How to fix Trochanteric Bursitis – A comprehensive guide

Written by Michael Clark, Registered Osteopath and Co-founder of Clarks Healthcare in Benfleet Essex

What Is Hip Bursitis?

Hip bursitis — or as it’s more accurately called, Trochanteric Bursitis — often begins as a dull, nagging ache on the outside of your hip. It’s easy to brush off at first. Perhaps it only flares up after a long walk, or if you’ve been sitting in one position too long. But more often than not, it gradually worsens. Sleeping on your side becomes uncomfortable. Walking upstairs feels awkward. You might start limping or find that even getting out of a chair sends a sharp pain through your hip. What begins as an occasional nuisance slowly becomes a daily problem — limiting your movement, affecting your gait, and draining your quality of life.

This is the hallmark of trochanteric bursitis: inflammation of a small fluid-filled sac called the bursa, which sits over the greater trochanter — the bony prominence on the outside of your thigh bone, near the hip.

But despite how common the diagnosis is, it’s often poorly understood — and even more poorly treated.

Trochanteric bursitis can affect all ages and is incredibly common. In fact, for those over 50, it’s one of the leading causes of chronic hip pain, yet it’s frequently misdiagnosed as arthritis or sciatica (Fearon et al., 2013). Many assume that bursitis is simply a swollen and inflamed bursa — and that taking anti-inflammatories or having a cortisone/steroid injection will fix it. But this is a short-term solution at best. The truth is, bursas don’t just inflame randomly — they inflame due to an underlying dysfunction.

What exactly is a bursa?

A bursa is a small, protective fluid-filled sac designed to reduce friction between tissues — most commonly where tendons pass over bone. Think of it as your body’s built-in shock absorber, friction pad or glide pad. It cushions movement, protecting both tendons and bones during walking, bending, climbing, and twisting.

The trochanteric bursa, specifically, sits between the outer hip muscles — like the gluteus medius and minimus — and the greater trochanter of the femur. If you touch the bony prominence on the lateral part of your hip that’s roughly where it is. It’s built to withstand friction and pressure. But when that friction becomes excessive or too repetitive, the bursa can’t keep up. The result? Inflammation, pain, and that all-too-familiar ache on the outside of the hip.

And this is the key misunderstanding: the inflamed bursa isn’t the true problem — it’s the result of an underlying dysfunction which is causing excessive friction to the bursa.

This is a big article — and that’s intentional. Whether you’re after a comprehensive deep dive or just skimming for key insights, there’s something useful for everyone. By the end, you’ll have a much clearer understanding of what really causes excessive friction at the bursa — and more importantly, what can be done to fix it properly, not just mask the symptoms. So, let’s dive in.

Why Painkillers, Anti-Inflammatories, or Cortisone Injections Aren’t the Answer

Most people with lateral hip pain follow a predictable pattern. Patients visit their General Practitioner (GP), receive prescriptions for painkillers or anti-inflammatory medications, and if the symptoms persist, they may be offered a cortisone/steroid injection. But in the majority of cases, there’s little investigation into why the bursa has become irritated in the first place (remember bursas don’t inflame for no reason). These interventions may offer temporary relief — but they don’t address the underlying dysfunction. And that means one thing: the pain comes back.

Cortisone injections, in particular, are still widely used as a first-line treatment for trochanteric bursitis. Yet mounting research suggests this approach is deeply flawed when it comes to long-term recovery.

While a single injection may ease pain in the short term, the benefits are usually short-lived. A study published in the British Journal of Sports Medicine found that over 50% of patients experienced a recurrence of symptoms within just six months of a cortisone injection (Mellor et al., 2020). Other studies report recurrence rates as high as 70–80% within 12 months (Bianchi et al., 2011; Rompe et al., 2009).

Even more concerning, multiple steroid injections are associated with long-term harm. Research shows that repeated cortisone use can weaken tendons, reduce collagen quality, and increase the risk of tendon rupture (Coombes et al., 2010; Dragoo et al., 2014). In the context of the hip — where the gluteal tendons and IT band are already under strain (due to the hip being a weight bearing joint) — this can lead to further degeneration and chronic dysfunction. In other words, the treatment may be worsening the very tissues it was meant to protect.

Even NICE guidelines (The National Institute for Health and Care Excellence) no longer recommend routine cortisone injections for lateral hip pain due to the lack of sustained benefit and increased risk of recurrence. Instead, they emphasise addressing the underlying cause through manual therapy (such as Osteopathy) individualised exercise and patient education— all of which have far better long-term outcomes.

Painkillers and anti-inflammatories follow the same faulty logic. They mask symptoms but leave the root cause untouched. And when the pain is numbed, patients continue to move with the same underlying dysfunctions that caused the problem in the first place — silently reinforcing the overload, leading to pain.

Ultimately, trochanteric bursitis isn’t a condition that completely goes away with quick fixes. It requires a deeper understanding of how your body is moving, why the excess friction is occurring in the first place, and how to correct the dysfunctions. Otherwise, the cycle of flare-ups, short-term pain relief, and recurrence continues — sometimes for years.

What Are the Common Causes of Trochanteric Bursitis?

Trochanteric Bursitis Isn’t the Problem – It’s a Warning Sign that somethings going wrong.

The key to resolving bursitis lies not in simply treating the pain — but in understanding why the bursa became irritated in the first place.

The trochanteric bursa sits on the outer/lateral thigh, cushioning the space between the greater trochanter (a bony prominence on the top side of the femur) and the powerful structures that pass over it — including the gluteus medius and minimus tendons, and the iliotibial (IT) band. Under healthy conditions, these structures glide smoothly across one another during walking, climbing, running, or twisting. The bursa absorbs friction and keeps movement efficient and pain-free.

But when biomechanics start to break down — when hip stability weakens, the pelvis loses alignment, muscle imbalances form, or walking patterns become inefficient — that smooth motion becomes a grind. The bursa, now exposed to excessive and abnormal rubbing, begins to inflame and at some point, you have bursitis.

Research shows that gluteal tendinopathy and abnormal hip mechanics are present in up to 90% of patients with confirmed trochanteric bursitis (Grimaldi et al., 2015).

Additionally, a 2020 systematic review in Journal of Orthopaedic Research confirmed that patients with altered pelvic control and weak hip abductors consistently show greater compression over the lateral hip structures, directly contributing to bursitis development (Mellor et al., 2020). Studies like this show why it makes no sense to simply take pain killers or have an injection and leave the underlying dysfunctions to get worse.

The takeaway? It’s not the bursa’s fault. The bursa is simply being asked to do too much, and it can’t cope and inflames. Unless the root cause is addressed the pain returns, repeatedly,

Let’s pause here and make sense of the hip a little more.

A Quick Look at the Hip Anatomy – And Why It Matters

The hip is a deep ball-and-socket joint. The actual hip joint — where the top of the thigh bone (femoral head) fits into the socket of the pelvis (acetabulum) — sits more in the groin region. But the outer part of your hip, where bursitis is located, is not the joint itself is a bony part of the femur called the greater trochanter. It’s an attachment zone for major stabilising muscles like the glutes and tensor fasciae latae (TFL), and this area takes a substantial portion of load during standing, walking, running, and side-to-side movement.

Each step you take involves complex coordination between the deep stabilisers of the hip, the glutes, the core, and the pelvis. When any of these components fail to perform properly — whether through weakness, stiffness, poor control, compensatory habits or even dehydration — load distribution becomes uneven, and structures like the bursa are left to pick up the slack.

In fact, biomechanical studies show that patients with poor pelvic control have up to 3x more lateral hip compression during walking (Semciw et al., 2016).

From my own clinical experience — having assessed and treated thousands of patients over the past 20+ years — hip bursitis is almost never an isolated issue but instead the result of underlying dysfunctions which have led to the bursa becoming inflamed.

Sadly, I can’t tell you about your individual cause without a thorough assessment. That’s why I always recommend seeking out an experienced practitioner who can look at the way you move, not just where it hurts.

But what I can do is share the most common causes I see in clinical practice, how I have successfully helped my patients recover and what the research shows. The more I can help you understand, the better equipped you’ll be to break the cycle of pain.

Let’s explore in detail the most common — and often overlooked — movement and postural dysfunctions behind trochanteric bursitis.

Trendelenburg Dysfunction and Gluteal Weakness

One of the most common dysfunctions I see in patients with trochanteric bursitis is gluteal weakness — particularly in the gluteus medius, the key muscle responsible for keeping the pelvis stable whenever we walk, run, or even stand on one leg. When this muscle becomes weak or fails to activate correctly, it can no longer hold the pelvis level and stable. Instead, the hip drops one side during movement, a classic sign of what’s known as Trendelenburg dysfunction.

It’s more common than you might think. I see it across all ages — even in teenagers. And it isn’t always obvious. Often, patients aren’t aware until I physically show them how their pelvis drops (or hikes) when they stand on one leg and when they walk. In more advanced cases, it creates a clear side-to-side sway known as a waddling gait. With my patients self-consciously telling me they feel off balance and walk like a penguin. Is this something you notice when you walk?

If you have a Trendelenburg dysfunction in your teens, if left unresolved you are setting yourself up for issues in either your back, hips, knees, feet, or ankles later in life. Therefore, correct this when you are young!

Even small instabilities like this can create significant stress over the greater trochanter given enough time. With every step you take, the altered loading causes friction across the bursa. And that repeated stress, day after day, is what gradually leads to inflammation and pain.

