Choose an answer, then open any option to work its reasoning.
MSK · Lower Extremity
The Lateral Hip: Bursa, Tendon, Pinch, and Snap
Side-of-hip pain is never "just bursitis" until you have said why. The greater trochanteric trio, the CAM pinch of the young athlete, and the IT band that fires with every stride. Route by geography: lateral, groin, or buttock, then by age and mechanism.
What this page makes you able to do
- Split the greater trochanteric pain syndrome umbrella: trochanteric bursitis versus gluteal tendinopathy by point tenderness and abductor weakness
- Route groin pain in a young active adult to femoroacetabular impingement, and name the CAM-pincer and FADIR-alpha angle pairs
- Localize the snapping hip by where the click lives, and run the IT band and piriformis tests
- Trigger on the red flags: groin pain in a runner, rest pain in the elderly, and femoral nerve findings
- Dr. Fatima Ali, DOPsychiatry residentPrimary reviewer
Last reviewed
The pearl
Lateral hip pain over the bone with point tenderness and pain on resisted abduction is greater trochanteric pain syndrome, and the treatment is the tendon's therapy: gluteal strengthening, not rest. Groin pain in a young athlete is FAI until the FADIR and the alpha angle say so. And a click is a map: lateral is the IT band, groin is the iliopsoas, deep and painful is the labrum.
Prove it
Opening question
Answer before you read anything, then carry the lateral-groin-buttock reflex through every section.
A 58-year-old woman has 4 months of right lateral hip pain. It is worst at night when she lies on the right side, so she sleeps on her back, and it is reproduced by rising from a chair and by climbing stairs. She denies groin pain, falls, and fever. Examination shows point tenderness directly over the greater trochanter and pain with resisted hip abduction and with the heel-drop test. Hip flexion, internal rotation, and the FADIR test are painless, and she has no abductor weakness.Which of the following is the most likely diagnosis?
- Why this is rightLateral hip pain worse lying on the affected side with point tenderness directly over the greater trochanter and reproduction by resisted abduction and the heel-drop test is the classic greater trochanteric pain syndrome picture. The bursa sits right on the bone, so the tenderness is maximal there, and the pain is mechanical. Rule: lateral pain over the bone, worse on the side, reproduced by resisted abduction: GTPS.
- Why this failsGluteal tendinopathy sits in the same umbrella, but it shows abductor weakness with a Trendelenburg sign, and its tenderness is more posterior and superior over the tendon insertion, not directly on the bone. This stem has no weakness and no Trendelenburg. Rule: bursitis is tender on the bone and strong; tendinopathy is weak and tender off the bone.
- Why this failsFAI lives in the groin of young active adults and reproduces pain on flexion with the FADIR test. This patient is 58, the pain is lateral, and the FADIR test is painless. Rule: groin plus FADIR is impingement; lateral plus heel-drop is the trochanter.
- Why this failsIT band friction fires at the lateral knee in runners after mileage increases, with a tight Ober test. The tenderness here is over the trochanter, not the knee, and there is no running story. Rule: the IT band hurts at the knee; the bursa hurts on the bone.
Work the reasoning
Lying on the affected side compresses the bursa and the underlying tendon against the trochanter, so the pain wakes the patient when she rolls over. It is mechanical, not inflammatory.
Dropping the extended leg loads the gluteus medius and its tendon, which stretches the bursa and reproduces the trochanteric pain. Together with resisted abduction it locks in the GTPS diagnosis.
Physical therapy with gluteal strengthening, activity modification, and analgesia; a guided corticosteroid injection for persistent pain. Most GTPS resolves with this combination.
The answer is A: trochanteric bursitis within GTPS. Lateral pain over the bone, worse on the side, reproduced by resisted abduction: the bursa is the victim, the tendon is the target.
GTPS IS AN UMBRELLA
The Trochanteric Trio: Bursa, Tendon, and Band
Greater trochanteric pain syndrome is the umbrella over three neighbors: trochanteric bursitis, gluteal tendinopathy, and IT band friction. The exam splits them before any image does.
Trochanteric bursitis is lateral pain worse lying on the affected side, with point tenderness directly over the greater trochanter and pain reproduced by resisted abduction and the heel-drop test. The bursa is usually the victim of tendon friction, which is why the treatment targets the tendon.
