By Dr. Zach Greenwade, DC, MS | Published: June 9th, 2026
You wake up, swing your legs out of bed, and feel a sharp, deep ache on the outside of your hip. It hurts when you lie on that side at night, stings when you climb stairs, and feels incredibly stiff when you stand up after sitting at your desk for an hour.
Most people assume that any pain in this region means something is wrong with the hip joint itself. In reality, lateral hip pain (pain on the outside of the hip) is rarely a simple joint issue. More often than not, it is driven by one of three completely distinct structures:
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The Gluteal Tendons (Gluteal Tendinopathy)
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The Hip Joint (Osteoarthritis)
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The Lumbar Spine (Low Back Referral)
Because these three conditions present with overlapping symptoms, they are frequently misdiagnosed. However, treating a tendon problem with low back protocols—or vice versa—is a recipe for chronic frustration.
Prefer video? Watch Dr. Greenwade break down the structural differences and self-tests:
1. Gluteal Tendinopathy (The “Hip Bursitis” Myth)
Gluteal tendinopathy involves localized irritation, micro-tearing, or degeneration of the gluteus medius or minimus tendons where they attach to the bony prominence on the side of your hip (the greater trochanter).
Is it really bursitis? Many patients walk into our Redmond clinic labeled with “hip bursitis.” Modern diagnostic imaging shows that isolated bursitis is actually quite rare. Instead, the trochanteric bursa usually becomes inflamed secondary to an underlying gluteal tendon pathology that isn’t handling physical load correctly.
Common Symptoms
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Sharp or aching pain directly over the lateral bony prominence of the hip.
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Intense discomfort when lying directly on the affected side at night.
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Pain that increases when climbing stairs, walking uphill, or standing on one leg.
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Increased stiffness or an ache after prolonged sitting (especially in deep, low couches).
4 Evidence-Based Clinical Self-Tests
When these four self-tests reproduce your familiar outside hip pain, gluteal tendinopathy is highly likely:
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Single-Leg Stance: Stand on your painful leg for 30 seconds. Positive if it triggers pain or your opposite hip drops.
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Resisted Abduction: Lie on your good side and lift your top leg straight up. Positive if it feels weak or replicates the ache.
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FADER Test: Sit, pull your knee to your chest, cross it toward your opposite shoulder, and turn your foot inward. Positive if the compression causes pain.
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Direct Palpation: Press firmly directly on and just above the hard bone on the outside of your hip. Positive if it is intensely tender.
Want to learn how we rebuild tendon resilience? Check out our dedicated guide to Evidence-Based Gluteal Tendinopathy Loading Protocols for an in-depth look at managing tendon compression.
2. Hip Osteoarthritis (Hip OA)
Hip osteoarthritis involves the gradual degradation of the protective cartilage inside the ball-and-socket joint deep within the pelvis. Its presentation is distinctly different from a tendon issue.
Common Symptoms
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The Classic “C-Sign”: Patients with joint arthritis rarely point to the side of the hip with one finger. Instead, they cup their hand around the side of their hip—forming a “C” with their thumb and fingers—indicating the pain is deep, wrapping from the front groin to the back glute.
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Deep, dull ache centered in the groin or front of the hip.
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Morning stiffness that visibly improves within 30 minutes of moving around.
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Difficulty with daily mechanical tasks, such as putting on socks and shoes, getting in and out of a car, or sitting cross-legged.
The Defining Clue: Loss of Range of Motion
Unlike tendon or back issues, true hip arthritis physically locks the joint. If you lie on your back and notice you cannot pull one knee to your chest or rotate it outward nearly as far as the healthy side, the joint itself is likely the primary driver.
Curious about how active physical medicine can delay or prevent joint replacement? Read our full breakdown on Active Conservative Management for Hip Osteoarthritis.
3. Lumbar Spine (Low Back) Referral
Your low back houses the nerve roots that travel down through your pelvis, glutes, and legs. If a lumbar disc or joint is irritated, it can “throw” or refer pain directly to the outside of your hip, even if your back doesn’t feel terribly painful.
Common Symptoms
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Lateral hip pain accompanied by a dull ache, tightness, or stiffness in the lower back.
