Gluteal Tendinopathy in Runners: Why It Keeps Coming Back

By Emma Glynn - The Hip & Knee Physio

If you are a runner dealing with pain on the outside of your hip that eases when you rest and returns every time you get back into training, you are most likely dealing with gluteal tendinopathy. And if you have already tried resting, stretching, foam rolling, and perhaps a cortisone injection - only to find it comes back - there is a specific reason for that. The way most runners manage this condition is exactly what keeps it going.

I am Emma Glynn, an APA Titled Musculoskeletal Physiotherapist who works exclusively with hip and knee conditions. I treat a lot of active adults in their 40s and 50s who run regularly and have been managing lateral hip pain for months or even years without a clear answer. This post explains how gluteal tendinopathy behaves in runners, why it recurs, and what evidence-based management looks like.

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What Is Gluteal Tendinopathy?

Gluteal tendinopathy is a condition involving the tendons of the gluteal muscles - primarily gluteus medius and gluteus minimus - where they attach to the greater trochanter on the outer side of the hip. It is the most common cause of lateral hip pain in active adults and is particularly prevalent in women over 40, though it affects runners of all ages (Grimaldi & Fearon, 2015).

The condition involves load-related changes in tendon structure rather than a straightforward inflammatory process. This distinction matters because it changes how the condition needs to be managed. Anti-inflammatory approaches - including rest and corticosteroid injection - can reduce pain in the short term, but do not address the underlying tendon load capacity deficit that causes recurrence (Mellor et al., 2018).

The condition is not resolved by reducing pain. It is resolved by rebuilding the tendon's capacity to tolerate load.

If you are not sure whether what you have is gluteal tendinopathy or something else, the bursitis vs gluteal tendinopathy post covers the key differences and how to distinguish between them clinically.

Why Runners Are Particularly Vulnerable?

Runners place repetitive compressive and tensile load on the gluteal tendons with every stride. Lateral hip pain in runners is often triggered by one or more of the following:

• A sudden increase in training volume or intensity

• Adding hill work, trail running, or cambered road surfaces

• Consistent treadmill running with a set incline

• Cross-training activities involving sustained hip adduction - particularly cycling, which places the hip in a compressive position for the entire session

• Returning to full training too quickly after a period of rest, without progressive loading

The hip adduction angle during running is a key variable. When runners overstride, have weak hip abductors, or run with a narrow step width, the pelvis drops on the swing side - a pattern called contralateral pelvic drop. This increases compressive load on the gluteal tendon and is a primary driver of both onset and recurrence (Allison et al., 2018; Grimaldi & Fearon, 2015).

Contralateral pelvic drop during running is not just a biomechanical observation - it is a direct mechanism by which the tendon is overloaded with every stride.

Why Does Gluteal Tendinopathy Keep Coming Back?

The recurrence pattern in runners with gluteal tendinopathy almost always follows the same sequence. Pain develops, the runner rests, pain settles, the runner returns to training, pain returns. The cycle repeats.

The reason is tendon biology. Tendons adapt significantly more slowly than muscle and cardiovascular fitness. When a runner rests for two to four weeks, cardiorespiratory fitness and muscle strength remain relatively well preserved. The tendon, however, has not regained the structural capacity to tolerate the loads that caused it to break down.

Returning at the same volume and intensity essentially guarantees a recurrence (Cook & Purdam, 2009).

Compressive load management between runs is the other critical piece. Activities and postures that compress the gluteal tendon against the greater trochanter - sitting with knees crossing inward, hip cross-body stretches, certain yoga poses, and poor sleeping positions - maintain an environment of ongoing tendon irritation. Many runners are unknowingly doing these things between sessions and wondering why the tendon is not settling.

The two factors that drive recurrence are directly related: the tendon is returned to full load before it has adequate capacity, and it is being compressed in between runs without the runner realising it.

What Does the Evidence Say About Management?

Current evidence, including the landmark LEAP trial (Mellor et al., 2018), demonstrates that a structured program combining load management education with progressive hip and gluteal strengthening produces significantly better outcomes at 8 and 52 weeks than corticosteroid injection or a wait-and-see approach. For runners, management involves three phases.

Phase 1: Reduce provocative load without stopping running entirely.

Temporarily modifying training is not the same as stopping. Reducing volume, avoiding hills and cambered surfaces, shortening stride length, and increasing running cadence can substantially reduce the compressive and tensile demands on the gluteal tendon while preserving cardiovascular fitness. Eliminating compression postures away from running is equally important during this phase.

Phase 2: Progressive loading program.