Gluteal tendinopathy is the more common driver: the gluteus medius and minimus tendons fail under load, and the stem gives abductor weakness, a Trendelenburg sign, and pain on resisted abduction with tenderness posterior and superior to the bone. When the tendon tears, it is the "rotator cuff of the hip."
IT band friction over the trochanter is the runner's third neighbor: lateral pain that runs from the hip toward the lateral knee, worse with mileage (see knee-front-pain).
Most GTPS resolves with physical therapy: gluteal strengthening plus activity modification, with a guided corticosteroid injection for persistent pain. Rest alone makes it worse, because the weak abductors are the reason the tendon is overloaded.
From the Attending
Every lateral hip stem is a two-question exam: is the tenderness on the bone (bursa) or off it (tendon), and is the abductor weak (tendinopathy) or strong (bursitis)? Point tenderness on the bone plus pain on resisted abduction with full strength is bursitis, and the answer is gluteal strengthening, not an MRI. Know your trio. Every time.
Flip between the two neighbors that share the umbrella.
CAM AND PINCER, YOUNG AND ACTIVE
The FAI Pinch: Groin Pain in the Young Athlete
Femoroacetabular impingement is the young active adult with deep groin pain that worsens with sitting and hip flexion. CAM bumps belong to young men, pincer overcoverage to women, and the FADIR test finds both.
The classic stem is a 24-year-old athlete with insidious groin pain, worse after sitting for long periods and with deep hip flexion, and reproduced by the FADIR test: flexion, adduction, and internal rotation pinches the femoral head-neck junction against the acetabular rim. Pain in the groin, not the lateral hip, is the routing clue.
CAM morphology is a bump on the femoral head-neck junction that makes the head aspherical; it dominates in young men. Pincer morphology is acetabular overcoverage pinching the neck against the rim; it dominates in women in their thirties and forties. Both shear the labrum, and labral tears are the frequent companion (see hip OA in oa-ra-jia for the older, stiff, loss-of-rotation picture).
Imaging starts with plain films. The alpha angle measured on a lateral radiograph is abnormal above 55 degrees and names the CAM bump; the crossover sign on the AP view names pincer overcoverage. MRI adds the labrum and the cartilage.
Treatment is conservative first: physical therapy and activity modification for months, then hip arthroscopy with labral repair and osteoplasty for the refractory patient. The boards grade PT-first every time.
Work the soccer player one hint at a time.
COXA SALTANS
The Snapping Hip: Three Clicks, One Map
A click is a map: lateral and visible is the IT band over the trochanter; groin and audible is the iliopsoas over the iliopectineal eminence. Deep, painful, and mechanical is the labrum.
External snapping hip is the most common: the iliotibial band or the gluteus maximus slips over the greater trochanter with hip flexion and extension. The snap is lateral, audible, and often visible, and dancers and runners get it from repetitive motion.
Internal snapping hip is the iliopsoas tendon snapping over the iliopectineal eminence or the lesser trochanter. The click is deep in the groin, audible but usually not visible, and it may be reproduced by moving the hip from flexion-abduction-external rotation into extension.
Intra-articular causes are the trap: a labral tear or loose body clicks deep with painful catching and locking, and this route crosses to the FAI workup (see hip fracture and AVN in fractures-trauma for the bone emergencies).
Most snapping hips are benign: reassure, and treat with PT to stretch the IT band and iliopsoas and strengthen the hip. Surgery, usually endoscopic release, is rare and reserved for refractory painful snapping.
Coxa Saltans
AMARA CHEN
32. Marathoner. A click in the right hip with every stride.
Two tendons cross this hip, and each can snap. The IT band rides the lateral thigh over the greater trochanter; the iliopsoas dives through the groin over the iliopectineal eminence. The click tells you which one is talking.
THE EXTERNAL SNAP
Lateral. Audible. Visible. The band over the bone.
Flexion pulls the band forward over the trochanter; extension snaps it back behind the bone. Lateral, audible, visible: the external snap, the most common type.
THE INTERNAL SNAP
Groin. Audible. Hidden. The psoas over the eminence.
RouteHip flexion-extension, then a click. Lateral and visible over the bone: IT band over the greater trochanter. Deep groin click with the hip moving from flexion-abduction-external rotation into extension: iliopsoas over the iliopectineal eminence. Deep click with painful catching and locking: intra-articular, the labrum, and the FAI workup starts.
PatternExternal snapping is the most common and the IT band is the usual suspect. Internal snapping hides in the groin, audible but not visible. Painful mechanical clicking is never a benign snap: think labrum and loose body.
