Many people who are delighted with a new hip later notice an aching, tender spot on the outside of it, often worst when they lie on that side. The pain usually comes from the muscles, tendons and cushion around the joint reacting to changes from surgery and recovery, not from a failing implant. Many of the causes are mechanical, so the problem usually has a reason that can be found and treated.
What Is Actually Inflamed on the Outside of the Hip
The greater trochanter is the bony point you can feel on the outside of your upper thigh. A bursa, a small fluid-filled cushion, sits over it and lets tendons and the thick band along the outer thigh glide across the bone. When that cushion or the tendons around it get irritated, the outside of the hip aches and hurts to press. Doctors increasingly call this greater trochanteric pain syndrome, and you may see that name on your notes, because the tendons are often involved as much as the bursa.
Day to day, it usually feels like an ache or burning on the outer hip that can spread down the side of the thigh. Lying on that side at night is often the worst part, and it wakes many people. Stairs, getting out of a car and standing on one leg can all bring it on. Pressing on the bony point is tender, which helps set it apart from the deep groin pain that more often comes from the joint itself.
A new joint can work well and still hurt because the implant replaces the ball and socket, not the muscles and tendons around them. Those tissues are cut, stretched or repositioned during surgery, so the joint can function nicely while its surroundings complain.
The bursa and the tendons share the same small space, so a doctor often cannot tell which is the main source. Being told “bursitis” or “tendinopathy” usually leads to a similar first plan.
Hip surgeons estimate that about 8% of their hip replacement patients develop it afterward.1PubMed Central. Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes Individual surgeons reported anywhere from almost none to 1 in 5 of their patients.2PubMed Central. Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes
How the Surgical Approach Plays a Role
Surgeons can reach the hip from the front, the back, or the side. Approaches from the side may cause more trauma to the surrounding soft tissue, which can lead to inflammation.3Clinical Research on Foot & Ankle. Risk Factors for Developing Trochanteric Bursitis after Total Hip Arthroplasty The front approach works between muscles rather than cutting through them. The back approach goes behind the joint, usually detaching small deep rotator muscles and often repairing them at the end. The side approach passes through or beside the muscles that attach to the bony point, putting those tissues closest to the surgical work.
In a large comparison, about 11.5% of patients after a back approach needed a steroid injection for this pain, compared with 7.3% after a front approach.4PubMed. Does Surgical Approach in Total Hip Arthroplasty Affect Postoperative Corticosteroid Injection Requirements? In a smaller trial, side-hip pain was more common after the back approach, yet satisfaction and the need for injections were similar.5PubMed. Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial Studies define the problem differently: pain reported by patients, injections given, or diagnoses recorded. That helps explain why results don’t line up neatly. Approach shifts the odds modestly but doesn’t decide whether you get it.
To find out which approach you had, check your operation note or discharge papers, which usually name it. The scar gives a rough clue too: front, side, or back of the hip. Knowing it helps a new doctor think through causes.
Leg Length and Offset Changes
Offset is how far the new hip sets the thighbone out to the side from the pelvis. Too much of it can tighten the side-hip muscles and the band along the outer thigh, causing pain whatever approach was used.6Journal of the American Academy of Orthopaedic Surgeons. Offset Considerations in Total Hip Arthroplasty Stems with high offset have been linked to a higher risk of this bursitis.7Orthopaedic Proceedings. TROCHANTERIC BURSITIS IN ASSOCIATION WITH HIGH OFFSET FEMORAL STEM COMPONENTS IN TOTAL HIP ARTHROPLASTY The reason is mechanical. The band along the outer thigh runs over the bony point, and the further out the thighbone sits, the tighter it stretches across that bone. A tighter band presses harder on the fluid cushion and rubs the tendons beneath it with each step. Over weeks of walking, that repeated friction can become a persistent, tender spot.
Leg length and offset are linked but different. Leg length is how long the limb is from pelvis to foot, while offset is how far outward the thighbone sits. A hip can be restored to the right length yet still sit too far out, or the reverse. Surgeons weigh both when choosing the implant and its position, trading off stability against tension in the soft tissue.
Patients whose new hip differed from their other hip by more than 5 mm in combined leg length and offset had side-hip pain about 29% of the time.8PubMed Central. Restoration of leg length and offset correlates with trochanteric pain syndrome in total hip arthroplasty Those within 5 mm had it about 8% of the time.9PubMed Central. Restoration of leg length and offset correlates with trochanteric pain syndrome in total hip arthroplasty Yet another study found these changes did not predict who developed symptoms.10Acta Orthopædica Belgica. A painful problem: trochanteric bursitis following total hip arthroplasty
Signs your leg length may have changed include one leg feeling longer, tilting when you stand, uneven shoe wear, or a feeling that you limp. Your surgeon can measure this on X-rays against the other side. A small shoe lift on the shorter side can ease strain, and physical therapy can address tight bands and weak muscles. Revision surgery for leg length alone is uncommon and a decision for your surgeon.
Tendon Tears and Pre-Existing Tendon Problems
The gluteus medius and minimus are tendons that attach to the bony point and help you stand on one leg. These tendons can tear with any approach, either unnoticed during surgery or by failing to heal after repair.11PubMed Central. Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes Many such tears have followed approaches through the side of the hip, and prompt diagnosis and repair can reduce lasting problems.12PubMed. Results following repair of gluteus medius defects following total hip arthroplasty
When you walk, these tendons keep the pelvis level each time one foot leaves the ground. Because they attach where the fluid cushion sits, damage there is felt as outer-hip pain. When they don’t work properly, the pelvis can drop and the body can lean to compensate.