Isometric exercises, then isotonic strengthening of the hip abductors and external rotators, form the foundation of rehabilitation. The goal is to systematically increase the tendon's load capacity. Clifford et al. (2019) demonstrated in a randomised controlled pilot study that both isometric and isotonic exercise protocols produced meaningful improvements in people with gluteal tendinopathy, supporting progressive loading as the core rehabilitation approach.

Meaningful tendon adaptation requires a minimum of eight to twelve weeks of consistent progressive loading. This is why two weeks of rest followed by a return to full training does not work - the tendon has not had time to adapt. A detailed guide to which gluteal tendinopathy exercises help and which ones delay recovery is available in a separate post.

Phase 3: Running-specific reintegration.

Return to full running involves a structured ramp, with attention to running biomechanics. Gait retraining to reduce contralateral pelvic drop — combined with targeted hip abductor strengthening — reduces tendon load during running and is associated with better long-term outcomes. Grimaldi and Fearon (2015) note that focused attention on reducing hip adduction during running, with real-time or video feedback, can produce meaningful improvements in frontal plane mechanics that strengthening alone does not reliably achieve.

Common Mistakes That Prolong Recovery

These patterns consistently extend recovery time in the runners I work with:

• Stretching the hip into adduction or cross-body positions to relieve tightness - this places the tendon in exactly the compressive position that drives the condition

• Treating the presentation as a hip flexor or piriformis problem and using soft tissue release techniques that load the tendon in compression

• Substituting running with heavy cycling - the seated hip position during cycling is one of the most compressive positions for the gluteal tendon, and it is not a neutral alternative

• Stopping running completely without addressing the underlying load deficit, which results in deconditioning and a significantly harder return

• Pursuing corticosteroid injection without pairing it with a supervised loading program - the injection reduces pain, but the window of reduced irritability needs to be used for progressive loading, not rest

What to Expect From Assessment and Physiotherapy

A thorough assessment of gluteal tendinopathy in runners should include a clear clinical diagnosis confirming the tendon is the primary driver of symptoms rather than referred pain from the lumbar spine or sacroiliac joint, a full running load history, an assessment of hip abductor strength, and where appropriate, a gait analysis or functional movement screen to identify frontal plane control issues during running.

Management should be built around your current training schedule, not a generic protocol. The goal is to keep you as active as possible while systematically building the tendon's capacity to meet your running demands.

Recovery timelines vary depending on presentation severity and history. For a runner with a reactive tendinopathy — recent onset, responding to load reduction - eight to twelve weeks of guided rehabilitation is a reasonable expectation. For someone with a longer history of recurrence and established tendon change, twelve to twenty-four weeks is more realistic. Understanding the factors that influence your individual timeline is covered in more detail in the how long does gluteal tendinopathy take to heal post.

When to Seek Assessment

If your lateral hip pain has persisted for more than six weeks despite rest, if it has recurred after a previous episode, or if it is limiting your ability to run consistently, a specific assessment is warranted.

Gluteal tendinopathy responds well to the right management and tends to persist or worsen with the wrong approach - the sooner it is accurately assessed, the more straightforward the path through it.

I offer assessments in Camberwell for runners who are in Melbourne. If you are outside Melbourne, I also offer telehealth consultations.

Emma

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References

Allison, K., Wrigley, T. V., Vicenzino, B., Bennell, K. L., Grimaldi, A., & Hodges, P. W. (2018). Hip abductor muscle activity during walking in individuals with gluteal tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 28(2), 686–695. https://doi.org/10.1111/sms.12942

Clifford, C., Paul, L., Syme, G., & Millar, N. L. (2019). Isometric versus isotonic exercise for greater trochanteric pain syndrome: A randomised controlled pilot study. BMJ Open Sport & Exercise Medicine, 5(1), e000558. https://doi.org/10.1136/bmjsem-2019-000558

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. https://doi.org/10.1136/bjsm.2008.051193

Grimaldi, A., & Fearon, A. (2015). Gluteal tendinopathy: Integrating pathomechanics and clinical features in its management. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 910–922. https://doi.org/10.2519/jospt.2015.5829

Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., &

Vicenzino, B. (2018). 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, 361, k1662. https://doi.org/10.1136/bmj.k1662

Souza, R. B., & Powers, C. M. (2009). Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 12–19. https://doi.org/10.2519/jospt.2009.2885

Medical Disclaimer: The information in this post is for general educational purposes only and does not constitute medical advice. It is not a substitute for assessment, diagnosis, or treatment by a qualified health professional. If you are experiencing hip pain, please seek assessment from a registered physiotherapist or your GP.