Have you been struggling with pain over the side of your hip? You may have gluteal tendinopathy and/or hip bursitis (in this case trochanteric bursitis), both referred to sometimes as Greater Trochanteric Pain Syndrome (GTPS). If you know you have this condition, but the exercises you’ve been doing don’t seem to help, or even make it worse, you may need to change or modify your exercise program. As experienced hip physiotherapists (physical therapists), we see many patients who have made the common mistakes we’ll be talking about in this blog. One of the first things we teach people, is which exercises to avoid or modify for gluteal tendinopathy and hip bursitis (GTPS) and direct them towards an evidence-based exercise program for GTPS.
Recovering from Gluteal Tendinopathy, Trochanteric Bursitis or GTPS
FIRST LESSON IS FREE!
In this blog on the exercises to avoid or modify for Gluteal Tendinopathy and Hip Bursitis, we'll be covering the following main topics:
Do you have hip bursitis or gluteal tendinopathy? Not sure where to start on your road to recovery? Or what your next steps should be?
This FREE resource provides a suggested treatment pathway, based on the available scientific evidence and Dr Alison Grimaldi's 30+ years of clinical practice as a physiotherapist and 20+ years as a researcher and educator in this field.
Gluteal tendinopathy and trochanteric bursitis, often known as hip bursitis, are related to a reduction in health of the soft tissues at the bony prominence at the side of your hip – the greater trochanter. Pain may develop in the tendons that join the deep gluteal muscles onto this bone – the gluteus medius and minimus tendons, or in the adjacent bursae. Bursae are small, flat pockets of fluid that are sandwiched between our tendons, bones and other structures, to reduce friction and help them slide and glide against one another.
This condition affects almost 1 in every 4 women (23.5%) and 8.5% of men in the age range of 50-79 years.1 It’s much more common in post-menopausal women, but in our physiotherapy clinics, we also see men and younger females with trochanteric bursitis and gluteal tendinopathy. You can read more about the causes of gluteal tendinopathy and trochanteric bursitis (GTPS) in another of our info-filled blogs. Just click the pink text in the last sentence to head to that blog.
If you have pain directly over the prominent bone at the side of the hip, and you are tender here to touch or lie on your side, you may well have this condition.
We have prepared a self-test in the first FREE LESSON of our self-help course.
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Let’s get back to those common mistakes: Exercises to avoid for gluteal tendinopathy and hip bursitis. There are quite a few things that can go wrong in an exercise program for gluteal tendinopathy and trochanteric bursitis. These are usually associated with poor performance of various exercises, and other exercises that should simply be avoided when you have gluteal tendinopathy or hip bursitis (GTPS).
The ‘clam’ or ‘clamshell’ exercise can be one of the most provocative exercises for hip bursitis and gluteal tendinopathy. It is also arguably one of the least helpful exercises, in terms of gluteus medius and minimus strengthening. However, it is unfortunately one of the most commonly prescribed exercises for hip pain and strengthening. If you have hip pain or weakness, you’ve probably been given this exercise somewhere along the way.
If you are not sure what the ‘clam exercise’ is - it involves lying on your side with hips and knees bent and stacked on top of each other, then repetitively lifting and lowering the top knee, ankles staying together. See the picture below.
The main reason the clam exercise aggravates painful tendons and bursae at the greater trochanter, is the compression and friction these structures are exposed to during this exercise. Compression of the gluteal tendons and bursae at the greater trochanter occurs in any position where the knee is moved across the body or hip is pushed out to the side relative to the knee – positions of ‘hip adduction’.
During the clam exercise, the top hip starts in a position of adduction, with the knee dropped down (across the body) relative to the hip. The iliotibial band (ITB/IT Band) that runs from the side of the pelvis to the side of the knee, is on stretch in this position, squeezing the underlying gluteal tendons and bursae against the underlying bone – the greater trochanter.
Then as the knee is lifted and lowered repetitively, the IT Band rubs across the greater trochanter, creating some friction on the tendons and bursae sitting between the bone and the IT Band.
There is also compression of the tendons, bursae and the IT Band of the underlying hip, due to the weight of the body pushing down on the greater trochanter.
