Hip pain: GTPS, gluteal tendinopathy & femoroacetabular impingement

What adult hip pain actually is

Hip pain is among the most common musculoskeletal presentations in Australian general practice. The clinical approach begins with anatomical localisation — lateral, anterior, posterior, or referred — because each location implies a distinct set of diagnoses with different management pathways.

Lateral hip pain — pain centred on or around the greater trochanter — is almost always greater trochanteric pain syndrome (GTPS), a condition now understood to represent gluteal tendinopathy of the gluteus medius and minimus tendons. GTPS is the most common extra-articular hip condition in adults: it affects approximately 10–25% of people aged 40–60, with a female-to-male ratio of roughly 4:1, peaking around the peri-menopausal years.

Anterior or groin hip pain in a younger active adult (typically 20–45 years) raises the possibility of femoroacetabular impingement (FAI) — a morphological mismatch between the femoral head and acetabulum that generates impingement with deep hip flexion and rotation.

eTG guidelines and the RACGP AFP both recommend a structured anatomical assessment before ordering imaging in adult hip pain — most presentations can be diagnosed clinically with examination, with targeted imaging to confirm or stratify.

A. Core clinical — the AU general-practice framework

Anatomy and differential framework

Location guides the differential:

• Lateral — GTPS / gluteal tendinopathy, iliotibial band friction, snapping hip (external), trochanteric fracture (always exclude after a fall)
• Anterior / groin — FAI, labral tear, hip osteoarthritis, iliopsoas tendinopathy, adductor / pubic-related groin pain, femoral neck stress fracture, inguinal hernia, referred abdominal or pelvic pathology
• Posterior — sacroiliac dysfunction, deep gluteal syndrome, hamstring origin tendinopathy, ischiogluteal bursitis
• Referred — lumbar L1–L3 radicular pain, vascular, intra-abdominal

Greater trochanteric pain syndrome

Pathology. The ICON 2020 Consensus on GTPS (BJSM) establishes that gluteal tendinopathy — reactive or degenerative change at the insertions of gluteus medius and gluteus minimus on the greater trochanter — is the primary lesion in most cases. Trochanteric bursitis, historically the default label, is secondary at best. This distinction matters clinically: the bursa is not the primary target of treatment.

Who is affected. Peri-menopausal women predominate (F:M ~4:1). Strong associations exist with BMI ≥30, ipsilateral knee osteoarthritis, and low back pain. Postural factors — excessive hip adduction in standing and walking — load the gluteal tendons into a compressive zone that drives tendinopathic change.

Clinical features:

• Pain over the greater trochanter, lateral hip, or lateral thigh
• Worse lying directly on the affected side at night — sleep disruption is a hallmark presentation
• Worse climbing stairs, prolonged sitting with legs crossed, or rising from a low chair
• Direct tenderness on palpation of the greater trochanter — the single most reliable physical finding
• Single-leg stance test ≥30 seconds — reproducing lateral hip pain on standing unilaterally for 30 seconds is a sensitive and specific test for GTPS

Other key examination findings:

• Trendelenburg test — positive (pelvis drops on the opposite side) indicates gluteus medius weakness
• FABER (Patrick’s) test — also stresses the sacroiliac joint; helps distinguish SIJ pain
• Single-leg squat — reveals gluteal control and kinetic chain loading

Investigation. Clinical diagnosis is sufficient in most cases with classic presentation:

• Hip / pelvis X-ray — excludes fracture, hip osteoarthritis, calcific tendinopathy
• Ultrasound hip (MBS 55036) — visualises tendinopathy, partial or full tendon tears, bursal effusion; cheap, dynamic, GP-orderable
• MRI hip — gold standard; reserved for refractory cases, suspected full-thickness gluteal tendon tear, or diagnostic uncertainty

Red flags — must not miss

Always consider:

• Trauma + inability to weight bear — neck of femur or pubic ramus fracture; urgent X-ray and orthopaedic input
• Fever + severe hip pain, refusal to weight bear — septic arthritis; urgent hospital admission and joint aspiration
• Night pain + weight loss + age over 50 — malignancy or bone metastases
• Progressive neurological deficit — spinal cord or cauda equina pathology; urgent imaging
• Bilateral shoulder and hip girdle pain + prolonged morning stiffness in adults over 50 — polymyalgia rheumatica (see RACGP resources)

B. Evidence on treatment — the LEAP trial and what it changed

Exercise first: the LEAP protocol

The landmark LEAP randomised controlled trial (Mellor et al. BMJ 2018) enrolled 204 adults with GTPS and compared three approaches:

1. Education plus targeted gluteal exercise supervised by a physiotherapist (LEAP protocol)
2. Corticosteroid injection (CSI)
3. Wait-and-see

At eight weeks: CSI provided the greatest short-term pain relief.
At 52 weeks: the education-and-exercise group significantly outperformed both CSI and wait-and-see on the Patient Global Impression of Change scale.

This trial established structured physiotherapy-supervised exercise — not injection — as the first-line approach for GTPS, supported by the highest-quality trial data available. The LEAP protocol comprises:

• Education — the tendon is load-sensitive, not structurally damaged by activity; avoiding use is counterproductive
• Load management — avoid crossing legs, sleeping directly on the affected side, prolonged hip adduction postures, and deep hip flexion when sitting
• Sleep position — pillow between the knees reduces compressive load on the greater trochanter; practical and immediately implementable
• Progressive gluteal loading — begin with isometric gluteus medius exercises (e.g. side-lying abduction press against a wall), advance to isotonic and then functional single-leg progressions over 8–12 weeks

Australian Physiotherapy Association guidance supports referral to a musculoskeletal or sports physiotherapist with tendinopathy experience as the cornerstone of GTPS management. Five Medicare-subsidised allied health visits per year are available under a GPCCMP (MBS 965/967).

Corticosteroid injection — role and limits

Corticosteroid injection (triamcinolone acetonide or methylprednisolone) at the greater trochanter provides clinically meaningful short-term pain reduction — useful as a bridge to physiotherapy when pain is too severe to engage in exercise rehabilitation. It is not a definitive treatment and should not be offered as a standalone or repeatedly used strategy.

In practice: consider one injection when pain limits participation in physiotherapy; limit to one or two per year; ultrasound-guided injection improves accuracy and is preferred when clinic-administered injection fails to provide expected relief. In-clinic injection under MBS 18266 is an appropriate GP procedure.

Additional treatment options

NSAIDs — a short course (one to two weeks) is appropriate for acute pain management. Per eTG guidelines, review cardiovascular, renal, and gastrointestinal risk before prescribing; NSAIDs are not a long-term strategy for tendinopathy.

Topical NSAIDs (diclofenac gel) — effective for superficial musculoskeletal pain; minimal systemic absorption; appropriate first-line for patients with cardiovascular or renal contraindications to oral NSAIDs.

Paracetamol — appropriate analgesic adjunct; modest evidence for musculoskeletal pain; low risk profile.

Extracorporeal shock wave therapy (ESWT) — reasonable adjunct for refractory GTPS not responding to physiotherapy; modest RCT evidence; available privately at physiotherapy and sports medicine clinics.

PRP (platelet-rich plasma) injection — emerging evidence from some RCTs suggests superiority to corticosteroid at 12–24 weeks; protocols are heterogeneous and evidence is less mature than exercise; no MBS funding; private cost only; refer to a sports and exercise physician for consideration.

Surgery — endoscopic or open gluteal tendon repair for confirmed full-thickness tear failing at least six months of conservative management; specialist referral required; outcomes variable.

C. Femoroacetabular impingement — a distinct clinical entity

FAI affects a different population from GTPS and requires a completely separate diagnostic and treatment approach.

