation, but full training volumes typically need to be reduced. Running on flat, even surfaces at reduced speed and distance, with attention to avoiding the compressive positions described above, is generally preferable to complete rest for maintaining fitness during rehabilitation. A physiotherapist with expertise in running injuries can provide specific guidance on run modification for individual presentations.