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Hip pain that changes dramatically based on your spinal posture (e.g., pain that flares up when slouching or bending forward, but clears up when standing straight).
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Pain that travels past the hip, radiating down into the buttock, outer thigh, or calf.
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Full, unrestricted hip range of motion when tested passively, despite the presence of hip pain.
Wondering if your hip issues are actually coming from your spine? Dive into our comprehensive patient resource on Lumbar Radiculopathy & Referred Pain Mechanics to learn how spinal positions alter extremity symptoms.
Quick-Reference Symptom Matrix
Use this matrix to see which structural pattern most closely matches your current limitations:
| Clinical Feature | Gluteal Tendinopathy | Hip Osteoarthritis | Lumbar Spine Referral |
| Primary Pain Location | Directly on the outside bone | Deep groin / Front of hip | Lower back, glute, & outer hip |
| Pain Lying on Your Side | Yes (Highly Classic) | Rare | Sometimes |
| Tender to Direct Touch | Yes (Sharp) | No | No |
| Morning Stiffness | Mild / Short-lived | Yes (Improves with movement) | Variable |
| Loss of Joint Mobility | No | Yes (Severe restriction) | No |
| Aggravated By… | Stairs, single-leg load | Deep bending, crossing legs | Sitting, lifting, spine twisting |
Why An Accurate Diagnosis Is Your First Step
The single biggest mistake we see active adults make is treating the wrong structure.
If you have a gluteal tendinopathy, stretching your hips out on a foam roller or aggressively pulling your knee across your body will actually increase tendon compression and make the condition worse. Conversely, if your hip pain is referred from a compressed nerve in your lower back, months of resting or icing the hip joint will yield zero long-term relief.
To get back to running, lifting, or simply sleeping through the night without pain, you must move away from generic “hip stretches” and build a plan tailored to the specific tissue involved.
Frequently Asked Questions
Why does my hip hurt more at night when I lay on it?
If you have gluteal tendinopathy, laying directly on that side compresses the already irritated gluteus medius and minimus tendons against the hard bone of the greater trochanter. Interestingly, laying on your uninjured side can also hurt because it allows your top (painful) leg to drop across your midline into adduction, which puts a prolonged stretch and compressive wrap on those same tendons. Try sleeping on your back, or on your uninjured side with a thick pillow between your knees to keep your leg neutral.
Can a foam roller fix outside hip pain?
If your pain is caused by gluteal tendinopathy, aggressively foam rolling the outside of your hip is one of the worst things you can do. Rollers smash the compressed, sensitive tendon directly against the bone, which usually triggers more inflammation. Foam rolling can feel temporary nice due to a brief nervous system override, but it doesn’t fix the underlying tendon tolerance issue. Focus on progressive loading instead.
How can I tell if my hip pain is actually coming from my lower back?
A major clue is posture and movement dependency. If sitting slouchy makes your hip ache flare up, but standing up straight or walking clears it up, your spine is likely the culprit. Furthermore, if you can lie on your back and smoothly move your hip through a full range of motion (pulling it to your chest, rotating it out) without restriction, but it hurts when you walk or bend over, the pain is likely referred from your lumbar nerve roots.
Is walking good for hip osteoarthritis?
Yes, movement is medicine for arthritic joints. Cartilage doesn’t have a direct blood supply; it relies on a process called “fluid imbibition”—basically a sponge effect—where joint movement pumps nutrients in and waste out. While heavy climbing or deep squatting might flare it up initially, regular walking on flat surfaces within your tolerance limits keeps the joint lubricated and reduces morning stiffness.
Get a Personalized Assessment in Redmond, WA
If you are tired of chasing short-term relief and want to identify exactly what is driving your limitations, our sports chiropractic team is here to help. We serve active adults and athletes across Redmond, Bellevue, Kirkland, Sammamish, and the greater Eastside Seattle area.
About the Author
Dr. Zach Greenwade, DC, MS, is a sports chiropractor, soft-tissue specialist, and rehab provider based in Redmond, WA. He utilizes an evidence-based approach that combines joint manipulation, progressive loading, and active movement retraining to help patients resolve chronic musculoskeletal pain and return to peak performance.