What FAI is

FAI arises from morphological mismatch between the femoral head and acetabulum:

• Cam morphology — bony excess at the femoral head-neck junction (asphericity); more common in young men; associated with adolescent sport participation (running, kicking, contact sports)
• Pincer morphology — acetabular over-coverage or retroversion creating premature contact; more common in women
• Mixed morphology — both cam and pincer features; the most common pattern in symptomatic FAI

With repeated impingement, the acetabular labrum is at risk of tearing and articular cartilage degenerates — the mechanistic pathway toward early hip osteoarthritis in active younger adults.

Diagnosis — the Warwick consensus

The Warwick agreement on FAI syndrome (BJSM 2016) established that clinical diagnosis requires all three of:

1. Symptoms — deep groin or anterior hip pain; worse with deep flexion (sitting, getting in or out of a car, sport); mechanical symptoms (clicking, catching, giving way)
2. Clinical signs — positive FADIR test (flexion-adduction-internal rotation reproducing deep groin pain); reduced internal rotation in flexion; positive FABER
3. Imaging — cam or pincer morphology on AP pelvis radiograph and Dunn (45° flexion) or frog-leg lateral view; alpha angle, lateral centre-edge angle

Cam or pincer morphology on imaging alone — without symptoms and signs — is not an FAI diagnosis. This distinction is important when interpreting radiology reports.

Treatment

Physiotherapy-led conservative care is first-line for all symptomatic FAI — targeted hip muscle strengthening, movement pattern modification, load management, and gradual return to sport over three to six months. Many patients with mild-to-moderate FAI achieve satisfactory outcomes with structured conservative management alone.

Hip arthroscopy — the FASHIoN randomised trial (Lancet 2018) enrolled 348 adults with symptomatic FAI and demonstrated significantly superior iHOT-33 scores at 12 months for arthroscopy versus physiotherapy alone, with effects persisting at three-year follow-up. However, the effect size is moderate, costs are substantial, and access to hip-preservation surgeons is limited in Australia. Hip arthroscopy is appropriate for patients with symptomatic FAI failing three to six months of adequate conservative management — not as a first-line approach.

A diagnostic intra-articular injection (local anaesthetic ± corticosteroid under imaging guidance) can help confirm that pain is intra-articular before surgical planning is undertaken.

D. Australian operations

MBS items

Service	MBS items
Standard GP consultations	23, 36, 44
GPCCMP (from July 2025)	965, 967
Allied health under GPCCMP (physio, EP — 5 visits/year)	10960, 10968
75+ Health Assessment	707
ATSI Health Assessment	715
Hip / pelvis X-ray	GP-referred; general schedule
Diagnostic ultrasound hip	55036
MRI hip (Medicare-eligible; often specialist referral required)	55712, 55713
Greater trochanter injection in-clinic	18266
Hip arthroscopy + FAI procedures	49315–49327

PBS prescribing

• Paracetamol — General Schedule
• NSAIDs (ibuprofen, naproxen, celecoxib, diclofenac) — General Schedule; topical diclofenac on General Schedule
• Triamcinolone acetonide 40 mg/mL — General Schedule for in-clinic injection
• Tramadol / oxycodone — General Schedule (acute use); PBS Authority for chronic non-cancer pain; SafeScript real-time prescription monitoring applies in most Australian jurisdictions

Full schedules at pbs.gov.au. Opioids are not recommended for chronic non-malignant hip tendinopathy.

Referral pathways

• Musculoskeletal or sports physiotherapist — first-line for both GTPS and FAI
• Sports and exercise physician — refractory tendinopathy, return-to-sport planning, RED-S evaluation in athletes, PRP consideration
• Hip-preservation orthopaedic surgeon — symptomatic FAI failing conservative management, full-thickness gluteal tendon tear
• Rheumatologist — suspected inflammatory hip arthropathy (e.g. psoriatic arthritis, polymyalgia rheumatica)
• Interventional radiologist — image-guided injections, MR arthrography for labral assessment

DVA Gold and White Card holders have equivalent allied health, imaging, and surgical access. Workers’ compensation covers occupational hip injury when mechanism and work exposure are documented.