One study found that gluteus medius weakness was present in 92–96% of patients with lateral hip pain (Grimaldi et al., 2015). Another paper in Sports Health reported that individuals with hip abductor weakness were 2.6 times more likely to develop chronic hip pain, particularly in active adults (Fredericson et al., 2000).

And gait analysis shows that people with lateral hip dysfunction experience up to 40% more compressive force over the greater trochanter while walking (Semciw et al., 2018). That’s a substantial mechanical overload, repeated thousands of times a day. No wonder so many develop hip pain.

Do you lean your weight onto one hip when you stand?
Do your hips drop when you walk?
Do your feet flick out when you jog?

These are all signs your body is compensating for a dysfunction somewhere!

When the glutes don’t provide proper support, the body looks for stability elsewhere. That’s when compensation kicks in — often through overusing the tensor fasciae latae (TFL) and relying too heavily on the iliotibial (IT) band. But these tissues aren’t designed to dynamically stabilise the pelvis. Instead, they pull tight across the hip, increasing compression and shearing across the outer hip structures — precisely where the bursa sits. This is why runners can become obsessed with foam rolling their IT bands — believing it will release tension or fix the pain (they are just damaging the tissues with excessive foam rolling). But in truth, the problem is rarely in the IT band itself. The issue is normally somewhere else e.g. if you have a Trendelenburg dysfunction you are overloading the lateral hip — and the bursa suffers.

In clinic, a positive Trendelenburg sign — where the pelvis noticeably dips when standing on one leg — is a red flag that the system is no longer managing load properly. This matters more than people realise.

Just standing on one leg places approximately four times your bodyweight through the hip and pelvis. When walking, the force increases to five to six times your bodyweight. During running, it rises even higher — to eight to ten times your bodyweight (Bergmark, 1989; Schache et al., 2003). So, when glute control fails, it’s not a small issue — it’s a biomechanical collapse under huge force.

Unless we address this root problem — improving gluteal activation, coordination, and true strength — any other treatment will be short-lived. Injections, medication, rest, they may ease the pain temporarily, but they don’t correct the dysfunction.

Ultimately, if we want to resolve trochanteric bursitis properly, restoring glute function and lateral hip stability isn’t optional. It’s required. Only when the glutes are firing again can we offload the bursa, restore natural movement, and prevent the problem from coming straight back once you return to normal life.

Femoral Torsion and Hip Alignment Issues

Another significant factor contributing to trochanteric bursitis, which often goes unnoticed, is functional femoral rotation/torsion. This refers to a subtle yet substantial rotational imbalance of the femur, altering the way forces are absorbed and transmitted through the hip, pelvis, and lower limb. Unlike fixed anatomical deformities, these imbalances are usually acquired through poor movement patterns, muscular imbalances, or long-standing bad postural habits — and the good news is, they can be corrected.

When the femur rotates inwards (excessive internal rotation) or outwards (excessive external rotation) due to faulty motor control, weakness, or stiffness in surrounding tissues, it changes the direction of load through the hip joint and beyond. Over time, even small misalignments like these increase stress on the gluteal tendons, tighten the IT band, and raise friction over the greater trochanter — the perfect recipe for bursitis.

One of the first clues I use in clinic is a simple visual assessment. I ask the patient to stand normally and look down at their thighs. Ideally, their knees and thighs should face straight ahead. But in many (even teenagers), the thighs are slightly rotated inward or cross the midline — something they’ve never noticed before. It’s a quiet dysfunction, but once pointed out, it often explains years of nagging pain.

This altered femoral rotation doesn’t just affect the hip. It creates a ripple effect down through the knee, ankle, and foot:

The knee joint becomes misaligned, with increased valgus strain (knock-knee posture) commonly linked to femoral internal rotation. This raises patellofemoral stress and the risk of runner’s knee, ACL strain, and medial knee pain(Powers, 2003).
The foot often compensates by overpronating, collapsing inwards to cope with the internal rotation above. This is linked to plantar fasciitis, Achilles tendonitis, tibial stress syndrome (shin splints), Sever’s Disease, and bunions.
A 2020 study published in Gait & Posture found that altered hip rotation mechanics significantly increased tibial torsion and knee joint loading, heightening injury risk throughout the lower limb (Chaudhari et al., 2020).

And from a mechanical perspective, the numbers are sobering Research shows that even a 10° increase in functional femoral internal rotation can raise knee joint loading by up to 30% and increase lateral hip compression by a similar degree during walking and stair climbing (Semciw et al., 2019).

Excessive functional internal rotation(commonly from weak glutes and tight adductors) increases tension across the IT band and glute medius, pulling aggressively over the greater trochanter.
Excessive functional external rotation(often driven by tight deep rotators or poor hip extension mechanics) limits hip mobility and pushes loading backwards into the sacroiliac joint and lumbar spine, while still increasing compressive strain laterally.

Clinically, I can confirm these imbalances rarely exist in isolation. They’re often part of a broader pattern — a glute that’s not firing, a pelvis that’s slightly twisted, and a foot that’s trying to compensate. And over time, that compensation adds up.

What’s essential to remember is this: functional torsions are fixable. With the right combination of manual therapy to release restrictions, neuromuscular re-education to improve alignment, and targeted strengthening to correct faulty movement patterns, we can significantly reduce the excessive friction and compression that cause bursitis.

One paper in the Journal of Orthopaedic & Sports Physical Therapy found that targeted interventions to improve hip rotation and pelvic control reduced lateral hip pain symptoms by over 70% within 8 weeks, even in chronic cases (Grimaldi et al., 2017).

So, if you’ve been told your pain is just down to “wear and tear” or “overuse,” it’s worth taking a closer look at how your hip — and your whole lower limb — actually moves. Because often, the pain isn’t random — it’s the result of thousands of steps, done slightly wrong, over many years. And when we correct that, the body often heals itself — because the bursa was never the problem. It was just the messenger.

Lower Cross Syndrome and the Hidden Strain on the Hips

Lower Cross Syndrome is one of those postural patterns people don’t notice — but over time, it sets the stage for chronic hip pain (and many other issues). It’s a deep arch in the lower back, the pelvis tilting forwards, the tummy sticking out, and the glutes pushed up and back. In some it’s quite obvious. In others, it’s subtle — something you’d only notice when movement starts to feel awkward or stiff. But make no mistake, it changes everything about the way your body handles load.

What makes it worse? Even small, heeled shoes. Just a 1-inch heel can tilt the pelvis forward by up to 11 degrees, drastically exaggerating the postural imbalance and increasing stress on the lumbar spine and hips (Lee et al., 2001). I routinely see this in my clinic and explain it to my patients — and the results are always eye-opening.

At its core, Lower Cross Syndrome is a series of muscular imbalances. For example, the hip flexors and lower back muscles tighten and overwork, while the glutes and deep core muscles become weak and underactive. This causes the pelvis to roll forward — known as anterior pelvic tilt — which deepens the lumbar curve and shifts the body’s centre of gravity forward.

One study found that up to 85% of sedentary adults show some degree of anterior pelvic tilt, even without being aware of it (Kendall et al., 2005).

Most people don’t think of this as a dysfunction — it just becomes “their posture.” But functionally, it disrupts the delicate load-sharing relationship between the pelvis, hips, and spine.

As the pelvis tips forward, the glutes — meant to drive and stabilise powerful movement — are stuck in a lengthened, underactive position. This leaves the body relying on less suitable tissues like the TFL and IT band for support. These structures weren’t designed for dynamic pelvic stability. They tighten and compress, and each time you move, they rub and shear across the greater trochanter — placing relentless pressure on the bursa.

Even worse, the forward tilt of the pelvis changes the angle of pull on the gluteal tendons. Instead of gliding smoothly over the greater trochanter, they become kinked and tethered at an awkward angle — dramatically increasing friction across the bursa with every step. This subtle misalignment, repeated thousands of times a day, gradually wears down the tendon and irritates the bursa beneath causing Trochanteric Bursitis.

A 2019 study in Gait & Posture confirmed that individuals with anterior pelvic tilt and increased lumbar lordosis were over twice as likely to experience lateral hip pain and gluteal tendinopathy (Hodges et al., 2019).

But the strain doesn’t stop at the hip.

Research shows that anterior pelvic tilt significantly increases stress on the lower back, particularly compressive loads through the L4-L5 and L5-S1 segments, the most common areas for spinal injury and degeneration. This can contribute to facet joint irritation, arthritis, disc herniation, and sciatic nerve compression — conditions that not only cause localised low back pain but also radiate discomfort down the leg, often confused with hip-related issues.

Over time, this type of alignment limits your body’s natural ability to absorb shock. A study in Clinical Biomechanics found that anterior pelvic tilt reduced pelvic control and shock absorption during walking, forcing more impact through the hips and knees (Preece et al., 2008). These constant, inefficient loads break down tendon resilience and irritate the bursa — especially with daily repetition over months or years.

In my clinic, Lower Cross Syndrome often hides in plain sight. It shows up in subtle ways — a swayback posture, a struggle to activate the glutes, a lack of control when standing up or walking uphill. But when we assess movement patterns under load, the picture becomes clearer. The hip is doing too much, the low back is over-arched, and the body is moving in a way that magnifies strain rather than absorbing it and for many it chronically inflames the bursa.

This is where a proper clinical assessment becomes essential.