A tear can go unnoticed at first. Pain and weakness are expected early after surgery, so a tear is easily mistaken for normal recovery, especially when a repaired tendon is stressed in the early weeks. It often shows itself only when progress stalls and a limp persists.
Suspect a tear rather than bursitis if you have a limp that doesn’t improve as you recover, weakness lifting the leg to the side or standing on it, or the hip dropping on the opposite side as you walk. It is reasonable to ask whether an ultrasound or MRI is needed. The difference changes the plan: bursitis is mostly irritation, which tends to respond to injections, medicines and therapy, while a tear is structural, and weakness can persist even if the pain is calmed for a while; some tears need surgical repair.
Tendons can also be the problem before the operation. People who had silent tendon damage before their replacement had more side-hip pain afterward.13PubMed. Asymptomatic Gluteal Tendinopathies Negatively Impact Outcomes of Total Hip Arthroplasty: A Propensity Score-Matched Study Sometimes surgery reveals a problem that was already there rather than creating it.
Tendons Overloaded as You Get Active Again
Before surgery, side-hip tendons are often underused because people limit activity and avoid putting weight on the painful side.14Dr Alison Grimaldi. Greater trochanteric pain after hip replacement After surgery, walking speed, step length and activity rise.15Dr Alison Grimaldi. Greater trochanteric pain after hip replacement If the load rises faster than the tendons can adapt, pain on the outside of the hip can develop.16Dr Alison Grimaldi. Greater trochanteric pain after hip replacement
The new hip now allows steps that were avoided for years, and the tendons haven’t been conditioned for them. This is a reason for pain to show up later, not a sign the hip is failing.
Building up walking in modest steps over several days works better than doubling the distance after one good day. Tendon pain often shows up a day later, so notice how the hip feels the next morning. If it flares, step back to the previous comfortable level for a few days and try again. Strengthening the side-hip muscles helps the tendons tolerate more.
Some habits press on irritated tendons. Sitting cross-legged or with knees together pulls them over the bone, and standing with your weight sunk into one hip adds compression. A pillow between the knees at night eases side lying.
Who Is More Likely to Get It
Women had about 1.8 times the risk of men.17PubMed. Risk Factors for Trochanteric Bursitis Following Total Hip Arthroplasty: A Radiographic Analysis A wider pelvis tends to set the hip joints farther apart, which changes how the tendons run across the bony point and may raise the pressure on the tissues. That is a plausible explanation rather than a settled one.
Narrowing of the spinal canal in the low back and past smoking were more common in people who developed it, though they are not proven as independent causes.18PubMed. Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment Younger patients and those with leg length differences are less likely to improve with non-surgical treatment.19PubMed. Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment The numbers describe groups, so they can’t tell any one person what will happen.
Other Causes of Outer Hip Pain to Rule Out
Hip pain after replacement can come from the low back, abdominal organs, tendon problems or a hernia, not just the bursa.20PubMed Central. Painful hip arthroplasty: definition. So doctors check X-rays and the joint itself before settling on bursitis.21PubMed Central. Painful hip arthroplasty: definition. MRI with special settings can now show soft tissue around metal implants.22PubMed Central. Radiological Imaging Evaluation of the Failing Total Hip Replacement Rarely, wear of implant parts can produce a mass over the hip that needs surgery.23Journal of Orthopedics and Joint Surgery. Delayed Adverse Reactions to Metal Debris Secondary to Polyethylene Liner Wear in Total Hip Arthroplasty Presenting as a Hemorrhagic Trochanteric Pseudotumor: A Case Report
Irritated nerves in the lower spine can produce pain in the buttock or outer hip. Back-related pain may come with numbness, tingling or pain that travels down the leg, and pressing on the bony point usually doesn’t reproduce it the way it does with bursitis.
Implant problems such as loosening more often cause pain in the groin or thigh, especially when you put weight on the leg. Plain X-rays are the first check and can show changes in the position of the parts. If they look normal but pain persists, further tests may be considered.
Report fever, redness, warmth or wound drainage promptly, as they could mean infection. A new lump or swelling over the hip should be examined.
How It Is Treated and Whether It Goes Away
Surgeons most often start with anti-inflammatory pills, structured physical therapy and steroid injections.24PubMed Central. Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes Around a third of patients don’t improve enough with physical therapy alone.25PubMed Central. Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes In one group, about three quarters of patients had a steroid injection, and all were managed without surgery.26PubMed. Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment Symptoms went away in 80% after injections, though nearly half needed more than one.27PubMed. Trochanteric bursitis after total hip arthroplasty: incidence and evaluation of response to treatment
At an injection visit, the clinician usually presses to find the tender spot, and ultrasound can help place the medicine accurately. A local anesthetic is often given with the steroid, so the area may feel better within minutes and then ache again as it wears off. The visit is short, and most people go home the same day. The steroid itself may take several days to work, and some people have a brief flare of pain in the first day or two. Resting from heavy activity for a short time is often suggested, then therapy continues. Repeat injections are common but limited in number.
Many people improve over weeks to a few months. If pain hasn’t eased after several months of treatment, ask for a review, and persistent pain warrants checking for a tendon tear.
For stubborn cases, platelet-rich plasma injections helped at 3 months in severe cases, but the benefit faded by a year.28Oxford Academic (Journal of Hip Preservation Surgery). The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review For long-lasting pain, surgeons can remove the bursa and release the tight band, open or through small cuts.29PubMed Central. Soft-Tissue Sources of Extra-articular Pain Following Total Hip Arthroplasty: A Comprehensive Review In a small series, 10 of 12 people had major relief after keyhole bursa removal.30PubMed Central. Soft-Tissue Sources of Extra-articular Pain Following Total Hip Arthroplasty: A Comprehensive Review