Greater Trochanteric Pain Syndrome (Gluteal Tendinopathy)
The most likely diagnosis is Greater Trochanteric Pain Syndrome (GTPS), specifically gluteal tendinopathy with possible abductor tendon tear, given the lateral hip pain worse at night, pain when lying on the affected side, and presence of a Trendelenburg gait indicating abductor weakness. 1, 2
Clinical Reasoning
The constellation of findings strongly points to GTPS rather than intra-articular hip pathology:
- Lateral hip pain (not groin pain) localizes the pathology to the peritrochanteric space, not the hip joint itself 1, 2
- Night pain interfering with sleep, especially when lying on the right side is classic for trochanteric bursitis and abductor tendinopathy 1, 3
- Trendelenburg gait indicates gluteus medius/minimus weakness or dysfunction, which occurs with abductor tendon pathology or tears 4
- Onset after starting jogging suggests overuse injury to the abductor mechanism 1
- Worsening after a long trip (likely prolonged sitting or walking) is consistent with GTPS 3
The Trendelenburg gait is particularly significant here—it suggests this may be more than simple trochanteric bursitis and could represent an abductor tendon tear, which is a more severe form of GTPS 4.
Diagnostic Workup
Start with AP pelvis and lateral hip radiographs to exclude alternative diagnoses such as osteoarthritis, fractures, or dysplasia 5, 6. However, radiographs showing greater trochanter surface irregularities >2mm have poor diagnostic accuracy for GTPS (only 24.7% positive predictive value) 7.
If the Trendelenburg gait persists or symptoms are refractory to initial conservative treatment, obtain MRI of the hip without contrast to evaluate for abductor tendon tears (gluteus medius and minimus) 5, 4. MRI is superior for detecting soft tissue pathology including tendon tears, which are found in a significant proportion of patients with chronic lateral hip pain 4.
Management Algorithm
Initial Conservative Treatment (First 3-6 months):
- Physical therapy focused on hip abductor strengthening is the cornerstone of treatment and shows superior long-term outcomes (60.5% symptom resolution at 15 months) 8
- NSAIDs for pain control 1, 2
- Activity modification: avoid prolonged side-lying on the affected hip and reduce aggravating activities 1
If Acute Symptoms Are Severe:
- Corticosteroid injection combined with PT is more effective than PT alone for acute symptom management 8
- However, PT alone provides better long-term outcomes than corticosteroid injections alone 8
If Conservative Treatment Fails After 3-6 Months:
- Consider extracorporeal shock wave therapy (ESWT), which shows 68.3% improvement in pain scores compared to controls 8
- Surgical repair of abductor tendon tears should be considered if MRI confirms a tear and conservative treatment has failed 4
Critical Pitfall
Do not assume this is simple trochanteric bursitis and dismiss the Trendelenburg gait. The presence of a Trendelenburg gait suggests significant abductor dysfunction, and 16 out of 28 patients with chronic lateral hip pain in one surgical series had abductor tendon tears on MRI 4. Six patients with preoperative Trendelenburg gait had normal gait one year after surgical repair 4. Missing an abductor tear leads to prolonged disability and treatment failure.