Rather than applying a one-size-fits-all exercise plan, I examine each patient to determine which specific muscles need to be released and which ones need to be strengthened. The goal is to restore a natural lumbar curve, not flatten it or over-arch it, and to redistribute force evenly across the spine, pelvis, and hips when you stand, and move. When the surrounding muscles are balanced and the pelvis is aligned correctly, the tissues that cross over the hip — including the gluteal tendons and the bursa — can finally move without excess friction or strain, and our patients get better.

Flat Back Syndrome and Loss of Shock Absorption

While anterior pelvic tilt tends to get all the attention, the opposite postural fault — Flat Back Syndrome — is just as damaging and far more likely to be overlooked. It’s especially common in those who spend long hours sitting, whether at a desk, in the car, or on the sofa. Over time, this prolonged sitting reduces or even eliminates the natural curve of the lower back, flattening the lumbar spine and fundamentally changing how the body manages impact.

In a healthy spine, the lumbar curve acts like a spring — it absorbs and distributes forces through the body, helping to protect joints and soft tissues during movement. When this curve disappears, that shock absorption is lost. Instead of being cushioned by the spine, forces from walking, standing, or running get dumped straight into the pelvis, hips, and knees.

Research confirms the impact is far from minor. Studies have shown that individuals with reduced lumbar lordosis experience significantly greater vertical ground reaction forces during walking and running — essentially meaning every step sends more force down into the lower limbs (Sahrmann et al., 2017). One study found that a loss of normal lumbar curve can reduce effective hip extension during gait by 15–20%, forcing the pelvis and hips to compensate inefficiently (Preece et al., 2008).

But it’s not just the hips that suffer. When the lumbar spine flattens, pressure builds up at the base of the spine — particularly the L4–L5 and L5–S1 segments — increasing the risk of:

Facet joint irritation.
Disc bulges and herniation.
Sciatica and nerve compression
Degenerative disc disease
Arthritis

A large MRI-based study (Park et al., 2015) found that loss of lumbar lordosis was directly associated with increased risk of lumbar disc herniation, especially in individuals with sedentary lifestyles. In these cases, the hip pain patients are experiencing may be the tip of the iceberg — with deeper mechanical dysfunction simmering under the surface.

Clinically, my patients with Flat Back Syndrome don’t just present with hip pain. They’ll often describe persistent tightness in the lower back, difficulty striding fully when walking, and a constant sense of stiffness after standing or walking. They tend to lean forward slightly when standing, unconsciously shifting their weight into the hips and knees because the spine isn’t doing its fair share. This forward shift throws off balance and load distribution, weakening the glutes and placing additional stress on the TFL and IT band, which then shear over the greater trochanter and irritate the bursa.

This loss of coordination in the kinetic chain doesn’t stop at the hip. It often leads to:

Knee pain due to altered force vectors and reduced hip extension.
IT band syndrome from excessive lateral tension
Foot dysfunction including overpronation and plantar fasciitis.
Hip flexor overuse from lack of glute engagement.

But there’s good news: correcting flat back posture has been shown to significantly reduce hip pain and improve overall movement quality. In a controlled trial by Arab et al. (2011), patients with chronic hip and low back pain showed notable pain reduction and improved functional scores following a six-week programme of manual therapy (such as Osteopathy) and tailored corrective exercise aimed at restoring lumbar curvature and pelvic alignment.

Another study published in Manual Therapy (Smith et al., 2014) found that patients with abnormal lumbar curves experienced a 37% improvement in hip function and pain relief after a targeted program combining joint mobilisation, lumbar curve retraining, and hip extension patterning.

What does this look like in practice? It starts with thorough clinical examination— not with an X-ray, but with hands-on assessment of posture, spinal movement, and muscle balance. This allows us to pinpoint which muscles need lengthening and which need strengthening to restore a healthy lumbar curve, re-engage the glutes and deep core, and redistribute load away from the lateral hip structures.

Correcting this postural fault also “unkinks” the gluteal tendons that cross over the greater trochanter. When the lumbar spine is flattened and the pelvis tips under, those tendons stretch tautly over the trochanter — increasing compression and friction with every step. As we restore normal spinal alignment and improve pelvic positioning, the tension across the gluteal tendons reduces, and the bursa gets the breathing room it needs to recover.

Ultimately, addressing Flat Back Syndrome isn’t just about getting someone to stand straighter. It’s about restoring the body’s natural shock absorbers, redistributing mechanical load, and giving the hip the structural support it needs to heal — not just temporarily, but for a long-term recovery without reoccurrence.

Poor Core Stability – Why It’s Essential for Hip Health

Everybody of all ages and health need a strong and fully functional core.

Core stability plays a direct role in maintaining pelvic alignment and controlling how force travels through the hips. Without a strong, coordinated core, the pelvis tends to tip or twist, altering hip mechanics and placing increased strain on the lateral structures of the hip — particularly the greater trochanter and the gluteal tendons and the bursa.

A study in Gait & Posture found that individuals with chronic lateral hip pain showed notable deficits in deep core muscle activation — especially the transverse abdominis and internal obliques (Hodges et al., 2019). These muscles are essential in stabilising the pelvis and supporting the lumbar spine, especially during movement. When they underperform, it’s the hips that often suffer the consequences.

And yet, despite all the hype around “core strength,” most people still don’t really understand what the core is — let alone how to train it properly.

Anatomically, the core isn’t your six-pack. It includes the transverse abdominis, pelvic floor, multifidus, diaphragm, and deeper hip stabilisers — all working together to maintain dynamic spinal and pelvic control. These muscles must not only be strong, but skilful. A functional core adapts reflexively to movement, regulates pressure, and provides a stable base for efficient load transfer.

Research shows that poor core control subtly alters the way we walk, stand, and even sleep — influencing the tilt and rotation of the pelvis in ways that increase friction over the trochanteric bursa. A study published in the Journal of Orthopaedic & Sports Physical Therapy found that core instability significantly raised hip joint load and was strongly correlated with recurring lateral hip pain and reduced gluteal activation during gait (Grimaldi et al., 2015).

And here’s the surprising part: I often assess patients who regularly attend Pilates or “core conditioning” classes, only to find their deep core isn’t functioning at all. They’re bracing with their superficial abs, clenching their glutes, and over-recruiting their hip flexors — while the real stabilisers remain switched off.

When I assess core function, my patients are shocked because they put in so much effort to look good and have a great core to only find that their core is still weak and highly dysfunctional. We often need to go back to basics and start again.

If you haven’t had your core assessed then all the core exercises you are doing are a pure guess and may be causing more harm than good.

First, I always start with teaching proper breathing mechanics (belly/diaphragmatic breathing) as all core exercises are actually forms of exaggerated breathing mechanics. I teach patients how to activate their deep core — not by holding their breath or sucking in and bracing, but by reconnecting with breath, alignment, and subtle postural control. They learn how to ensure their core is creating a lumbar neutral during standing, walking, and climbing stairs.

From there, we build a solid foundation using functional movement patterns: learning how to stabilise during movement, under load, and eventually in real-world challenges — lifting, bending, twisting, lifting in difficult positions, running, jumping and any realistic task they come up against.

And my approach works. A study in Clinical Biomechanics showed that integrating deep core retraining into hip rehab programmes significantly reduced pain and improved hip control within 6–8 weeks (Semciw et al., 2016). Another paper in Spine found that targeted core retraining reduced lumbopelvic instability and improved outcomes in patients with both back and hip pain (Hides et al., 2001). In fact, the British Journal of Sports Medicine found that patients who completed core-focused rehab had over a 40% improvement in functional movement scores compared to traditional approaches (Chan et al., 2022).

Ultimately, if your core can’t support your spine and pelvis, your hips may pay the price. Whether you’re a grandparent who wants to stay independent, a teen athlete building strength, or someone recovering from injury — getting your core assessed and retrained is not a nice extra. It’s an important to a full and lasting recovery.

Poor Walking and Gait Mechanics

Walking might seem like the most natural thing in the world — but when your movement patterns are off, every single step becomes a repetitive strain on the hip.

In a healthy gait (our walking pattern), each part of the body plays its role: the glutes stabilise the pelvis, the core controls hip rotation and spinal position, the hips extend smoothly behind you, and the foot and ankle absorb shock and adapt to the ground. But when this coordination breaks down — even slightly — the consequences start stacking up, step after step, day after day. The hip, particularly the structures around the greater trochanter, often ends up bearing the brunt.

My patients rarely notice the early signs. Often, it’s just a bit of stiffness after long walks, or a mild ache on one side. But when I examine patients walking pattern, I’ll see subtle gait deviations — maybe a slight drop of the opposite hip, a shortened step, or increased lateral sway. These aren’t just quirks; they’re compensations that shift load toward the outer hip, increasing friction over the bursa.

Research shows just how significant these patterns can be. A study in The Journal of Biomechanics found that individuals with recurrent lateral hip pain showed a 20–30% increase in lateral trunk lean and a marked reduction in hip extension during walking — both of which dramatically increased strain over the gluteal tendons and bursa (Semciw et al., 2019). Another paper in Gait & Posture noted that a lack of hip extension alone could reduce stride efficiency and increase ground reaction forces through the hip by up to 25%, accelerating overload across the lateral hip (Grimaldi et al., 2015).

What’s often missed is that poor gait mechanics don’t originate in the hip. They’re usually the downstream result of other dysfunctions — flat feet, tight hip flexors, weak glutes, stiff ankles, poor core control etc. These create a ripple effect up the chain: the foot collapses, the knee turns in, the pelvis drops, the trunk leans — and the greater trochanter becomes the target of repeated, abnormal forces and you may end up with an arthritic hip or Trochanteric Hip Bursitis.

