Is it hip osteoarthritis or lateral hip pain (GTPS)?
Both present as hip pain in middle-aged and older adults, and both get called 'a hip problem' casually, but they live in different tissues. Hip osteoarthritis is a joint problem. Pain sits deep in the groin, range of motion is restricted, and internal rotation is the movement that suffers first. Greater trochanteric pain syndrome, which is mostly gluteal tendinopathy with or without associated bursitis, is a tendon and soft tissue problem on the outside of the hip. The point of tenderness is on the bony bump of the greater trochanter, range of motion at the hip is usually preserved, and the pain pattern is dominated by compression, side-lying, and single-leg loading rather than by stiffness.
Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. A brief in-person exam sorts these out reliably.
Hip Osteoarthritis
Groin and hip pain with stiffness from osteoarthritis, often worse with longer walks and getting in and out of a car
Greater Trochanteric Pain Syndrome (Lateral Hip Pain)
GTPS, gluteal tendinopathy, and lateral hip pain formerly called trochanteric bursitis
Side by side
The patterns that separate hip OA from GTPS / lateral hip in clinic. Read across each row and compare.
| Aspect | Hip OA | GTPS / lateral hip |
|---|---|---|
| Where the pain sits | Deep in the groin, sometimes wrapping to the front of the thigh or referring to the knee. When I ask people to point, they often cup the front of the hip rather than the side. | Right on the outside of the hip, over the bony point of the greater trochanter. People can usually put one finger on the spot. Pain may refer down the outside of the thigh but rarely into the groin. |
| Stiffness pattern | Morning stiffness that eases with movement, absent or usually lasting no more than 30 minutes. Stiffness also after prolonged sitting, with a characteristic "start-up" feeling getting out of a chair. | Not a stiffness-dominant presentation. The hip does not feel globally tight. The issue is sharp, localised pain with specific loads and positions. |
| Hip internal rotation | Restricted and often painful, especially in flexion. Loss of internal rotation is one of the more useful clinical signs of hip OA. | Usually preserved and comfortable. If internal rotation is significantly limited, a co-existing or primary intra-articular problem should be considered. |
| Lying on the affected side | Often tolerable or mildly uncomfortable. Sleep disturbance tends to come from overall stiffness rather than from direct side pressure. | Classic aggravator. Night pain lying on the painful side is a common pointer to GTPS, and lying on the opposite side with the top knee falling across the body can hurt too because it compresses the tendons. |
| Single-leg stance | Usually manageable for 30 seconds, although prolonged standing can ache in the groin. A Trendelenburg drop is not the main finding. | Reproduces pain over the greater trochanter within 30 seconds in many cases. A drop of the pelvis on the opposite, unsupported side (Trendelenburg sign) can point to difficulty with the hip abductors of the standing leg, but it is not specific to a gluteal tendon problem. |
| Stairs, hills, and uneven ground | Stairs are often uncomfortable, particularly going up with the affected leg, because of the demand on hip flexion and rotation in the groin. | Walking uphill, climbing stairs, and stepping off a curb all load the gluteal tendons and are common aggravators. |
| Imaging findings | X-ray shows joint space narrowing, subchondral sclerosis, cysts, or osteophytes. Radiographs are more informative than MRI for OA and are usually sufficient. | Imaging is usually not needed. When obtained, MRI or ultrasound may show gluteus medius or minimus tendinopathy, partial tears, or trochanteric bursa fluid. Incidental findings are common in asymptomatic adults. |
| Typical age and sex | Commonly 50 plus, rising sharply with age. Affects men and women. Prior hip injury, FAI, or dysplasia raise the odds. | Most common in women aged 40 to 60. Women outnumber men by roughly 2 to 4 to 1 in published series. Often coincides with changes in running volume, new walking programs, or long periods of sitting with crossed legs. |
Where the pain sits
Hip OA
Deep in the groin, sometimes wrapping to the front of the thigh or referring to the knee. When I ask people to point, they often cup the front of the hip rather than the side.
