What is the best course of treatment for a patient with right lateral hip pain and a positive right-sided Trendelenburg gait after starting jogging?

Right Lateral Hip Pain with Trendelenburg Gait After Starting Jogging

This presentation indicates gluteal tendinopathy or hip abductor insufficiency, and you should immediately initiate a minimum 3-month structured exercise program targeting hip abductor strengthening with progressive loading, as this is the evidence-based first-line treatment. 1

Diagnosis Confirmation

• Lateral hip pain over the greater trochanter combined with a positive Trendelenburg gait strongly suggests gluteal tendinopathy or hip abductor mechanism pathology (gluteus medius/minimus weakness or tear). 1, 2
• Obtain plain radiographs (AP pelvis and lateral hip views) to rule out bony pathology, hip osteoarthritis, or femoral acetabular impingement morphology before proceeding with conservative treatment. 1, 3
• If radiographs are negative and symptoms persist beyond 6-8 weeks of structured exercise, obtain MRI to evaluate for abductor tendon tears, as surgical repair may be indicated for complete tears that fail conservative management. 4, 2

Primary Treatment: Structured Exercise Rehabilitation

The cornerstone of treatment is a minimum 3-month progressive hip abductor strengthening program, as this duration is critical for optimal outcomes. 1

Exercise Prescription Parameters

• Target the gluteus medius, gluteus minimus, hip flexors, and trunk stabilizers with adequate load to produce strength gains, typically 60-80% of 1-repetition maximum. 1
• Progressive loading must include gradually increasing load magnitude, sets (starting 2-3 sets, progressing to 3-4 sets), repetitions (8-12 range), and time under tension over the 3-month period. 5, 1
• Exercise frequency should be 3-4 sessions per week with adequate rest between sessions (48-72 hours) to allow tissue adaptation. 5
• Report and track specific exercise descriptors including load magnitude, number of repetitions and sets, duration of contractile element (concentric/eccentric phases), time under tension, rest between repetitions, and range of motion. 5

Referral Considerations

• Consider physical therapy referral for supervised exercise prescription if the patient cannot perform exercises with proper form or if self-directed exercise fails after 4-6 weeks. 1
• Reassess progress at 4-6 week intervals using patient-reported outcomes such as the Hip and Groin Outcome Score or International Hip Outcome Tool, along with objective measures like single-leg stance time and Trendelenburg gait assessment. 1

Adjunctive Symptomatic Management

• NSAIDs can provide symptomatic relief during the rehabilitation phase to allow participation in exercise therapy. 1
• Avoid corticosteroid injections in this acute overuse scenario, as they are not indicated for gluteal tendinopathy in the absence of confirmed hip joint pathology. 1
• Never prescribe opioids for this condition, as consensus recommendations strongly oppose opioid use for hip-related pain. 5, 1

Patient Education and Load Management

• Explain that pain does not equal damage and that gradual progression with controlled loading is essential for tendon healing. 1
• Discuss realistic expectations about the 3-month minimum treatment duration before expecting significant improvement. 5, 1
• Implement load management by temporarily reducing or modifying running (decrease mileage, avoid hills/cambered surfaces, consider cross-training with cycling or swimming) while maintaining hip strengthening exercises. 1
• Plan gradual return to running only after achieving adequate hip abductor strength (single-leg stance >30 seconds without Trendelenburg, pain-free hip abduction against resistance). 1

Critical Pitfalls to Avoid

• Do not allow unstructured "rest only" without concurrent strengthening, as this will not address the underlying hip abductor weakness. 1
• Do not proceed directly to MRI without first attempting a 6-8 week trial of structured exercise therapy, as this violates evidence-based guidelines and may lead to overtreatment of incidental findings. 1
• Do not rush return to running before completing the 3-month strengthening program and achieving adequate hip abductor strength, as premature return will perpetuate the injury cycle. 1
• Do not assume this is simple trochanteric bursitis without addressing the underlying hip abductor weakness that causes the Trendelenburg gait. 2

When Conservative Treatment Fails

• If symptoms persist after 3-6 months of structured exercise therapy, obtain MRI to evaluate for complete abductor tendon tears. 4
• Surgical repair using soft tissue anchors may be indicated for confirmed complete tears, though this carries a relatively high failure rate (approximately 30% in one case series) and should be reserved for refractory cases. 4