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Soft Tissue Hip Pain Disorders

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About Soft Tissue Hip Pain Disorders

Soft-tissue hip disorders are a group of conditions characterized by pain arising from the peri-articular soft tissues of the hip, including tendons, bursae, muscles, and related connective tissues, rather than from primary intra-articular joint pathology. These conditions are commonly load-related and may develop gradually in response to cumulative mechanical stress or following changes in activity, work demands, or biomechanics.

Common presentations include greater trochanteric pain syndrome (GTPS)/gluteal tendinopathy, proximal hamstring tendinopathy, and hip flexor or adductor-related soft-tissue pain. Symptoms may overlap with lumbar spine or pelvic conditions.

Most soft-tissue hip disorders are managed conservatively, with an emphasis on education, activity modification, and progressive rehabilitation.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Soft Tissue Hip Pain Disorders Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity.
  • Main complaint: Location (lateral hip, anterior hip/groin, deep buttock), onset (gradual vs acute), duration, radiation, frequency, intensity, character, aggravating/relieving factors (stairs/hills, walking, running, prolonged sitting, side-lying), associated symptoms (e.g., back pain, leg symptoms, clicking/catching, weakness).
  • Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
  • Health, lifestyle, and history: Past medical conditions (e.g., osteoarthritis, low back pain, inflammatory disease, diabetes), medications (including anticoagulants/corticosteroids where relevant), supplements, injuries/hospitalizations/surgeries, exercise and training history (recent load changes, hills, speed work), sleep habits (including side-lying tolerance), smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment (standing, lifting, stairs, prolonged sitting).
  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation, access to care and ability to modify work/physical demands.
  • Previous treatments and responses: Document prior treatments, effectiveness, and any adverse effects.
  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
  • Flag considerations: Identifyred, orange, and yellow flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS) and diagrams.
  • Function and Participation: Evaluate impact on daily activities (LEFS, PSFS, WHODAS).
  • Recovery: Use Self-rated recovery scales.
  • Quality of Life: Assess using tools such as SF-12.
  • Work/school Status: Monitor participation and return to activities.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient Feedback: Gather and integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

  • Suspected septic arthritis: Acute onset of severe hip or groin pain, inability to weight-bear or move the hip, fever or systemic illness, hot or swollen joint.
  • Suspected fracture or major trauma: History of significant trauma (e.g., fall, motor vehicle collision), deformity, severe pain with minimal movement, or inability to weight-bear.
  • Progressive neurological compromise: New or worsening neurological deficits, saddle sensory disturbance, or bowel or bladder dysfunction suggestive of serious spinal pathology.

ACTION: Refer to appropriate medical provider:

  • Possible malignancy or serious systemic disease: History of cancer, unexplained weight loss, persistent or worsening night pain, constitutional symptoms.
  • Inflammatory or infectious conditions: Prolonged morning stiffness, multi-joint involvement, systemic inflammatory features, or signs of infection.
  • Stress fracture or avascular necrosis: Deep, activity-related hip or groin pain that worsens with weight-bearing and does not improve with rest, particularly in individuals with risk factors (e.g., corticosteroid use, bone density disorders).
  • Intra-articular hip pathology requiring further evaluation: Mechanical symptoms such as true locking or catching, marked loss of hip range of motion, or progressive functional decline not consistent with a soft-tissue disorder.
  • Persistent, atypical, or progressive pain: Symptoms not responding to appropriate conservative care or not fitting a mechanical soft-tissue pattern.
  • Persistent or progressive hip abductor weakness, significant gait disturbance, or failure to improve with appropriate conservative care may warrant further medical assessment to evaluate for clinically significant tendon pathology.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination  for Soft Tissue Hip Disorders
  • Observation and posture: Standing and dynamic posture, pelvic control, trunk lean, limb alignment, and symmetry.
  • Gait and functional tasks: Walking, stair ascent/descent, sit-to-stand, and single-leg tasks; note antalgic patterns, load intolerance, or compensatory strategies.
  • Pain mapping: Confirm location of symptoms (lateral hip, deep buttock, anterior hip/groin) and reproduction with functional loading.
  • Range of motion: Active, passive, and resisted hip range of motion (flexion, extension, abduction, adduction, internal and external rotation), with lumbar spine screening to differentiate hip-related versus spinal contributions.
  • Strength and load testing: Hip abductor and posterior chain strength/endurance; graded functional loading to reproduce familiar pain rather than reliance on isolated strength testing alone.
  • Palpation: Local tenderness over relevant soft-tissue structures (e.g., greater trochanter, posterior buttock/ischial region) when clinically indicated.
  • Neurological screen: Sensory, motor, and reflex testing when symptoms suggest lumbar spine or neural involvement.
  • Special tests: Use selectively to support clinical reasoning; no single test is diagnostic for soft-tissue hip disorders.
  • Imaging considerations: Routine imaging is not recommended for typical presentations; consider selectively in the presence of red flags, atypical findings, or lack of improvement with appropriate conservative care.