In one study published in Clinical Biomechanics, inefficient walking patterns were shown to increase compressive loading over the greater trochanter by 40% in individuals with gluteal tendinopathy. That’s a huge mechanical tax being paid with every step — and it adds up fast.

Even worse, these dysfunctional patterns significantly increase recurrence rates. A follow-up study of patients treated for trochanteric bursitis found that those with unresolved gait issues were more than twice as likely to experience recurring symptoms within a year (Mellor et al., 2020).

That’s why I explain to my patients correcting gait mechanics isn’t really optional if they want to minimise recurrence. When I assess a patient’s movement, I’m not just looking at how they walk; I’m tracing the root of their dysfunction. What muscles are underactive? Which joints aren’t moving properly? Where is the compensation starting?

By retraining their movement patterns — restoring proper hip extension, strengthening gluteal support, improving foot control, and correcting posture — we can unload the lateral hip significantly, reducing friction, and significantly improve their long-term recovery.

Because if we don’t fix the way you move, the problem won’t just come back. It never really left.

Why Sedentary Jobs and Lifestyle Lead to Hip Dysfunction

Modern life encourages us to sit — at work, during the commute, at home. A state of near constant inactivity! And the more we sit, the more our bodies forget how to move well. This doesn’t just create tight hips a flat back and weak glutes; it often leads to a breakdown in fundamental movement patterns like squatting. I’m not talking about lifting weights in the gym — I mean natural, everyday squatting that we all need: getting out of a chair or the car, lowering down to the floor, getting off the floor or sitting on the toilet without awkwardness or pain.

Many people have lost the ability to perform a deep squat — one where the heels stay flat, the spine stays neutral, and the movement is smooth and controlled. If you can’t do this, it’s not just a mobility issue. It’s a sign that your deep hip stabilisers, pelvic floor, lumbar spine, and glutes aren’t coordinating properly. And this dysfunction plays a hidden role in hip pain, bursitis, and even low back and knee problems.

Young children instinctively move with perfect biomechanics. Watch a toddler squat — they sit effortlessly, spine upright, playing on the floor for ages. But by the time kids hit school age, they’re already spending most of their day in chairs. By secondary school, the natural squat pattern is usually gone — replaced by tight hips, poor glute activation, and compensations that linger for life unless retrained.

With my own patients, I regularly need to re-teach the squat pattern — even to elderly clients. Of course, I adapt it sensibly, but the principle remains the same: restore the body’s ability to squat and move well, and the dysfunction often fades.

And the research backs this up. A study in Clinical Orthopaedics and Related Research (Neumann et al., 2019) found that populations who squat regularly throughout their daily routines — such as in parts of Asia and Africa — had significantly lower rates of hip osteoarthritis, bursitis, and IT band syndrome (and many other problems) compared to Western populations. Their hips remained mobile, strong, and well-aligned well into old age, not because they did more exercise, but because they never stopped moving naturally.

Another study in the Journal of Applied Biomechanics (Kaplan et al., 2018) showed that individuals who sit for more than six hours a day are 40% more likely to develop hip pain — even if they exercise regularly. That’s the critical point: movement variability and natural patterns matter more than just hitting the gym. Prolonged sitting changes pelvic posture weakens the deep stabilisers and stiffens the hips — setting the stage for a host of orthopaedic problems including trochanteric bursitis.

But it doesn’t stop at the hips. When squat function is lost, other joints are forced to compensate. Without proper hip hinge mechanics, the knees take on extra load during walking and rising from chairs (do your knees creek when you get out of a chair?). The feet, too, lose their natural engagement — often leading to overpronation (flat feet) plantar fasciitis, Achilles tendonitis and even bunions. The entire kinetic chain becomes less efficient, more stressed, and more prone to injury.

Research in the Journal of Anatomy (Kjaer et al., 2009) has also shown that sedentary behaviour reduces collagen turnover in tendons, increasing stiffness and reducing load tolerance. This helps explain why simply being inactive doesn’t just cause weakness — it causes the very tissues we rely on for movement to become biologically less resilient and structurally weak.

Modern hip dysfunction isn’t caused by too much movement — it’s caused by too little variation. Our hips are built to move in a full range, shift, stabilise, and adapt. To be strong and supple. But when we stop asking them to do what they are designed for and instead to sit still all day, this state of near constant inactivity causes them to weaken and break down.

Reintroducing fully functional hip movements is one of the most overlooked but powerful tools we have in long-term recovery of trochanteric bursitis.

Why Women Are More Prone to Bursitis.

Women are up to four times more likely to develop trochanteric bursitis than men — and that’s not just because of biological general strength differences to men. A deeper look reveals a combination of anatomical, biomechanical, and hormonal factors that make the outer hip of women more vulnerable to strain.

One of the key anatomical differences is the Q-angle — short for quadriceps angle. It’s a measurement of how the thigh bone (femur) angles from the pelvis to the knee. To calculate it, a clinician would draw one line from the anterior superior iliac spine (ASIS) — a bony point at the front of the pelvis — to the centre of the kneecap, and another from the centre of the kneecap to the tibial tuberosity (the bony bump on the shinbone). The angle formed between these two lines is the Q-angle.

Because women statistically have a far wider pelvis, they naturally have a larger Q-angle, which causes the femurs to angle inward more steeply (the wider the pelvis the more mechanical load). This shifts the knees inward (valgus alignment), increases tension in the iliotibial (IT) band, and places more compressive and shearing force over the greater trochanter — the exact area where the gluteal tendons and bursa sit. Over time, this mechanical stress increases the risk of excessive friction, irritation, and chronic pain in the outer hip.

A study in The American Journal of Sports Medicine (Mellor et al., 2020) found that women with larger Q-angles had significantly higher rates of lateral hip pain and gluteal tendinopathy, confirming the impact of anatomical alignment on hip health.

But structure isn’t the only factor. Hormonal fluctuations, particularly during the luteal phase of the menstrual cycle (the two weeks leading up to a period), can also play a significant role. During this phase, levels of relaxin, progesterone, and oestrogen shift dramatically — and studies have shown that this reduces core activation, especially in the transverse abdominis and pelvic floor muscles (Tenan et al., 2016). These deep core muscles are vital for maintaining pelvic control and spinal stability. When they’re underactive, the body struggles to control pelvic movement during walking, running, or lifting. As a result, more strain is offloaded to passive tissues like the IT band, gluteal tendons, and — you guessed it — the bursa.

This is why women are not only more likely to develop bursitis, but also more likely to experience flare-ups and instability at specific points in their cycle. For many of my patients, the hormone influence of musculoskeletal stability this isn’t something they’ve ever been told. Also, I explain that it will influence how they should exercise during different stages of their monthly cycle.

Women should be extremely cautious exercising hard, attending spin classes, bootcamps or HIT classes during this stage of their monthly cycle!

Once they understand the hormonal influence and pattern on their core function, it becomes clear why certain movements feel harder or less stable at different times of the month.

Ultimately, preventing and managing bursitis in women isn’t just about doing more glute work. It means understanding how pelvic alignment, biomechanics, and hormonal rhythm all intersect — and tailoring rehabilitation accordingly. That includes timing corrective exercises, improving neuromuscular control during vulnerable phases of the cycle, and ensuring long-term support for the structures around the hip.

The Hidden Role of Hydration in Bursitis

It’s easy to underestimate the role hydration plays in joint health — especially when dealing with something like bursitis. But the truth is, your bursae are directly affected by how well-hydrated you are. Their effectiveness relies heavily on the quality and quantity of synovial fluid — and synovial fluid is largely composed of water.

When the body is even mildly dehydrated, synovial fluid production can drop, and its lubricating properties become compromised. Less lubrication means more friction between moving parts, and bursitis is the result of excess friction.

A review in The Journal of Anatomy highlighted how hydration status influences the viscoelastic properties of joint structures, including cartilage, synovial membranes and bursa affecting their ability to withstand load and recover from stress.

In practical terms, this means someone who isn’t drinking enough water throughout the day might unknowingly be increasing their risk of bursitis.

I often tell patients: hydration isn’t just about energy levels, headaches, high blood pressure or avoiding cramps. Think of your bursae as shock absorbers that cushion and reduce friction. They work better when they are full — not dried out.

What Else Could Be Causing Your Hip Pain?

Relying solely on imaging or pinpointing the area that hurts is one of the most common ways patients are misdiagnosed — and unfortunately, it happens a lot.

Studies show that up to 45% of patients presenting with lateral hip pain do not have bursitis at all, but instead are suffering from gluteal tendinopathy, referred pain from the lumbar spine, or coexisting dysfunctions (Grimaldi et al., 2015). In fact, isolated trochanteric bursitis is far less common than most people (and sadly, many clinicians) assume.

That’s why I have to accurately identifying which tissues are truly involved — not just which area hurts. “Lateral hip pain, it must be bursitis” is not a diagnosis and just lazy practice.

If we don’t accurately figure out what’s actually irritated — be it the gluteal tendons, bursa, sciatic nerve, or referred pain from L2–L3 nerve roots — then any treatment is guesswork.

Any experienced clinician and I will always begin with a detailed case history and examination to accurately determine the actual tissue source of your pain. However, we don’t just focus on what hurts — we also assess posture, movement, load tolerance, muscle function, and more.