PearlA snap without pain is benign: reassure and stretch (IT band and iliopsoas) with hip strengthening. Surgery is rare. The click that hurts, catches, or locks is the only click that gets imaging.
The iliopsoas tendon snaps over the iliopectineal eminence as the hip moves from flexion to extension. Groin, audible, hidden: the internal snap. Painless: stretch and strengthen; painful or locking: image it.
Route the click: which door fits which snap?
A patient has a clicking hip. Which door fits which click?
OBER LOCKS THE LEG
The IT Band and the Runner: Lateral Knee Pain With a Hip Story
Iliotibial band syndrome is the runner with lateral knee pain after a mileage jump. The Ober test locks the diagnosis, and the treatment is the band, the glutes, and the form.
IT band syndrome is lateral knee pain in runners, classically after increasing mileage or adding downhill work. The band rubs against the lateral femoral epicondyle as the knee flexes and extends, and the pain builds with repetition and fades at rest (see knee-front-pain for the anterior knee differential).
The Ober test is the bedside lock: side-lying with the affected leg up, the examiner abducts and extends the hip, then releases. A tight band holds the leg up instead of dropping to the table, which reproduces the lateral tension. It tests the structure, not the diagnosis, but it is the classic positive.
Treatment is mechanical: foam rolling and stretching of the band, gluteal strengthening, and running form and cadence work (shorten the stride, reduce downhill load), with relative rest of the aggravating mileage. Injection is for the refractory case.
The lateral thigh has its own map. Burning pain and numbness over the lateral thigh that worsens with a tight belt is the lateral femoral cutaneous nerve, meralgia paresthetica, a nerve story not a band story (see nerve-palsies). Pain is the band; numbness is the nerve.
Localize the lateral complaint.
A 29-year-old marathoner has 3 weeks of lateral right knee pain that began after a long downhill training run. It hurts during the run and resolves at rest. Which finding would best support iliotibial band syndrome over the alternative causes of lateral knee pain?
A. Tenderness over the lateral epicondyle with a positive Ober test. The band rubs the lateral femoral epicondyle with repetitive knee flexion, and Ober demonstrates the tight band: the leg stays abducted instead of dropping. That is the IT band signature. B. Lateral thigh numbness. Burning numbness over the lateral thigh is the lateral femoral cutaneous nerve (meralgia paresthetica), not the IT band, and a waistband does not move the knee. C. Effusion and anterior drawer. That is an ACL story: trauma, instability, and hemarthrosis, not a runner with lateral pain. D. Patellar tendon pain. That is patellar tendinopathy, anterior and over the patellar tendon, not lateral. Rule: lateral knee pain in a runner with a tight Ober test is the IT band until proven otherwise.
PIRIFORMIS AND THE SCIATIC
The Deep Gluteal: Buttock Pain That Travels
Piriformis syndrome is buttock pain with a sciatica flavor, worse on sitting, reproduced by the FAIR test. Before the muscle gets the blame, the lumbar spine has to be cleared.
Piriformis syndrome is the deep buttock pain with radiation down the posterior thigh that comes from the piriformis muscle irritating the sciatic nerve as it crosses the sciatic notch. Sitting, which compresses the muscle, worsens the pain, and the FAIR test, flexion-adduction-internal rotation, stretches the piriformis and reproduces the pain.
The exam is the split: piriformis gives local tenderness over the muscle and a positive FAIR test with a normal neurologic exam. Lumbar radiculopathy gives dermatomal weakness, reflex loss, and pain that worsens with Valsalva, and it does not care about the piriformis stretch (see sciatica-localizer and spondylo-confusion).
Ischiofemoral impingement is the rarer deep-gluteal neighbor: pain between the ischium and the lesser trochanter, reproduced by hip extension with adduction, and seen on MRI as narrowing of the ischiofemoral space.
Treatment of piriformis is conservative: PT with stretching and strengthening, activity modification, and NSAIDs, with a guided injection for the refractory case. The boards grade the diagnosis split, not the injection.
On rounds, your attending stops outside the exam room: a 46-year-old with buttock pain and sciatica, worse after two hours in a desk chair.
Attending
Sitting makes it worse, standing makes it better. Reflexes are intact, strength is full, and the FAIR test lights up the pain. Where is the lesion?
You
The sciatic notch, not the spine. Local tenderness over the piriformis, a positive FAIR test, and a normal neuro exam: that is piriformis syndrome, not a disc.