8. Clinical Presentations for Soft Tissue Hip Disorders

Includes greater trochanteric pain syndrome (GTPS)/gluteal tendinopathy with or without tear, proximal hamstring tendinopathy, hip flexor and adductor-related soft-tissue pain, bursitis, and other peri-articular soft-tissue conditions of the hip.

  • Definition: Soft-tissue hip disorders are conditions affecting the peri-articular muscles, tendons, bursae, and related connective tissues of the hip that are not due to serious underlying pathology requiring medical attention (e.g., infection, fracture, tumor) and are typically amenable to conservative care (e.g., education, exercise, manual therapy).
  • Pain: Hip or peri-hip pain that may be localized (lateral hip, deep buttock, anterior hip/groin) with or without referred pain.
  • Signs/Symptoms: Load- and activity-related pain; may be sharp, dull, aching, or deep; symptoms often fluctuate with activity and position.
  • Exam: Pain reproduced with functional loading and resisted movements; neurological deficits are not expected in isolated soft-tissue hip disorders.

Soft-tissue hip disorders represent common causes of non-arthritic hip pain in primary care and rehabilitation settings, with overlapping mechanisms, symptoms, and examination findings.

Greater Trochanteric Pain Syndrome (GTPS) / Gluteal Tendinopathy

  • Common presentation, particularly in middle-aged and older adults; more frequent in females.
  • Lateral hip pain, often worsening with walking, stairs, hills, prolonged standing, and side-lying on the affected side.
  • GTPS includes gluteus medius and/or minimus tendinopathy with or without partial- or full-thickness tear and may overlap clinically with bursitis.
  • Symptoms reflect compressive and frictional loading of the lateral hip structures.
  • Exam findings include lateral hip tenderness and pain reproduced with hip abductor loading; no neurological deficits.

Proximal Hamstring Tendinopathy

  • Common in physically active individuals and those with prolonged sitting demands.
  • Deep buttock pain near the ischial tuberosity, often aggravated by prolonged sitting, uphill walking or running, acceleration, or hip flexion loading.
  • Pain typically worsens with posterior chain loading rather than passive stretch alone.
  • Exam findings include pain with resisted hip extension or knee flexion; no neurological deficits.

Hip Flexor or Adductor-Related Soft-Tissue Pain

  • May follow acute strain or gradual load accumulation.
  • Anterior hip or groin pain, often activity-related (e.g., sprinting, kicking, lifting, directional changes).
  • Pain reproduced with resisted contraction or stretch of the involved muscle group.
  • Exam findings reflect local load intolerance; no neurological deficits.

Bursitis (Hip)

  • May present with localized pain and tenderness, often overlapping clinically with GTPS.
  • Pain aggravated by direct pressure, movement, or repetitive loading.
  • Exam findings include localized tenderness and pain with movement; no neurological deficits.

Clinical interpretation

  • Presentations are often non-specific and overlapping, and pain location alone does not identify a single pain generator.
  • Mechanical soft-tissue hip disorders are characterized by load-related symptom behaviour rather than constant or progressive pain.
  • Posterior hip or buttock pain may also reflect referred lumbar spine pathology or deep gluteal syndrome (sciatic nerve entrapment); neurological findings or persistent neural symptoms should prompt reconsideration of the diagnosis and referral as appropriate.
  • Failure to improve with appropriate conservative care, marked abductor weakness, or significant functional decline should prompt reconsideration of the diagnosis and consideration of further investigation or referral.
9. Treatment Considerations for Soft Tissue Hip Disorders

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across clinical practice guidelines and established clinical practices for soft-tissue hip disorders, particularly greater trochanteric pain syndrome (GTPS) and related tendinopathies. These interventions target patient-important outcomes, including pain, function, participation, and quality of life.

Management should be individualized, taking into account symptom behaviour, functional limitations, response to care, comorbidities, and contextual factors (e.g., work demands, caregiving responsibilities, access to care).