E. Special populations

Peri-menopausal women. GTPS peaks around menopause, with oestrogen-related tendon vulnerability, increased BMI, and altered hip abductor loading all contributing. Hip adduction posture in standing and walking — a common compensatory pattern — is a high-yield biomechanical observation that a physiotherapist can identify and correct. Weight management via dietitian support (available under GPCCMP) reduces long-term tendon load.

Young female athletes and RED-S. Insidious anterior hip pain in a female distance runner, dancer, or military recruit warrants urgent consideration of a femoral neck stress fracture. The inability to single-leg hop should trigger immediate non-weight-bearing and urgent orthopaedic review — a displaced femoral neck stress fracture is a surgical emergency. Screen for Relative Energy Deficiency in Sport (RED-S): menstrual irregularity, low energy availability, disordered eating, and low bone mineral density are the red flags. A sports and exercise physician can coordinate the multidisciplinary assessment.

Older adults. Hip osteoarthritis presents with anterior groin pain, loss of internal rotation (earliest physical finding), and morning stiffness lasting less than 30 minutes. It overlaps in demographics with GTPS and may coexist. For severe OA with significant functional limitation, referral for total hip replacement is appropriate — outcomes are excellent and waiting times are accessible through public pathways. Opioid analgesia for chronic non-malignant hip pain in older adults carries particular risk: falls, confusion, constipation, and dependence. Non-pharmacological approaches remain preferred.

Post-surgical rehabilitation. Following hip arthroscopy or total hip replacement, structured physiotherapy-guided rehabilitation is essential for functional recovery. Allied health access under GPCCMP can support ongoing post-surgical recovery in general practice without requiring repeated specialist review.

When to escalate

Refer or escalate when:

• Acute trauma + inability to weight bear — urgent X-ray; if fracture confirmed or suspected, orthopaedic emergency referral
• Fever + severe hip pain — septic arthritis is a joint-threatening emergency; same-day hospital admission
• Night pain + systemic features in adults over 50 — malignancy workup
• GTPS failing eight weeks of structured physiotherapy-supervised exercise — consider image-guided corticosteroid injection, then sports and exercise physician review
• Suspected full-thickness gluteal tendon tear on ultrasound or MRI — hip-preservation orthopaedic or sports surgery referral
• FAI failing three to six months of adequate conservative care — hip-preservation orthopaedic referral for arthroscopy assessment
• Suspected femoral neck stress fracture in a young athlete — immediate non-weight-bearing and urgent orthopaedic review
• Bilateral hip and shoulder girdle pain with prolonged morning stiffness in adults over 50 — polymyalgia rheumatica assessment and rheumatology referral
• Avascular necrosis suspected (history of high-dose corticosteroids, alcohol excess, sickle cell disease, solid organ transplant) — MRI hip and urgent orthopaedic referral

What this article is and is not

This is general health information drawn from current Australian general practice evidence — Therapeutic Guidelines (eTG), the RACGP AFP, the ICON 2020 consensus on GTPS (BJSM), and the landmark LEAP trial (BMJ 2018) and FASHIoN trial (Lancet 2018). It does not constitute personal medical advice and does not create a doctor–patient relationship. Decisions about injection, imaging, or specialist referral are made in consultation with your treating GP, physiotherapist, and specialist.

For general information: HealthDirect — Hip pain, Arthritis Australia, Better Health Channel.

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Sources cited

1. RACGP AFP — Hip pain in adults
2. Therapeutic Guidelines (eTG) — Hip pain
3. ICON 2020 Consensus on greater trochanteric pain syndrome / gluteal tendinopathy — BJSM
4. Mellor R et al. — LEAP trial: education + exercise vs corticosteroid injection vs wait-and-see for GTPS (BMJ 2018;361:k1662)
5. Warwick agreement on femoroacetabular impingement syndrome — BJSM 2016
6. FASHIoN trial — hip arthroscopy vs physiotherapy for FAI (Lancet 2018)
7. Australian Physiotherapy Association — Hip clinical resources
8. HealthDirect — Hip pain
9. Arthritis Australia
10. Better Health Channel — Hip pain