GTPS / lateral hip
Right on the outside of the hip, over the bony point of the greater trochanter. People can usually put one finger on the spot. Pain may refer down the outside of the thigh but rarely into the groin.
Stiffness pattern
Hip OA
Morning stiffness that eases with movement, absent or usually lasting no more than 30 minutes. Stiffness also after prolonged sitting, with a characteristic "start-up" feeling getting out of a chair.
GTPS / lateral hip
Not a stiffness-dominant presentation. The hip does not feel globally tight. The issue is sharp, localised pain with specific loads and positions.
Hip internal rotation
Hip OA
Restricted and often painful, especially in flexion. Loss of internal rotation is one of the more useful clinical signs of hip OA.
GTPS / lateral hip
Usually preserved and comfortable. If internal rotation is significantly limited, a co-existing or primary intra-articular problem should be considered.
Lying on the affected side
Hip OA
Often tolerable or mildly uncomfortable. Sleep disturbance tends to come from overall stiffness rather than from direct side pressure.
GTPS / lateral hip
Classic aggravator. Night pain lying on the painful side is a common pointer to GTPS, and lying on the opposite side with the top knee falling across the body can hurt too because it compresses the tendons.
Single-leg stance
Hip OA
Usually manageable for 30 seconds, although prolonged standing can ache in the groin. A Trendelenburg drop is not the main finding.
GTPS / lateral hip
Reproduces pain over the greater trochanter within 30 seconds in many cases. A drop of the pelvis on the opposite, unsupported side (Trendelenburg sign) can point to difficulty with the hip abductors of the standing leg, but it is not specific to a gluteal tendon problem.
Stairs, hills, and uneven ground
Hip OA
Stairs are often uncomfortable, particularly going up with the affected leg, because of the demand on hip flexion and rotation in the groin.
GTPS / lateral hip
Walking uphill, climbing stairs, and stepping off a curb all load the gluteal tendons and are common aggravators.
Imaging findings
Hip OA
X-ray shows joint space narrowing, subchondral sclerosis, cysts, or osteophytes. Radiographs are more informative than MRI for OA and are usually sufficient.
GTPS / lateral hip
Imaging is usually not needed. When obtained, MRI or ultrasound may show gluteus medius or minimus tendinopathy, partial tears, or trochanteric bursa fluid. Incidental findings are common in asymptomatic adults.
Typical age and sex
Hip OA
Commonly 50 plus, rising sharply with age. Affects men and women. Prior hip injury, FAI, or dysplasia raise the odds.
GTPS / lateral hip
Most common in women aged 40 to 60. Women outnumber men by roughly 2 to 4 to 1 in published series. Often coincides with changes in running volume, new walking programs, or long periods of sitting with crossed legs.
What I check in person to separate them
These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain why an in-person exam sorts these so quickly.
Hip internal rotation range of motion in flexion
With you on your back and the hip and knee bent to 90 degrees, I rotate the lower leg outward to measure internal rotation at the hip. A painful, hard block short of the other side is a useful bedside sign of hip OA.
FABER test (Flexion, Abduction, External Rotation)
You lie on your back and I place the ankle of the affected leg on the opposite knee in a figure-four position. Deep groin pain points toward the hip joint (OA or labral irritation). Pain felt over the lateral hip or sacroiliac region points elsewhere.
FADIR test (Flexion, Adduction, Internal Rotation)
The hip is flexed, then pulled across the body and internally rotated. Sharp groin pain supports an intra-articular source such as hip OA or labral pathology. It is sensitive but not specific, so I combine it with range and history.
Single-leg stance test (30 seconds)
You stand on the affected leg for up to 30 seconds. Reproduction of focal pain over the greater trochanter within that window, with or without a visible pelvic drop, is a useful clinical pointer to gluteal tendinopathy and GTPS.
Palpation over the greater trochanter
Direct pressure over the greater trochanter reproduces the familiar pain in GTPS. Pain with palpation, a positive single-leg stance and pain on resisted hip abduction together support gluteal tendinopathy, although no single finding confirms it.