Once we have reached a diagnosis of what’s causing your pain e.g. bursitis and identified the why (the underlying dysfunctions), we begin what we call the Relief Care phase — the first step in our treatment framework — focused on calming down the pain and irritation as quickly as possible and increasing the recovery rate.

But here’s the key: we don’t rely on generic stretches and exercises. Most patients who come to us have already tried that — and many have already had cortisone injections too. While these can offer temporary relief, their success rate in true long-term recovery is surprisingly low. One large-scale review published in The BMJ found that although corticosteroid injections can reduce pain in the short term, they had no benefit at 12 months and were associated with higher rates of recurrence (Coombes et al., 2010).

Similarly, many patients are given generic exercise sheets, a one size fits all approach. I’m often baffled what some of the exercises are actually meant to do for the patient in front of me. No wonder they haven’t helped.

Studies show that non-individualised care is far less effective than treatment plans designed to specifically for the needs of the individual patient (Cook et al., 2017). That’s why our Relief Care phase is hands-on and precise. By understanding the real cause, we can use targeted treatment interventions that affectively calm the irritated tissue, offload the stress, and allow the body to reset — all while we build a plan for fixing the deeper issues.

Here are some of the most common conditions I see misdiagnosed as bursitis — or coexisting alongside it:

Gluteal Tendinopathy
This is now recognised as the most common cause of lateral hip pain, particularly in women over 40. Research by Grimaldi & Fearon (2015) found gluteal tendon pathology in 88% of those presenting with “trochanteric bursitis.” The tendon thickens and becomes painful due to issues such as poor loading patterns, often from poor hip and pelvic control.

Hip Osteoarthritis
While true hip joint pain tends to be felt in the groin, the body often compensates by altering movement compensation putting the pressure off to one side— and this overloads the outer hip, leading to secondary pain at the bursa or gluteal tendon region.

Lumbar Referred Pain (L2–L3 Nerve Roots)
If your pain aggravates/improves when your spine moves — not your hip — it’s often coming from the back. Compressive issues such as disc herniation, facet joint irritation, nerve root sensitivity etc can all cause pain that mimics bursitis.

IT Band Syndrome
Most commonly associated with runners and cyclists, this condition causes excessive lateral tension across the hip and knee. It often contributes to friction over the trochanter — especially in people with a tight or dominant tensor fasciae latae (TFL) due to a multitude of dysfunctions.

Femoroacetabular Impingement (FAI)
FAI causes stiffness, restricted internal rotation, and deep groin pain, but compensation from limited hip mobility often leads to overuse of the lateral structures as patients compensate to take the pressure of the hip joint— setting the stage for secondary bursitis.

Piriformis Syndrome
When the piriformis muscle becomes tight or overactive, it can compress the sciatic nerve and alter hip movement. This often leads to compensations in walking or standing posture, which increases compression at the greater trochanter.

Sacroiliac Joint Dysfunction
Instability or hypomobility in the sacroiliac joint (SIJ) alters pelvic mechanics and frequently results in asymmetric loading through the glutes and IT band — a common contributing factor in persistent lateral hip pain.

Sciatica
Although more commonly associated back and shooting leg pain, mild forms of sciatica can mimic outer hip discomfort — especially if lumbar nerve root compression overlaps with gluteal irritation.

It’s also extremely common to see more than one issue at play. For example, someone with weak glutes and a poor squat pattern may have gluteal tendinopathy and SIJ dysfunction, both feeding into pain over the bursa. Similarly, if they have an arthritic knee, they will often lean more on the other leg leading to bursitis. Therefore, if we only treat one part, the pain often returns.

That’s why we always perform a thorough biomechanical exam, hands-on assessment, orthopaedic testing and sometimes refer for imaging (but only when it helps clarify the clinical picture and patient management). Once the painful tissue is correctly identified, we can treat it effectively with targeted hands-on manual therapy, while simultaneously creating a plan to correct the underlying dysfunctions.

In fact, when pain relief and corrective rehabilitation are combined — not separated — outcomes improve dramatically. One study published in The Lancet (Mellor et al., 2018) showed that a targeted gluteal strengthening and movement retraining programme led to greater improvements than cortisone injections at every time point measured — 8 weeks, 6 months, and 12 months.

At the heart of it, we don’t just want to make your pain go away. We want to ensure it stays away by correcting the dysfunctions that led to your pain in the first place. And that starts with an accurate diagnosis — because if you don’t know what’s truly causing the problem, you can’t fix it.

What an Examination Should Include

A good clinical diagnosis doesn’t start and stop at “bursitis.” It starts with identifying exactly which tissues are causing your pain — and more importantly, understanding why. If we don’t find the root dysfunction causing excessive friction at the bursa, we’re just chasing symptoms. Below is the framework for a thorough and patient centred assessment:

Detailed Case History

Every examination begins with a deep dive into your story — when the pain started, what aggravates it, what helps, and what else has changed over time. We ask about your daily activities, previous injuries, sleep quality, hydration, lifestyle, footwear, desk setup, and even your general movement/inactivity habits. This helps us spot patterns that imaging alone can’t reveal.

The more we understand your symptom picture, how you move and your lifestyle, the more accurate our diagnosis and the more effective our treatment will be.

2. Observation and Postural Assessment

Before we ask you to move, we observe. Your posture holds clues: how you distribute your weight, how your pelvis is aligned, how your spine curves, and how your hips, knees and feet behave when you’re standing still.

Observation and light palpation of the symptomatic area often confirm whether the pain pattern matches typical trochanteric bursitis — or something else. It also helps us identify other types of bursitis such as haemorrhagic or septic bursitis. These are rare, but basic clinical observation will spot these.

We observe and test:

Pelvic alignment – An anterior or posterior tilt changes how your hips absorb force.
Spinal curvature – e.g. a flat lumbar spine reduces your natural shock absorption, sending more impact through the hips.
Knee positioning – Valgus collapse (knees falling in) increases strain at the lateral hip.
Foot mechanics – Collapsed arches or over-pronation rotate the femur inward, destabilising the hip.
Femoral torsion – Excessive internal or external rotation of the femur alters hip loading. This is particularly relevant in women and adolescents.
Subtle asymmetries and compensation patterns- like a small pelvic tilt or flat foot on one side, leaning to one side, a spinal side bend, slouched posture etc can cause the entire chain above it to compensate. Over time, that compensation may become the source of your pain.

3. Passive Examination and Palpation

Next, we gently test how each joint and tissue responds. We palpate the glutes, IT band, lumbar spine, bursa, and all the surrounding soft tissues. Often the pain isn’t from one structure but from several overlapping problems. In fact, research shows that over 88% of patients with lateral hip pain have underlying gluteal tendinopathy, not bursitis alone (Grimaldi & Fearon, 2015).

We also check passive and active range of motion in both hips, knees, ankles, and the lumbar spine. Comparing both sides helps us see where movement is restricted, sloppy, or painful. Quality of motion matters just as much as range — is the hip smooth, or does it catch or clunk, do your knees crack when you sit down etc?

4. Functional and Orthopaedic Movement Testing

Testing muscles in isolation isn’t enough. You don’t live in a vacuum — you move, walk, bend, sit, climb stairs and multiple muscles and joints have to work together. So, we also test how your body functions as a whole. Whether you’re 8 or 88 years old, we adapt the tests to your level — but everyone deserves a thorough examination.

Some key tests we perform commonly include:

Single-Leg Stance Test – This tells us everything about your hip stability. Can you stand on one leg without wobbling? The gluteus medius plays a huge role here. Weakness leads to pelvic drop (Trendelenburg sign), which significantly increases bursal loading. A 2017 study showed reduced glute medius activation and single-leg stability in nearly all patients with lateral hip pain (Grimaldi et al., 2017).

Step-Down Test – Can you control your body as you lower down a step? This test mimics stairs — a daily task — and highlights poor hip control, knee valgus, and compensatory patterns.

Squat Mechanics – Squatting isn’t just for athletes. It’s for getting off the toilet, out of the car, and onto/off the floor. We modify this test for each patient’s abilities and age, but it often reveals hidden dysfunction like poor hip mobility or excessive femoral rotation.

Gait Analysis – Watching you walk tells us how your whole body works under load. A lateral sway, short stride, or hip drop might be the source of your pain. Even mild deviations, repeated over thousands of steps and over, can lead to bursitis and even severe arthritis in the long term.

Additional Orthopaedic Tests – We may test your lumbar spine, SI joints, knees, and feet — often, the problem lies outside the hip. For example, referred pain from the lumbar spine is common, particularly from the L2-L3 nerve roots.

When is Imaging Needed?

Not as often as people think. A skilled clinical exam can often identify the true cause of pain without needing an MRI and it tests the body moving not just what it looks like laying down and still. Imaging tends to show many “false positives” — abnormalities that look dramatic but aren’t actually causing symptoms. One study found that up to 49% of people with no hip pain still showed signs of gluteal tendon pathology on MRI (Silvis et al., 2011). Therefore, The National Institute of Clinical Health and Excellence reserve imaging for cases that aren’t responding as expected or where something rare is suspected — such as a fracture or septic bursitis.

Should I have a Scan?

Why Imaging Alone Won’t Give the Full Picture

This is one of the most frequent questions we get — and the honest answer is: not usually.

The bursa is a superficial structure, easily examined through physical palpation and functional testing. If you’re tender over the outside of your hip, an experienced clinician can often identify whether it’s likely to be bursitis (or something else) without needing a scan.