Healthy tendons and bursae are fairly good at tolerating these sorts of loads for a while, but painful tendons and bursae will generally not tolerate this type of load well, particularly if the exercise is done frequently. So, it's better to avoid this exercise if you have gluteal tendinopathy or trochanteric bursitis (GTPS).
The other reason we do not recommend clams for gluteal tendinopathy or hip bursitis, is that clams are not a good choice for gluteus medius and minimus strengthening – despite popular beliefs!
Electromyography studies that detect levels of muscle activity, have reported low levels of activation during the clam exercise in most parts of the gluteus medius and all of the gluteus minimus muscle.2 The researchers concluded that the clam exercise was unlikely to generate sufficient activation and force across these muscles to stimulate improvements in strength or muscle size.2
As the deep gluteal muscles (gluteus medius and minimus) are quite inefficient in this exercise, the motion is likely to be largely produced by more superficial muscles such as the gluteus maximus and muscles around the front corner of the hip, like the Sartorius muscle.
We know from other research that people with gluteal tendinopathy and trochanteric bursitis are weak in hip abduction (moving the thigh out to the side) and have atrophy (smaller size) in the gluteus medius and minimus muscles that perform that action. If we want to choose an exercise for targeting these muscles and their tendons, then the clam is not high on the list!
For both of these reasons, you are better to avoid clams and follow a more evidence-based program for gluteal tendinopathy or trochanteric bursitis (GTPS). This generally involves weightbearing or closed chain (foot pushing through the ground) exercises, which are a great stimulus for the glutes.
Evidence-based physical therapists and physiotherapists now advise people with gluteal tendinopathy and trochanteric bursitis to avoid IT band stretches and certain buttock – glute stretches. The scientific literature also now recommends avoiding these stretches for gluteal tendinopathy.3,4 These types of stretches can provoke pain, may contribute to unhealthy loading on painful tendons and are, in most cases, unnecessary.
IT band stretches are performed in a variety of positions, but all involve some variation of hip adduction – where the knee is pulled towards the midline, or the hip pushes out to the side relative to the knee. Certain buttock stretches also involve pulling the knee across the body. See the pictures below.
You now know that such positions, particularly when sustained, can irritate hip pain related to gluteal tendinopathy and trochanteric bursitis. This is due to the compression of the tendons and bursae between the IT band and the greater trochanter in positions of hip adduction.
As we mentioned above, healthy tendons and bursae cope with normal levels of these types of loads, but painful tendons and bursae with reduced health are not so tolerant.
Do you have hip bursitis or gluteal tendinopathy? Not sure where to start on your road to recovery? Or what your next steps should be?
This FREE resource provides a suggested treatment pathway, based on the available scientific evidence and Dr Alison Grimaldi's 30+ years of clinical practice as a physiotherapist and 20+ years as a researcher and educator in this field.
Compressive loads may also contribute to a lack of ‘homeostasis’ or healthy balance within the internal structure of the tendon. During rehabilitation for gluteal tendinopathy, we try to help improve tendon health and restore some homeostasis, by reducing exposure to compressive loads and gradually imposing healthier loads on the tendons through specific exercises.
You can learn all about this in our new gluteal tendinopathy and hip bursitis self- help course.
The final and perhaps most relevant argument to avoid ITB stretches for hip bursitis and gluteal tendinopathy, is that most people with this condition ARE NOT TIGHT IN THE ILIOTIBIAL BAND and DO NOT NEED TO STRETCH THEIR ITB!
It has been a long-held belief that the main underlying cause of trochanteric bursitis, is a tight IT band, but this is a complete myth! There is absolutely no science to back this up! In fact, of the large volume of patients I have seen with this condition as a hip physiotherapist of over 30 years, most have been long, NOT SHORT, in their ITB and hip abductor muscles at the side of the hip and thigh.
Sure, there are a smaller subgroup of people with this condition who might be tight, but stretching does not help and is more likely to aggravate the condition due to the excessive compression. We can gradually restore better length with active lengthening through a high-quality exercise program.
Recovering from Gluteal Tendinopathy, Trochanteric Bursitis or GTPS
FIRST LESSON IS FREE!