Which pattern fits you better?
Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.
Hip OA
Your pattern more closely matches hip osteoarthritis if the pain sits in the groin or front of the hip, morning stiffness lasts around half an hour before easing, internal rotation feels blocked and painful, and stairs or sitting for a long time start the hip up stiffly. Getting out of a car or putting on socks and shoes is often awkward. Pain referring to the knee from the groin is not uncommon, which is why knee pain in an older adult always deserves a hip screen.
Read the hip OA pageGTPS / lateral hip
Your pattern more closely matches GTPS or gluteal tendinopathy if the pain is on the outside of the hip and you can put a finger on it, lying on that side at night wakes you, walking uphill or climbing stairs flares it, and standing on one leg reproduces it within thirty seconds. There is often a recent change in walking or running volume, a new weight-loss ramp-up, or a long stretch of sitting with crossed legs.
Read the GTPS / lateral hip pageIf you still cannot tell
The two can coexist, and occasionally present together in one hip, which is when an exam helps most. I check passive internal rotation first because it is one of the more useful signs for telling OA from soft-tissue pain on the outside of the hip. Then I palpate the greater trochanter, run single-leg stance, and test resisted hip abduction. If internal rotation is clean and lateral palpation reproduces your familiar pain, GTPS moves up the list. If internal rotation is clearly limited and groin pain dominates, hip OA moves up the list. It is usually diagnosed from the history and exam; when an X-ray would change the plan, I flag it to your family doctor or specialist and refer you (an X-ray, not MRI, comes first).
When both are going on
Hip OA and gluteal tendinopathy can occur together in older adults, and changes in how the joint is loaded may play a part. Equally, a person with long-standing GTPS can protect the hip in ways that add stiffness. Treating one and missing the other can be one reason lateral hip pain or post-arthroplasty stiffness lingers longer than expected.
When to see a doctor first
- A fall followed by hip or groin pain and difficulty putting weight on the leg. Go to emergency to rule out a hip fracture.
- Groin or hip pain in a runner that builds with each run, hurts when hopping on that leg, or aches at rest or at night. Possible femoral neck stress fracture. Stop running and all impact exercise, keep weight off the leg, and get medical assessment today. If you cannot put weight on the leg or the pain is severe, go to emergency. An early X-ray can look normal.
- A hot, swollen or very painful hip, with or without a fever, or feeling unwell. Seek same-day medical care to rule out a joint infection, or go to emergency if you feel unwell. Infection is possible even without a fever.
- A child or teenager with a new limp that has no clear explanation. Get a prompt medical assessment before starting exercises. A hip problem can be felt only in the thigh or knee.
- A limping child or teenager with sudden hip, thigh or knee pain, who cannot put weight on the leg, whose leg looks deformed, or who has a fever and feels unwell. Go to emergency now.
- A suspected slipped growth plate at the hip (slipped capital femoral epiphysis, or SCFE). Do not let the child walk on the leg, and seek emergency assessment today. In a teenager this can show up as a limp with hip, groin, thigh or knee pain, even when they can still walk.
- Unexplained weight loss, a history of cancer, or constant night pain. See your family doctor before starting physiotherapy.
Questions patients ask about telling these apart
I have pain on the outside of my hip. Is that always GTPS or bursitis?
Usually it is gluteal tendinopathy rather than pure bursitis. The modern framing of lateral hip pain, including on imaging, points to the gluteus medius and minimus tendons as the main drivers, with any bursal irritation considered secondary. The rehab target is the same: calm the compressive positions that squash the tendons against the trochanter, then build load capacity through progressive strengthening exercises.
Do I need an X-ray or MRI to find out which one it is?
Often not to start. Hip OA is suspected clinically from groin pain with restricted internal rotation and morning stiffness, and confirmed with a plain X-ray if imaging is needed. GTPS is a clinical diagnosis from lateral tenderness, night pain on that side, and positive single-leg stance. MRI is reserved for cases that are not responding, that suggest a significant tendon tear, or when surgical decisions are on the table. Incidental findings on MRI are common in pain-free adults, so imaging is not a substitute for a careful exam.
