Gluteal Tendinopathy and Menopause

This month is International Menopause Month, and something I see very often in my clinic is women of menopausal age coming in with pain on the outside of their hips.

You might think it’s just a sign of getting older, but if you’re chalking it up to that, you could be missing the real issue. Many women – and even some doctors – don’t make the connection between menopause and a condition called GTPS (greater trochanteric pain syndrome), also known as gluteal tendinopathy. This can cause severe and distressing lateral hip pain and is often poorly treated because of outdated understanding of how to best treat the problem.

Let’s break this down. What exactly is GTPS? Why does menopause increase your chances of getting it? And most importantly, what can you do about it?

What is Gluteal Tendinopathy (GTPS)?

Let’s start by getting the terminology right. Clinicians now refer to lateral hip pain as ‘GTPS’ (greater trochanteric pain syndrome), but you might also hear it called gluteal tendinopathy or hip bursitis, or even trochanteric bursitis.

An important point of confusion is around the bursa, the small fluid-filled sac near the hip, which was historically blamed for being the evil culprit. However, research shows that bursa irritation only occurs if the gluteal tendons are irritated, and many people have gluteal tendinopathy without the bursa being irritated.

The tendons attach to the greater trochanter, which is that bony lump on the outside of your hip that you can feel when you press it. Many patients think that this is their hip joint (because if they rotate their leg, they can feel something moving, but it’s not the joint, and the hip joint is actually deep in the groin).

Our glutes are crucial for walking, running, and even standing on one leg. Normally, tendons can handle a bit of wear and tear during exercise, and the body repairs them, laying down stronger fibres. But during menopause, things change.

Why Does Menopause Increase the Risk of GTPS?

Oestrogen plays a huge role in keeping tendons healthy. Oestrogen stimulates collagen production and collagen turnover – it helps to keep tendons flexible and strong. When oestrogen levels drop, the tendon robustness declines and the body becomes less efficient at repairing these tendons, and when tendons are less compliant (shock-absorbing) they are more prone to injury.

You might notice that you can’t tolerate activities that used to be fine. Long walks, standing for extended periods, or even just sitting for too long can trigger pain. Some women find it’s particularly uncomfortable to lie on the affected side at night, disrupting their sleep. Menopause also brings about weight gain and postural changes, which can further contribute to hip pain.

How Do You Know if You Have Gluteal Tendinopathy?

The symptoms can vary, but they often include:

• Pain when lying on the affected side, especially at night.

• Discomfort or pain after walking or standing for long periods.

• Pain during or post-exercise, especially impact exercise.

• Pain when getting up after sitting for a long time.

If this sounds like you, there’s a good chance you’re dealing with gluteal tendinopathy. But keep in mind that not all lateral hip pain is GTPS. Other conditions, like hip osteoarthritis, hip dysplasia, a lumbar disc bulge or facet joint arthritis can cause referred pain. If your pain radiates from the front of your hip or down the back of your leg, or if you have a ‘C-shaped’ pain that wraps around your hip, it’s important to get a proper assessment.

Getting the Right Diagnosis

Most cases of GTPS can be diagnosed through a combination of a clinical history and a physical exam. Key signs include tenderness around the greater trochanter and pain when resisting hip abduction (moving the leg outwards). In some cases, if the diagnosis isn’t clear, an MRI or ultrasound to rule out other conditions can be needed.

What Doesn’t Help GTPS?

Here’s where things get tricky. In my clinic, I regularly meet patients who have been told to stretch their hips, or who have been doing exercises like the ‘clam’. If that’s you, please stop right now.

Stretching, particularly poses like the ‘Figure Four’ or ‘Pigeon pose’, can compress the gluteal tendons under the iliotibial band (ITB), making things worse. In fact, yoga can often provoke hip pain, particularly if you’re doing poses that involve deep hip flexion or external rotation. Sitting for long periods also exacerbates the condition, so try to avoid it where possible.

Instead, focus on modifying your activities to avoid aggravating the tendons. If you’re into high-impact exercise like running or HIIT, consider switching to lower-impact activities like swimming or cycling until the pain is under control. This way, you can stay active without overloading the tendons.

The LEAP Trial and What Actually Works

The LEAP (Lateral Hip Pain) trial was a pivotal study that compared three approaches to treating GTPS: education and targeted exercise, waiting to see if it got better on its own, and corticosteroid injections. The results were clear – the group that received education and did exercises under the guidance of a physio had significantly better outcomes in terms of pain relief and overall function.

What exercises should you be doing? The key exercises in the trial included:

• Isometric hip abduction

• Hip bridge progressions

• Functional loading (standing and squatting)

• Frontal plan abductor loading

The trial also emphasised the importance of load management. This means listening to your body, avoiding pain that’s higher than a 3 or 4 out of 10, and gradually increasing your activity levels without pushing into significant discomfort.

What About Steroid Injections?

While corticosteroid injections can provide short-term pain relief, they don’t address the root cause of the problem. Worse still, repeated injections can weaken the tendons over time, making things worse in the long run. So, unless you’re in a crisis and can’t bear the pain, it’s usually better to focus on rehabilitation and load management.

What about shockwave therapy (ESWT)?

Several studies have found that shockwave therapy may be beneficial for treating GTPS. These studies report pain reduction and improved function in patients after a series of ESWT treatments. For example, a 2021 meta-analysis concluded that ESWT was superior to placebo treatments and was comparable to corticosteroid injections in terms of short-term pain relief, but with fewer long-term complications. In other words, there are some encouraging results, but let's get the basics right first..

The Role of HRT in Gluteal Tendinopathy (GTPS)

One area of interest is the use of hormone replacement therapy (HRT) for treating GTPS. The GLOBE randomised controlled trial looked at the effectiveness of transdermal HRT cream combined with exercise. The results were mixed. Women with a BMI under 25 who used the HRT cream had significantly better outcomes than those using a placebo cream. However, for women with a higher BMI, the HRT didn’t make much difference.

This suggests that weight management plays a big role in tendon health, especially during menopause. But if you’re considering HRT for other menopausal symptoms like night sweats and poor sleep, it could be worth discussing with your GP, as better sleep could also help manage your pain.

Key Takeaways

If you’re experiencing lateral hip pain during menopause, it’s important to get a proper diagnosis and avoid unhelpful advice.

• Avoid stretching your hips, especially with poses like the Figure Four and Pigeon pose, and stop doing clam exercises.

• Sitting for long periods will aggravate the condition, so try to stay active without pushing into pain.

• Focus on strengthening exercises like those from the LEAP trial, and work with a physio or osteo who understands how to treat GTPS.

• Avoid steroid injections – they might mask the pain, but they won’t fix the underlying issue.

Finally, if you’re struggling with severe pain, or if you’re unsure whether your pain is due to GTPS, come and see me.