MRI and ultrasound can show inflammation, yes — but inflammation isn’t always the problem. And sometimes, it’s not even relevant. Studies have shown that 30% of people with no pain at all still show signs of bursal inflammation on MRI (Long et al., 2019). These are called false positives — findings that look worrying on a scan but aren’t actually causing your symptoms. On the flip side, people in real pain often show little on imaging. This is why relying on scans without a proper physical exam leads to misdiagnosis and mistreatment.

A scan is just a static image of the painful area, it doesn’t show what the body does under load, or what happens when you bend squat and move. All this vital information is missed!

In fact, a study from the Journal of Bone & Joint Surgery found that patients who were diagnosed using scans alone had significantly higher recurrence rates than those who received a proper biomechanical assessment and movement-based rehabilitation (McGovern et al., 2021).

That’s because imaging can only confirm what’s inflamed — not why. And unless we understand why the bursa is being overloaded in the first place, all we’re doing is chasing symptoms.

Even more telling, Grimaldi et al. (2015) reported that up to 45% of patients diagnosed with “trochanteric bursitis” don’t actually have bursitis at all, but rather gluteal tendinopathy or referred pain from the lumbar spine. Without identifying the correct structure, treatment is just guesswork.

Guidelines from leading musculoskeletal bodies such as NICE and the British Journal of Sports Medicine agree that imaging should only be used when red flags are present — such as suspected infection, tumour, or trauma — or if conservative care has failed.

Why Imaging Can Be Misleading:

30–49% of asymptomatic people show abnormalities on hip MRI (Silvis et al., 2011; Long et al., 2019)
Imaging doesn’t show how you move, where your strength is lacking, or which mechanics are faulty.
People diagnosed via imaging alone have higher recurrence rates and poorer long-term outcomes (McGovern et al., 2021)
NICE guidelines discourage routine imaging unless “serious pathology is suspected, or symptoms persist despite conservative treatment.”

The Bottom Line

Scans can be useful — but only when used at the right time and interpreted in the right context. A tender bursa may show up on imaging, but without understanding the postural faults, muscular imbalances, or movement dysfunctions that led to the inflammation, treatment is unlikely to work long-term.

That’s why any experienced clinician includes a detailed case history, hands-on examination, detailed functional testing, and clinical reasoning. If something unusual is suspected, or you’re not improving as expected, then and only then should you be referred for imaging (as per the NICE guidelines).

Should I Have a Cortisone/Steroid Injection?

For many patients with trochanteric bursitis, cortisone/steroid injections are often the first-line treatment recommended by GPs or orthopaedic specialists. These injections can reduce pain and inflammation in the short term — but their role in long-term recovery is far more limited.

Corticosteroids are powerful anti-inflammatory agents that help suppress pain by reducing local swelling in the bursa and surrounding tissue. In acute cases — where inflammation is the dominant cause of pain and its preventing treatment and rehabilitation — a single injection may offer rapid relief, sometimes within days. But when bursitis is linked to chronic mechanical overload, gluteal tendinopathy, or poor hip stability, injections do nothing to fix the underlying issue.

Research shows that patients who report short-term pain reduction after a cortisone injection, less than 30% maintain that relief beyond six months (Mellor et al., 2020). Worse still, recurrence rates exceed 80% within a year when mechanical issues are not addressed (McGovern et al., 2021). Repeated injections have also been shown to weaken tendon structure and inhibit collagen repair, increasing the risk of rupture or chronic tendinopathy (Coombes et al., 2013).

This is why injections should never be the only treatment. They can temporarily ease pain — but unless the cause of excessive friction and overload is corrected through targeted rehab, the pain usually returns.

There are some instances where cortisone may be helpful:

When pain is severe and preventing all movement, a single injection may create a window to begin treatment and rehabilitation.
In short-term scenarios where immediate relief is needed (e.g. travel or work commitments).
If rehabilitation has been completed and all mechanical issues have been addressed, but residual inflammation still lingers.

But even then, the injection should be used strategically — not as a standalone solution.

Patients who rely solely on pain relief without correcting dysfunctional movement patterns often fall into a cycle of repeated injections, worsening the problem. Masking pain without fixing the cause encourages a premature return to activity, which leads to further stress on the irritated tissue. Studies confirm that repeat cortisone use can reduce the effectiveness of each subsequent injection and increase tissue degeneration over time (Coombes et al., 2013).

What About Surgery?

Surgery for trochanteric bursitis is rarely needed. The vast majority of cases respond well to conservative treatment, including hands-on therapy, neuromuscular retraining, and targeted rehabilitation. But in rare situations — such as gluteal tendon tears that fail to heal, persistent bursitis unresponsive to treatment, or structural abnormalities like bone spurs — surgical intervention may be considered.

Surgical options may include:

Bursal excision (removal of the bursa),
Gluteal tendon repair if significant tearing is present,
IT band release in cases of extreme lateral compression.

However, even when surgery is performed, rehabilitation remains essential. Removing the bursa or repairing the tendon doesn’t fix the movement dysfunctions that led to the issue in the first place. Without correcting these through post-surgical rehab, the pain can return — even after a successful operation.

A systematic review in The Journal of Bone & Joint Surgery found that only 5–10% of patients with trochanteric bursitis required surgery, and the best long-term outcomes occurred when rehab was prioritised either before or after surgical intervention (McGovern et al., 2021).

In short: cortisone and surgery can play a role — but only as part of a broader strategy. At Clarks Healthcare, we believe the key to success is restoring optimal movement, not just masking the pain.

Why You Must Treat Symptoms and the Dysfunction — Never Symptoms Alone

Most of our patients come to my practice because they are in pain. Our first priority is to help them feel better — this is the foundation of our Relief Care phase. Once the pain begins to ease, we move swiftly into the next phase Corrective Care: correcting the underlying dysfunctions that caused the injury in the first place. Because if you don’t fix what caused the friction, the pain will come back.

From my clinical experience (and a whole host of research) the most effective treatment outcomes include both targeted hands-on treatment AND tailored rehabilitation. Calm the inflamed or painful tissue (such as the bursa or gluteal tendons) and the mechanical restrictions to set the stage for tailored rehabilitation to restore normal alignment and function. Rehabilitation without hands on treatment often fails because pain itself inhibits movement and healing. Likewise, hands on treatment without rehabilitation means almost certainly the problem will return.

This is why generic advice — like cortisone injections or “just rest” — so often fails. Research shows corticosteroid injections for trochanteric bursitis provide only short-term relief, with recurrence rates exceeding 50% within 6 months (Brinks et al., 2011). (Over studies show over 80%). Worse, repeated injections have been linked with tendon weakening and delayed healing (Dean et al., 2014).

In fact, NICE guidelines recommend manual therapy and exercise as the first line of care for lateral hip pain, rather than medication or imaging alone.

Treating the root cause is what prevents recurrence.

As we’ve discussed throughout this article, trochanteric bursitis is often the end result of mechanical overload. Maybe your gluteus medius is weak. Maybe your femurs rotate excessively inward. Maybe your pelvic control is poor, or your flat feet is destabilising the chain from below. Regardless, if we only calm your pain and skip fixing these dysfunctions, the pain will likely return.

Clinical research supports this: a 2021 study by McGovern et al. found that patients who received only symptom-focused treatment (like rest, NSAIDs, or injections) had a recurrence rate over 60% within one year. Those who also received biomechanically targeted rehabilitation had significantly better long-term outcomes.

And this isn’t theory — it’s something I see every day in clinic.

Hands-on osteopathic treatment plays a vital role in reducing pain, improving joint mechanics, and preparing the body for movement. Manual therapy techniques like myofascial release, joint mobilisation, and targeted soft tissue work not only improve comfort but have been shown to enhance circulation, reduce local inflammation, and even improve neuromuscular activation patterns. For example, a review by Bialosky et al. (2009) found manual therapy significantly improves short-term pain and function in musculoskeletal conditions — particularly when paired with exercise.

So, what does that look like in practice?

A typical care plan includes:

Accurate diagnosis of both the symptoms and the dysfunctional movement patterns.

Hands-on osteopathic care to relieve pain, restore mobility, and improve soft tissue function.

Targeted corrective exercises designed uniquely for you — not a YouTube routine or generic handout. These focus on rebuilding strength, coordination, and movement control.
Personalised care based on your unique body and goals — not a one-size-fits-all approach.

Our aim isn’t just to get you out of pain. It’s to get you back doing what you love — walking, running, climbing stairs, or simply moving without fear of the pain returning.

Hands-On Osteopathic Treatment (Relief Care)– Why It Matters and How It Works

Once we’ve accurately identified all of the tissues causing your pain i.e. the bursa, tendon, nerve etc along with the underlying dysfunctions, one start hands-on osteopathic treatment (Relief Care). Manual therapy helps to reduce pain and inflammation, restore mobility, improve joint alignment, and rebalance soft tissue tension — all of which are crucial before strengthening begins.

I know from my own clinical experience and research consistently shows that combining manual therapy with exercise leads to significantly better outcomes than manual therapy alone or likewise exercises alone. For example, a 2017 study published in Manual Therapy found that patients with lateral hip pain who received both joint mobilisation and targeted rehabilitation had a 76% greater improvement in pain and function than those who only did exercises (Reid et al., 2017). Another systematic review by Bialosky et al. (2009) concluded that manual therapy improves neuromuscular function and reduces pain more effectively particularly when paired with exercise than either approach on its own.