The general guidelines below can be helpful for getting back on track with exercise when you have pain over the side of your hip, related to gluteal tendinopathy or trochanteric bursitis (GTPS). You can gain a more in-depth understanding of the points below in our self-help course – Recovering from gluteal tendinopathy, trochanteric bursitis or GTPS.
Tendons HATE rapid changes in activity or loads imposed through exercise. So, one of the best rules is to start with less than you think your hip can tolerate, then gradually build up. As a very general guide, try not to increase activity or exercise loads by more than 10% per week.5 This may vary depending on your chronic training load (what you’ve been doing in the last month particularly) and what level you’re starting from. Put this together with the next 2 points, for a robust approach to exercise.
Some of the best exercises for gluteal tendinopathy and trochanteric bursitis are weightbearing exercises like squats, lunges and step ups. However, done with poor technique, they can be just as provocative as the clam!
The main thing to be mindful of is excessive adduction – hip drifting out to the side, or knee drifting in towards the midline. Use a mirror wherever you can for your weightbearing strength exercises, especially when you are first starting out, or progressing to a harder exercise.
Finally, a word about pain. ‘No Pain – No Gain’ is used a little too much. While it’s important not to stop exercise at the slightest awareness of discomfort, ignoring pain completely and pushing through it, is an equally bad strategy. Monitor your pain during exercise, as well as in the hours/evening after and the next morning.
Moderate pain means ‘modify,’ and severe pain means ‘STOP’ your current level of exercise and seek assistance if it is not easing. Mild pain that settles after exercise, and is not worse the next day, is generally ok.
Focusing on gradual progression and good exercise form will reduce the chances of a pain flare. If you are still experiencing pain with exercise, it might be about your exercise selection. In this blog we’ve talked about a couple of the exercises to avoid, but there are other culprits that might be thwarting your attempts at recovery.
You can empower yourself with knowledge by following our self-help course for recovering from gluteal tendinopathy, trochanteric bursitis and greater trochanteric pain syndrome. In this course we walk you step-by-step through a progressive gluteal tendinopathy – hip bursitis exercise program, letting you know exactly when and how to progress and what to do if you are experiencing any difficulties.
For most people, an evidence-based exercise program appears to be an essential element for recovering from gluteal tendinopathy and trochanteric bursitis. However, this is only part of the solution, and some argue that high-quality education around managing gluteal tendon loads is even more important, or for some people may be all that is needed.
Education for participants of scientific research trials, such as our LEAP randomised controlled trial,6 includes detailed information that helps in understanding the condition – what it is and why it occurs, and specific tendon ‘load management’ approaches – learning what to do and what not to do, to settle the tendon and bursae. We have touched on some of this in this blog, but there is so much more we would love to share with you.
If you’d like further detailed information, provided in bite-sized, easy-to-understand lectures, as well as a condition-specific exercise program with video and text instructions, join us for our online self-help course. Hope to see you online soon.
Do you have hip bursitis or gluteal tendinopathy? Not sure where to start on your road to recovery? Or what your next steps should be?
This FREE resource provides a suggested treatment pathway, based on the available scientific evidence and Dr Alison Grimaldi's 30+ years of clinical practice as a physiotherapist and 20+ years as a researcher and educator in this field.
Recovering from Gluteal Tendinopathy, Trochanteric Bursitis or GTPS
FIRST LESSON IS FREE!
If you'd like a physiotherapist and physical therapist that knows hips to guide you through a recovery program, you can find the location of our Hip Pain Professionals below.
Visit our Pain Locator Map to learn more about pain in different regions around the hip and pelvis.
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This blog was written by Dr Alison Grimaldi, an expert physiotherapist, educator and researcher with over 30 years working in the field, a special interest in the hip and 20+ years contributing to hip research.
Dr. Alison Grimaldi BPhty, MPhty(Sports), PhD is Practice Principal of PhysioTec Physiotherapy Clinic in Brisbane, an Australian Sports Physiotherapist, an Adjunct Senior Research Fellow at the University of Queensland, and a Fellow of the Australian College of Physiotherapists.