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment when selecting and sequencing interventions.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

This pathway is not prescriptive and does not list all possible interventions. Where other treatments are used, they should be applied as adjuncts to core, evidence-based care, rather than as stand-alone treatments.

Core Conservative Care 

Education and Self-Management

Education is a foundational component of care and should emphasize the mechanical and load-related nature of most soft-tissue hip disorders and the generally favourable prognosis with appropriate management.

Key elements include:

  • Reassurance and explanation of the condition and recovery expectations
  • Guidance on activity modification and load management, including avoidance of sustained compressive positions (e.g., prolonged side-lying on the affected hip)
  • Promotion of continued movement and participation using pacing strategies
  • Support for self-management behaviours (physical activity, sleep, nutrition, stress management)

Exercise Therapy

Exercise therapy is recommended as first-line treatment for soft-tissue hip disorders.

Programs should be:

  • Individualized and progressive
  • Focused on improving hip and pelvic strength, load tolerance, movement control, and functional capacity
  • Adapted to symptom response and stage of recovery

No single exercise approach has been shown to be superior. Exercise programs should align with patient goals, functional demands, and tolerance. 

Manual Therapy

Manual therapy may be used as an adjunct to support pain modulation, movement confidence, and engagement in active rehabilitation.

Manual therapy should:

  • Be integrated with exercise and education
  • Not be used as a stand-alone intervention

Adjunct or Escalation Options (Selected Cases)

Corticosteroid Injections

Corticosteroid injections may provide short-term pain relief but are not recommended as stand-alone or first-line treatment.

They may be considered:

  • When pain significantly limits participation in rehabilitation
  • As a temporary adjunct to enable engagement in exercise

Extracorporeal Shockwave Therapy (ESWT)

ESWT may be considered for persistent pain that has not responded to appropriate conservative care.

  • Evidence supports short-term improvements in pain and function
  • Use should be selective, with attention to patient preference, cost, and availability

Considerations for Tendon Tears

  • Conservative care remains first-line, even in the presence of imaging-identified tears
  • Referral for further medical assessment may be appropriate when there is:
    • Marked or progressive hip abductor weakness
    • Significant gait disturbance
    • Failure to improve with appropriate conservative care

(NICE 2026; Kjeldsen 2024; Ladurner 2021; Gazendam 2022; NICE 2011; Nasser 2021)

10. Risk and Prognostic Factors

Risk Factors

Soft-tissue hip disorders are multifactorial. Common risk factors include:

  • Age and sex: Greater prevalence in middle-aged and older adults; higher rates of lateral hip pain in females.
  • Mechanical loading factors: Repetitive or sustained loading, rapid changes in activity level, prolonged standing or walking, stair or hill use, and sustained compressive positions (e.g., side-lying on the affected hip).
  • Biomechanical factors: Reduced hip abductor strength, altered pelvic control, and gait deviations that increase lateral hip load.
  • Occupational and recreational demands: Work or sport involving prolonged weight-bearing, repetitive lower-limb loading, or high training volumes.
  • Comorbidities: Co-existing low back pain, obesity, metabolic conditions, and reduced physical conditioning may increase risk and symptom persistence.

Prognostic Factors

Factors associated with slower recovery or persistent symptoms include:

  • High baseline pain and disability at presentation
  • Prolonged symptom duration prior to initiating appropriate care
  • Marked hip abductor weakness or gait disturbance
  • Poor load tolerance or inability to modify aggravating activities
  • Psychosocial factors, including fear of movement, low recovery expectations, or low adherence to active rehabilitation
  • Limited access to or engagement with exercise-based care

Imaging findings alone (including tendon degeneration or tears) are not reliable predictors of outcome and should be interpreted in the context of clinical presentation and functional impairment.

Prognosis

The prognosis for soft-tissue hip disorders is generally favourable with appropriate conservative management.

  • Many individuals experience meaningful improvements in pain and function with education, load management, and progressive exercise.
  • Recovery may be gradual, particularly in cases with longer symptom duration or higher baseline disability.
  • Short-term symptom relief may occur with adjunct interventions; however, exercise-based care is associated with more sustained improvements.
  • A subset of individuals may experience persistent or recurrent symptoms, particularly when risk and prognostic factors are not addressed.

Failure to improve with appropriate conservative care, or the presence of progressive functional impairment, should prompt re-evaluation and consideration of referral, rather than escalation based on imaging findings alone.

(Barratt 2017; Mellor 2018; Ladurner 2021; Nasser 2021; Kjeldsen 2024; Kamper 2015)

11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References