Manual therapy is not about “cracking” joints — it’s about helping rebalance the system so your body can heal effectively. In cases where clear joint fixation is present — such as lumbar facet locking or sacroiliac joint restriction techniques such as joint articulation and pumping or high-velocity low-amplitude (HVLA) manipulations, commonly known as joint adjustments, can rapidly restore segmental motion and reduce pain. Studies suggest that when used appropriately, spinal manipulations can improve pain scores by up to 60% in just a few sessions for mechanical dysfunction (Furlan et al., 2010). For patients stuck in a pattern of lower back tightness and hip overload, these techniques can create instant improvements in walking comfort, standing posture, and glute engagement. However, any experienced clinician will utilise a complete range of different hands-on treatment techniques never just one and will select the right ‘tools’ for the patient. In my opinion the best results are achieved when a multitude of hands-on techniques are incorporated together never just one.

Patients who receive early manual therapy are up to 40% less likely to need surgical intervention for lateral hip pain compared to those who start with exercises alone (Bennell et al., 2018).

Here’s how we may do that:

Joint Mobilisation, Manipulation, and Pelvic Articulation – Releasing Restrictions That Drive Dysfunction

Many patients with bursitis have underlying joint restrictions that cause faulty mechanics. When the hip doesn’t glide properly or the pelvis is misaligned, it forces surrounding tissues to compensate — often overloading the gluteal tendons and bursa.

Targeted soft tissue therapy to the bursa – Particularly helpful for reduce pain and inflammation at the symptom site and surrounding soft tissues.
Posterior hip capsule mobilisation – Particularly important in patients with femoral anteversion or reduced posterior glide, as these patterns increase lateral hip pressure. One study found that restricted hip mobility increases lateral hip compressive forces by up to 35%, significantly raising the risk of gluteal tendinopathy and bursitis (Semciw et al., 2019).

Pelvic balancing techniques – Osteopathic articulation of the pelvis helps restore even force distribution, reducing chronic strain on one side.

Lumbar and sacroiliac joint mobilisation or manipulation – Restrictions here can alter lumbopelvic rhythm, increasing lateral hip load. Where joint fixation is present, Joint articulation, pumping, manipulation/adjustment, and HVLA (clicking) techniques may be used to release the restriction and restore segmental function. There’s a vast range of techniques available from very gentle and subtle techniques to more direct and focused.
ELDOA techniques – Targeted fascial decompression methods that create space around the hip, spine, and sacroiliac joints, supporting long-term hip alignment, decompression, postural correction, and joint proprioception. These techniques are particularly helpful in patients with longstanding postural adaptations or asymmetries, such as one-sided hip pain, lumbar disc herniations (slipped discs) or scoliosis.

Fascial Release & Soft Tissue Therapy – Easing the Load on the Bursa

The lateral hip is rich in fascia — and when this becomes stiff or adhered, it creates abnormal tension across the IT band, TFL, and gluteal tendons. Instead of just “releasing” tight muscles, we focus on restoring fascial glide and balance.

Think of fascial tissue as the body’s internal cling film — when it’s twisted or stuck, everything underneath suffers. Releasing these layers helps decompress the area around the bursa and restore normal function.

Gluteus medius and minimus release – Essential when tendinopathy coexists with bursitis — which studies show happens in up to 88% of cases (Grimaldi & Fearon, 2015).

IT band decompression – While the ITB doesn’t stretch, myofascial release can improve its mobility across the greater trochanter, reducing friction and irritation.

Thoracolumbar and lumbar fascia work – Tension in the back fascia can shift loads down to the hip. Releasing these areas restores lumbopelvic rhythm and stability.

Inflammation control – Specific techniques (such as effleurage, lymphatic drainage, myofascial stretching, and neuromuscular therapy) help reduce swelling and local inflammatory by-products, accelerating recovery.

A study in Physical Therapy in Sport (2018) found that manual therapy (such as Osteopathy) paired with neuromuscular re-education led to 30% faster return to activity in patients with gluteal tendinopathy than exercise alone. And a separate meta-analysis in Spine Journal (2010) found that spinal manipulation was significantly more effective than medication or usual care for mechanical pain in the lumbar region, reinforcing the value of osteopathic techniques in relieving dysfunction.

Why Hands-On Therapy should always be included.

Better pain outcomes, particularly when combined with corrective exercise.
Quicker return to normal activities and sports.
Significantly lower rates of recurrence.
Patient confidence, by relieving pain and supporting all stages of recovery.

Before asking the body to work harder, we need to make sure it’s moving well. That’s what hands-on osteopathy provides the foundation.

Manual therapy such as Osteopathy acts like “clearing the road” before driving — it removes the barriers so your muscles and joints can be retrained to perform as they’re meant to.

This is why we never skip it.

Corrective Care – Rebuilding Strength, Control, and Function

Once hands-on treatment has reduced your pain and restored mobility, the next stage is ‘Corrective Care.’ Without this stage, patients may feel better temporarily but the underlying dysfunction is still there and is highly likely to return.

For corrective/rehabilitation exercise to be successful they need to be specific for you. It’s not about just strengthening the glutes or following generic exercises from a sheet. It’s about restoring the right muscles to fire at the right time, under load, during real-life movement.

I’ve seen thousands of patients over the years that came to me due recurrent hip bursitis, despite diligently following NHS care. The reason their pain returned was almost always due to one following:

Being misdiagnosed
Using anti-inflammatories or cortisone as a standalone treatment
Exercises given were far too generic to help.
Exercises focused on isolated muscle groups e.g. glutes or using resistance bands and therefore had little real-world benefit.
The patient stopped as soon too early (normally as soon as they felt better)

Throughout this article, I’ve repeated how trochanteric bursitis rarely arises by itself and never for no reason. The pain is often caused by long term deeper dysfunctions: e.g. anterior femoral rotation, poor lumbopelvic control, movement dysfunction, gluteal inhibition, overactive TFL, flat feet, or stiff thoracic and lumbar segments etc. Each of these issues contributes to the way force travels (or fails to travel) through the body. And this is where corrective exercise comes in — not to isolate and “fix” one muscle group, but to retrain the entire system.

This applies to everyone, not just athletes. Whether you are a retired person wanting to walk confidently without pain, a parent lifting your child, or someone who is active wants to return to the gym or sport — the principles remain the same. The rehab process is personalised, progressive, and anchored in how each body moves in the real world and the demands you are going to place on it.

A 2021 study in The Journal of Bone & Joint Surgery found that patients who underwent long-term movement re-education had a 70% lower risk of recurrent hip pain (McGovern et al., 2021). Meanwhile, a 2020 review in Musculoskeletal Science and Practice found that patients who only received cortisone injections or minimal rehab were up to 3 times more likely to experience recurring hip pain within 12 months. In contrast, structured rehab — combining manual therapy, exercise, and functional retraining — had recurrence rates as low as 5%.

Rebuilding Correct Movement: From Dysfunction to Integration

Step 1: Wake Up the Right Muscles

After hands-on care has calmed pain and inflammation, unlocked stiff joints, and reset dysfunctional tissue tone, our next job is to get the right muscles firing properly again. This is why we may need to include some of the following:

Side-lying abduction tests often reveal poor glute activation and excessive TFL firing. A 2018 study found that retraining this pattern reduced hip pain by 40% in just 8 weeks (Dickinson et al., 2018). We utilise a range of extremely specific, targeted exercises to retrain these muscles.
Hip and pelvic strengthening and ELDOA postures help restore posterior chain, strength, endurance, and function and decompress overloaded hip tissues.
Segmental spinal stabilisation drills reintroduce control at the lumbopelvic region — a must if poor core function contributed to overload in the first place.
Core conditioning and sequencing — especially targeting the transversus abdominis, multifidus, and pelvic floor — ensures the core fires correctly and maintains optimal spinal, pelvis and hip position and support. Core conditioning is not about looking good but ensuring muscles do the job they were designed for.

Key concept: A muscle that’s strong but firing late or compensating is still dysfunctional.

Step 2: Train Pelvic Control Under Load

Once muscles are firing, we need to teach them to work properly together so you can life without fear of relapse — This means training pelvic control during walking, stair climbing, squatting, running, jumping, twisting, changing direction and under load. We may include:

Single-leg stance drills help patients regain proprioceptive awareness, balance stability and confidence when on one leg. Since walking is essentially a series of one-legged stances, this is a cornerstone of functional rehab.
Step-downs, lateral lunges, and resisted walking drills retrain eccentric lowering control and reduces the load on the lateral hip. For example, eccentric glute loading helps absorb force gradually and correct a Trendelenburg dysfunction— a key to preventing impact overload on the bursa.
Gait retraining is essential. Walking correctly without compensating, backwards walking exercises, cueing strategies (“soft knees,” “push the floor away”), and tripod foot drills help correct poor walking mechanics. Even after pain resolves, many patients walk with locked knees or poor hip extension — patterns that continue to stress the body including the bursa.

A study in Gait & Posture found that gait retraining alone reduced lateral hip pain recurrence by 50% in six months (Semciw et al., 2019). Patients who perform dynamic pelvic control training show lower recurrence rates of bursitis than those doing strength-only programs (Grimaldi & Fearon, 2015).