Why does my hip OA pain show up in my knee?
Referral from the hip to the knee is common because the nerves supplying the hip joint also supply parts of the knee. It is one of the classic reasons older adults with isolated knee pain get an unexpected hip finding on exam. When the knee hurts but internal rotation of the hip is limited and painful, I always screen the hip before settling on a knee diagnosis.
Will strengthening make my GTPS worse before it gets better?
It can flare briefly if the early dose or position is wrong. Some stretches and exercise positions aggravate the outer hip, particularly when the hip drops into adduction (the thigh drifting across the body). I start by reducing the compressive positions (sleep position, crossed legs, hanging your weight onto one hip), begin strengthening in a position and dose the hip tolerates, often with isometric holds, and progress according to how it responds. Many people notice the pain easing over several weeks, while tendon capacity keeps building over the following months.
Can hip OA be managed without surgery?
Yes, often for a long time. Current guidelines such as NICE and OARSI recommend education, exercise therapy, and weight management as first-line care, with manual therapy, strengthening exercises, and gait work all having a role. Injections and surgery sit as later options for those whose function and sleep are significantly affected despite a proper rehab trial. I plan around keeping you active, not around managing decline.
I was told it is just bursitis and given an injection. It came back. Why?
Often because the pain involves the gluteal tendons, and injections can quiet the pain without changing the load pattern that irritated the tendons in the first place. The 2018 LEAP trial compared education plus exercise, corticosteroid injection, and wait-and-see for gluteal tendinopathy. At both 8 weeks and 12 months, more people reported overall improvement with education plus exercise than with the injection; pain was lower with exercise at 8 weeks and similar at 12 months. Injections have a role, but they are not the whole plan.
Evidence this page draws on
Sources I lean on when separating these two conditions in clinic.
The current physical therapy guideline for hip osteoarthritis covers patient education, exercise, manual therapy, and gait training as non-surgical management.
Koc TA Jr, Cibulka M, Enseki KR, et al. "Hip Pain and Mobility Deficits - Hip Osteoarthritis: Revision 2025." JOSPT Clinical Practice Guideline. Journal of Orthopaedic & Sports Physical Therapy 2025; 55(11): CPG1-CPG31.
For gluteal tendinopathy, education plus a progressive loading program gave more people overall improvement than a corticosteroid injection or wait and see at 8 and 52 weeks. Pain was lower than with the injection at 8 weeks and similar at 52 weeks.
Mellor R, Bennell K, Grimaldi A, et al. "Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial." BMJ 2018; 361: k1662.
Lateral hip pain once labelled trochanteric bursitis is now thought to come mainly from the gluteal tendons. Diagnosis is based on a careful clinical examination, including tenderness over the side of the hip and tests such as standing on one leg and resisted hip movements. Imaging is used when the picture is unclear, because tendon changes on scans are also common in people without pain.
Grimaldi A, Fearon A. "Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management." JOSPT 2015; 45(11): 910-922.
Treatments that commonly sit inside either plan
The specific mix depends on the assessment and your goals. These are the pieces I draw from most often for both conditions.
Exercise Therapy
Personalized exercise programs designed to restore strength, flexibility, and function.
Joint Mobilization
Graded techniques to restore joint movement and reduce stiffness.
Soft Tissue & Myofascial Therapy
Targeted hands-on techniques to ease muscle tension, tenderness, and stiffness.
Post-Surgical Rehabilitation
Physiotherapy after orthopedic surgery, from the first weeks to full activity, working to your surgeon's protocol.
Book an assessment
If this page has helped you narrow things down, or if it has left you wanting a proper exam, I see patients at Endorphins Health & Wellness Centre in Burlington. Direct insurance billing is available, and a physician referral is not required.
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Burlington, ON L7M 0W9
Direct billing. No referral needed.
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