Attending
Then your hands are on the muscle, not the MRI. Stretch it, strengthen it, and save the scan for the spine symptoms.
Buttock pain with a normal neuro exam is a muscle story. The FAIR test is the hand on the muscle.
Match each buttock pain to its door.
AVN, STRESS, AND THE FEMORAL NERVE
The Red-Flag Split: When Lateral Hip Pain Is Not Mechanical
Groin pain in a runner, rest pain in the elderly, and a femoral nerve picture are never injection cases. Each one names its own study.
Avascular necrosis of the femoral head follows steroids, alcohol, and sickle cell disease, and it presents with progressive anterior hip or groin pain. MRI is positive before the x-ray changes, and the x-ray is normal early (see AVN in fractures-trauma).
Femoral neck stress fracture is the runner with insidious groin pain, not lateral pain: "groin pain in a runner is the femur until proven otherwise." MRI is the study, and a missed fracture can displace into a surgical emergency (see fractures-trauma).
The femoral nerve carries the L2-L4 segments out of the pelvis to the hip flexors and the quadriceps: weak hip flexion plus an absent patellar reflex is the nerve signature, and it crosses to the nerve-palsies workup.
Tumor in the elderly is the rest pain and night pain that wakes the patient, with weight loss and no mechanical trigger (see bone-tumors).
From the Attending
Lateral pain that behaves is the trochanter. Groin pain in a runner, night pain in the elderly, or weakness with a lost patellar reflex is a bone or nerve question and the answer is never an injection. MRI comes before the needle, every time. Trigger on the red flags first; the bursa can wait.
Tick every red flag you would act on today.
THREE TESTS, ONE BEDSIDE
The Exam Battery: What Each Test Proves and Misses
FADIR for the pinch, heel-drop and resisted abduction for the trochanter, Ober for the band, Trendelenburg for the abductors, log roll for the joint. Run them in order, and know what each one cannot see.
FADIR, flexion-adduction-internal rotation, reproduces the deep groin pain of FAI by pinching the head-neck junction against the rim. It is sensitive but not specific: a positive test can also be a labral tear, and a negative test in a stiff hip does not clear the joint.
The heel-drop test, dropping the extended leg, plus resisted abduction reproduces the lateral pain of GTPS. The Ober test locks the IT band: the leg stays abducted on release. The Trendelenburg test shows abductor weakness: the contralateral pelvis drops during single-leg stance.
The log roll and passive internal rotation test the joint itself: pain and early loss of rotation point to OA or AVN (see oa-ra-jia), not the soft tissues around it.
No single test is the diagnosis. FADIR positive in an athlete with groin pain suggests FAI; Ober positive in an asymptomatic runner means nothing; a Trendelenburg positive with lateral pain is gluteal tendinopathy until the MRI says otherwise.
Put the lateral hip exam in order.
LATERAL, GROIN, OR BUTTOCK
The One-Screen Discriminator: Where Is the Pain?
Geography first, then age and mechanism. Lateral is the trochanteric trio or the IT band; groin is FAI, OA, AVN, or stress; buttock is the deep gluteal; a click is the map.
Run the rows in order. Lateral pain over the bone, worse lying on the side, reproduced by resisted abduction: GTPS, treated with gluteal strengthening plus injection. Lateral knee pain in a runner: IT band, Ober positive, form work. Groin pain in a young active adult: FAI, FADIR and alpha angle. Groin pain in a runner: femoral neck stress fracture, MRI. Groin pain with morning stiffness and loss of rotation in the older patient: OA. Steroids, alcohol, or sickle cell: AVN. Buttock pain with sciatica worse on sitting: piriformis, FAIR positive, normal neuro exam, spine cleared. A click: lateral is external, groin is internal, painful catching is the labrum.
Age and mechanism are the tiebreakers. The 24-year-old with groin pain and a positive FADIR gets plain films and PT before any MRI. The 58-year-old with point tenderness on the bone gets PT and a possible injection before any MRI.
The runner with groin pain, the elderly patient with night pain, and the steroid-exposed hip get the MRI before any injection.
Run the injection-versus-MRI decision. Tick every row that applies.
Red flags checked 0
Prove it
Walkthrough: the lateral hip in seven cases
Original practice scenarios, one at a time. Choose an answer, then open any option to work its reasoning.
Clinical walkthrough