Step 3: Never Neglect Mobility

Do you have stiff hips — or even a stiff lumbar spine, knees, or feet? These chronic restrictions and lack of flexibility changes how force flows through your body and may lead to your pain. That’s why we may need to include:

Mobility maintenance even when you are better. We include dynamic and static stretching, and mobility exercises to keep you supple and moving well. They are often simple to do at home e.g. while watching TV in the evenings.
ELDOA and fascial stretching — These decompression postures support long-term joint health and undo the structural changes caused by sitting, poor posture, or old compensation patterns.

Step 4: Restore Real-World Movement Patterns

Corrective exercise must translate into daily life and be practice and useful. It’s not enough to be strong — you must move well. Therefore, your treatment may need to include:

Squat/lunge retraining — Whether someone is squatting to lift shopping bags, tie their shoes, get up from the floor, to get out of a car or playing sports, you must squat/lunge correctly with a good gravity line. Poor technique leads to problems somewhere in your body. For every age group we retrain hip hinge, foot placement, gravity lines and even glute engagement. One study in Clinical Biomechanics showed that retraining squats significantly lowered recurrence of hip pain for all ages (Neumann et al., 2018). Older adults with poor squat mechanics have up to 2.5x the fall risk (Muehlbauer et al., 2015). Restoring squat function isn’t optional — it’s foundational.
Sit-to-stand training to the height of a chair is amazingly practical and beneficial for older adults or those with severe arthritis.
Shock absorption drills (heel raises, soft knee walking, toe taps) improve force distribution when walking.
Stair climbing/descending, directional changes, and balance work layer in resilience for real-life demands around the home at in the outside world.

Train all movement patterns and in combination. In life every movement we do is one of or a combination of a pull, push, squat, lunge, twist, bend, and gait. For example, to get out of your car is a lateral lunge, bend, and twist. To throw a ball is a lunge, twist, and push. Therefore, although in earlier stages or recovery for hip pain we may train certain muscles by themselves, we always aim to integrate all movement patterns. That way our patients recover well, move well, and have very little recurrence.

Why Generic Exercises May Fail

Every patient presents differently. A “glute bridge” is a very generic exercise (often done poorly), it may help one person but frequently aggravates symptoms in another. That’s why our exercise plans are built on assessment-first principles, not a one-size-fits-all checklist and guessing.

A generic exercise sheet of one-size-fits-all exercises have a high dropout rate. In my experience when patients know why they are doing certain exercise and how exactly they should perform them tend to stick to them.

Research in JOSPT found that patients receiving individualised programs had significantly better outcomes and lower dropout rates than those given standard home exercise sheets (Bennell et al., 2017).

This is why we never skip steps, we never give generic exercises for the sake of it, and every exercise is adapted for our patients.

But even with great progress, there’s one critical thing that separates those who stay pain-free from those who don’t: what happens next.

Why Does Trochanteric Bursitis Keep Coming Back?

One of the most frustrating things for patients is when their bursitis returns — sometimes after weeks, sometimes months later with patients saying, “but I thought it had gone?”

The truth is that pain relief is not the same as recovery. We often see patients make great early progress — pain fades, movement improves. But healing isn’t just about what gets better in the first month. It’s about what stays better over time. And that’s where many people unknowingly slip.

Unless your original dysfunctions are corrected — whether it’s poor pelvic control, gluteal inhibition, tight hips, faulty walking mechanics (or any of the issues I have discussed in this article) — the same dysfunctions that overloaded and caused excessive friction to your bursa will return. And with them, so will your pain.

A 2021 study in The Journal of Orthopaedic Research showed that patients who stopped rehab after pain relief had a 50–60% recurrence rate within 6 months (McGovern et al., 2021). In contrast, those received hands on therapy and continued completed proper strength training and movement correction had recurrence rates under 5%. That’s a substantial difference.

We support our patients through a complete care plan. From getting them feeling better and moving better, to correcting the underlying dysfunctions, all the way back to normal activities. When our patients are proactive and commit to their recovery they achieve impressive results with an extremely low rate of recurrence.

7 Mistakes That Cause Bursitis to Return — And How to Avoid Them

Before we dive into those mistakes, it’s worth understanding what often causes even a well-managed recovery to unravel. These aren’t failures — they’re common traps that nearly everyone risks falling into unless guided properly. Too often, people following the same pattern:

Pain improves.
Treatment/exercises stop.
Underlying dysfunctions remain.
Pain returns.

Stopping Hands-On Treatment Too Early
Manual therapy such as Osteopathy lays the foundation — effectively reducing pain, improving joint mobility, and resetting tissue tone. But some patients stop as soon as they start to feel better to ‘see how it goes.’ This is a mistake!

Hands-on treatment helps tremendously but it’s not a magic pill and it forms a part of the care plan. Similarly chronic issues such as facet joint restrictions, SIJ dysfunction, capsular tightness etc takes years to develop so they will need disappear in one session and may need a course of treatment to hold. Once they do hold, it’s still vital to complete tailored corrective exercises. Stopping treatment early leaves your recovery incomplete, and your pain will likely return.

Stopping Corrective Exercise Too Early
When your pain improves and you feel better, it’s easy to assume you are back to normal and stop your exercises prematurely thinking your problem is completely gone. However, pain relief doesn’t mean full recovery.

Under the surface even though you are feeling better, your body hasn’t finished correcting the underlying dysfunction. Glute strength, pelvic stability, and neuromuscular timing takes 8–12 weeks or more to fully return, other issues can take multiple months. If rehab is cut short because you feel better, the dysfunction returns quietly, and the pain follows.

Relying on Injections as a ‘Fix’
Cortisone Injections are NOT treatment; they are symptom management. Cortisone injections are rarely needed and although they can calm symptoms, they NEVER fix movement dysfunctions, weaknesses, or any of the list of issues which could have resulted in your pain. Studies show 60–80% of patients experience a return of pain within 6 months after injection unless proper rehab is done (Mellor et al., 2020). Worse, repeated injections may weaken the gluteal tendons and cause degeneration over time (Coombes et al., 2013).
Overstretching and Excessive Foam Rolling
Muscles can easily be overstretched with the faulty assumption they just need more and more stretching. Repeated stretching and massage of the IT band or lateral hip increase bursal compression leading to further pain and inflammation (Semciw et al., 2019). And foam rolling — while useful in the right context — can cause more harm than good when used aggressively over the bursa or IT band. I see patients all the time who are obsessed with ‘working the knots out,’ but are unknowingly damaging the bursa, tendon, and fascia, thinking they’re helping. Yes, we prescribe specific stretches tailored for the patient but not in excess and strength and control should come first.
Returning to Activity and Sports Too Soon
Returning to running, sports, or even fast walking before restoring shock absorption and pelvic control is a fast track to flare-ups. We understand our patients want to get back to normal life but impatience and rushing this phase sets you up for another round of pain and a longer recovery time.
Ignoring Everyday Movements and Habits
You might master the strength exercises and use of resistance bands or generic bridges — but if your daily habits don’t change i.e. how we sit for work, sit on the sofa, our posture, how much time we spend bent over looking at our phones, how we stand and generally move, it can easily undo your progress.
Following Exercises Found Online or from a Well-Meaning Friend
YouTube videos, Instagram reels, or advice from a friend might seem helpful — but the wrong exercises and advice often do more harm than good! These suggestions don’t take into account the complexity of your biomechanics, postural imbalances, or specific tissue overloaded. Even seemingly harmless moves like bridges, clamshells, or hip stretches can irritate the area if done with poor form or at the wrong time in recovery. I’ve seen so many patients whose pain worsened after trying online routines or listening to a friend. Your friend or youtuber hasn’t assessed you therefore it is just a guess. You wouldn’t take someone else’s prescription because it helped them so why would you follow someone else’s advice? — it’s a clinical process built on a thorough assessment. Trust your clinicians plan, not a youtuber, friend colleague or google search.

Conclusion:

Most people come to us because they want to stop hurting. But what most really want is to get back to living their normal life without the worry of hip pain. That might mean walking the dog, lifting the grandkids, playing sports, or just moving without flinching. And yes, for most, that’s absolutely possible — but it only happens when we address what’s causing the pain, and why it happened in the first place.

Trochanteric bursitis doesn’t return because of bad luck. It returns because something was left unresolved — a weak link, a faulty pattern, or simply stopping treatment or rehab too soon. And if those things are not corrected, it’s only a matter of time before the pain creeps back.

The good news experienced practitioners know how to get you feeling better and minimise the chance of your pain retuning. I’ve helped thousands of patients over the last 20+ years — from active pensioners to busy parents, teenager to professional athletes. What helped them all personalised is care plan based on a detailed assessment, hands-on treatment, tailored exercises, and movement retraining and never symptom only care or a generic sheet of exercises.

When patients receive the right advice, treatment and exercises and follow it through to the end their pain fades, their movement improves, and recurrence rates plummet.

If that’s the kind of care you want — we’re here to help.

I hope you have found this article informative, interesting, and helpful.

Warm regards,

Michael Clark
Registered Osteopath
Rehabilitation and Corrective Exercise Specialist
Holistic Lifestyle Coach
Co-founder of Clarks Healthcare

For personalised support regarding any of the issues discussed in this article, if you are experiencing pain or recurring issues, or if you wish to improve your health, consider consulting with me or my team at Clarks Healthcare. You can reach us at 01268795705

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Meet Michael Clark, a registered Osteopath, rehabilitation specialist, and holistic lifestyle coach. As the co-founder of Clarks Healthcare in Benfleet, Essex, Michael, alongside Lisa and their dedicated team, has guided over 8,000 patients towards pain relief and improved health over the past 21 years.

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