What could be causing bilateral upper hip pain in an elderly male that resolves with stretching?

Bilateral Upper Lateral Hip Pain in an Elderly Male

This presentation is most consistent with Greater Trochanteric Pain Syndrome (GTPS), which includes gluteus medius/minimus tendinopathy, trochanteric bursitis, or iliotibial band friction—the most common cause of lateral hip pain in adults. 1, 2

Key Diagnostic Features Supporting GTPS

The bilateral lateral location of pain that resolves with stretching strongly points toward extra-articular soft tissue pathology rather than intra-articular hip disease:

• Lateral hip pain is the hallmark of GTPS, distinguishing it from intra-articular pathology (like osteoarthritis or labral tears) which typically causes anterior groin pain 1, 3
• The absence of groin pain effectively excludes femoroacetabular impingement and labral pathology 1
• Pain relief with stretching suggests muscular or tendinous involvement rather than bony or cartilaginous pathology 4

Alternative Diagnoses to Consider

While GTPS is most likely, you must systematically exclude other causes based on pain location:

Lumbar spine pathology (L3 radiculopathy):

• Would present with dermatomal sensory loss along the medial lower leg, which distinguishes it from hip pathology 5
• Typically includes buttock, lateral hip, and anterior-lateral thigh pain following L3 distribution 5
• The bilateral nature and response to stretching makes this less likely

Intra-articular hip osteoarthritis:

• More common in elderly patients but typically causes anterior/groin pain, not lateral hip pain 2, 6
• Would not respond as readily to stretching exercises 4

Recommended Diagnostic Workup

Initial imaging:

• Obtain AP pelvis and lateral hip radiographs bilaterally to exclude osteoarthritis, fractures, dysplasia, or other bony pathology 1, 3
• Radiographs serve as an excellent screening tool and guide selection of additional imaging 4

Physical examination findings to assess:

• Palpate for tenderness over the greater trochanter (supports GTPS) 2
• Perform FADIR test (flexion-adduction-internal rotation)—if negative, this helps exclude intra-articular pathology 1, 3
• Assess for Trendelenburg gait, which suggests gluteus medius weakness or tear 1
• Examine lumbar spine to exclude concurrent spinal pathology 3

Advanced imaging if initial workup is negative or symptoms persist:

• MRI of the hip without contrast is recommended if Trendelenburg gait persists or symptoms are refractory to 6-12 weeks of conservative treatment 1
• MRI evaluates for abductor tendon tears (gluteus medius/minimus), which may require surgical intervention 1
• Ultrasound can evaluate soft tissues and guide diagnostic/therapeutic injections 4

Management Approach

Conservative treatment (first-line for GTPS):

• Static stretching exercises performed daily when pain is minimal, holding stretches 10-30 seconds 4
• Isotonic strengthening exercises for muscles supporting the hip 4
• Activity modification and NSAIDs for pain control 5
• Monitor for 6-12 weeks unless red flags develop 5

Common pitfall: Do not rely on imaging findings alone—incidental findings are common in asymptomatic individuals and must be correlated with clinical presentation 1. Greater trochanter surface irregularities on radiographs have poor diagnostic accuracy (only 24.7% positive predictive value) 1.

Referral indications:

• Progressive neurologic deficit 5
• Failure of conservative management after 6-12 weeks 5
• Persistent Trendelenburg gait suggesting significant tendon tear 1