Soft Tissue Hip Pain Disorders

• 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.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

• 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.

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.

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)

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)