Hip pain that occurs specifically when pressure is applied, such as when lying on your side, suggests a localized issue with the soft tissues on the outer hip. This symptom is distinct from the deep, throbbing ache associated with problems inside the hip joint, like arthritis. The pain is typically felt around the prominent bony point on the side of the thigh, known as the greater trochanter. This pattern of pain usually points toward inflammation or injury of superficial structures, specifically the tendons and bursae covering this landmark.
Primary Causes of Pain When Pressed
The most frequent cause of localized, pressure-sensitive hip pain falls under the umbrella term Greater Trochanteric Pain Syndrome (GTPS). This syndrome is recognized as primarily involving the gluteal tendons, with or without associated inflammation of the bursa. The pain is noticeable when external force compresses these irritated structures against the underlying greater trochanter.
Gluteal Tendinopathy
Gluteal tendinopathy involves the tendons of the gluteus medius and gluteus minimus muscles, which attach to the greater trochanter. This condition is characterized by deterioration of the tendon tissue, often resulting from repetitive strain or changes in physical load. Weakness in the hip abductor muscles can lead to abnormal hip biomechanics, increasing compressive forces on the tendons by the iliotibial band (ITB).
The pain from pressure results from direct mechanical compression of the irritated tendon fibers against the bone. Activities that cause this compression, like sleeping on the affected side or sitting with crossed legs, aggravate the pain. Tendinopathy is rooted in structural changes within the tendon itself, rather than being a purely inflammatory condition.
Trochanteric Bursitis
The greater trochanteric bursa is a small, fluid-filled sac that acts as a cushion between the gluteal tendons and the greater trochanter. Bursitis occurs when this sac becomes inflamed, often due to friction from the overlying tendons or direct trauma. Inflammation causes the bursa to swell, making it highly sensitive to pressure.
Direct pressure, such as lying on the side during sleep, squeezes the inflamed bursa, leading to a sharp increase in pain. While historically considered the main cause of lateral hip pain, current understanding suggests that bursitis often coexists with or is secondary to gluteal tendinopathy.
Structural and Neurological Contributors
Pain sensitive to pressure can also originate from structures other than the tendons and bursae, including nerves and muscles. These conditions can sometimes mimic GTPS but are caused by different underlying physiological processes. Recognizing these differences is important for accurate diagnosis.
Meralgia Paresthetica
Meralgia Paresthetica is a nerve entrapment condition involving the lateral femoral cutaneous nerve (LFCN), which provides sensation to the outer thigh. The nerve can become compressed as it passes through a tunnel near the inguinal ligament, leading to symptoms like burning, numbness, or hypersensitivity. External pressure from tight clothing, belts, or firm bedding can significantly aggravate the nerve irritation.
Referred Pain
Issues in the lumbar spine can sometimes cause pain felt in the hip and buttock area, known as referred pain. While often less sensitive to direct palpation than tendinopathy, this pain can be confusing. A healthcare provider will look for other symptoms, such as pain that travels below the knee or is worsened by specific back movements, to differentiate it from local hip pathology.
Muscle Trigger Points
Myofascial pain can arise from highly localized, hyperirritable spots, or trigger points, within the gluteal muscles, such as the gluteus medius or piriformis. These points are extremely tender when pressed, reproducing a patient’s pain pattern. The discomfort is caused by localized muscle tension and dysfunction rather than tendon or nerve pathology.
Clinical Evaluation and Diagnosis
A definitive diagnosis relies on a thorough physical examination and patient history, as GTPS is primarily a clinical diagnosis. The provider will ask about activities that worsen the pain, such as side-lying at night or climbing stairs, which are classic indicators of lateral hip pathology. This history helps to distinguish soft tissue issues from deeper joint problems like hip osteoarthritis.
Physical Examination
The examination includes specific tests designed to isolate the painful structure. Direct palpation over the greater trochanter frequently reproduces the pain if a bursa or tendon is involved. Strength testing, particularly resisted hip abduction (lifting the leg against resistance while lying on the side), can pinpoint gluteal tendon involvement. The single-leg stance test, where the patient stands on the affected leg, is also a sensitive test for gluteal tendinopathy.
Imaging Modalities
Imaging can be used to confirm a diagnosis, exclude other conditions, or guide treatment. Plain X-rays are useful for ruling out bone issues, such as hip osteoarthritis or stress fractures. Ultrasound is a good second-line investigation because it can clearly visualize the soft tissues, revealing signs of inflammation in the trochanteric bursa or changes within the gluteal tendons. Magnetic Resonance Imaging (MRI) is reserved for complex cases, as it provides detailed images of the tendons and surrounding structures.
Management Strategies and Recovery
Treatment for pressure-sensitive hip pain is non-surgical and guided by the specific diagnosis. The majority of patients, over 90%, respond well to conservative management strategies. Recovery often takes several months, and patient education regarding this timeline is an important part of the management plan.
Self-Care and Lifestyle Modification
Reducing direct mechanical pressure on the affected area is the first step for symptom relief. This includes modifying sleeping positions, such as sleeping on the unaffected side with a pillow placed between the knees to prevent the top leg from compressing the hip. Avoiding activities that involve prolonged standing, stair climbing, or crossing the legs can also reduce irritation. Short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation.
Non-Invasive Medical Interventions
Physical therapy is the cornerstone of long-term recovery, focusing on strengthening the hip abductor muscles (gluteus medius and minimus). A therapist will design a program of progressive mechanical loading exercises, often starting with isometric contractions to manage pain. This strengthening helps stabilize the hip joint, reducing abnormal forces and compression on the tendons.
Invasive Interventions
If conservative measures are not effective, a physician may recommend a corticosteroid injection, which delivers anti-inflammatory medication directly into the bursa or around the tendon. Although effective for short-term pain relief, especially in cases of true bursitis, repeated injections are discouraged due to the potential for weakening tendon tissue. Surgical intervention is rare, reserved for cases, typically less than 10%, that involve chronic tendon tears or remain refractory to all other treatments.