The Clinical Coach: Dry Needling the Hip

By the end of this newsletter, you will be able to:

Differentiate gluteal tendinopathy from other sources of lateral hip pain in the older recreational runner using targeted clinical testing.

Apply dry needling to the gluteus medius and minimus using safe anatomical landmarks and appropriate needle angles.

Design a progressive hip loading program that avoids compressive positions during the early phase of rehabilitation.

Evaluate patient outcomes using single-leg stance endurance, pain provocation testing, and the VISA-G.

Tuesday morning. My second patient of the day is a 52-year-old woman who has been running the same five-mile loop for fifteen years.

She walks in holding the side of her hip. Not the groin. Not the back. The side.

That detail matters more than most clinicians give it credit for.

Subjective

D is a recreational runner. Three races a year, nothing competitive, but running is her identity and her stress relief. About three months ago she started getting pain over the outside of her right hip. It came on gradually. No fall, no twist, no single bad run she can point to.

"Where exactly does it hurt?" I ask.

She puts one finger right on the greater trochanter. Textbook.

The pain is worse going up stairs. Worse standing on that one leg to put on pants. And here is the finding that tells me where this is heading: it wakes her up at night when she lies on that side. She has started sleeping with a pillow between her knees because lying on the other side, the painful hip drops into adduction and that hurts too.

She has already been to urgent care. They told her it was bursitis and gave her a steroid dose pack. It helped for about a week. Then it came right back.

Sound familiar?

Objective

Observation: She stands with a subtle drop on the right side of her pelvis. Nothing dramatic. When she walks across the room I watch her right hip and see a small Trendelenburg pattern. Her abductors are not holding her level.

ROM: Hip range of motion is symmetrical and within normal limits in flexion, extension, and rotation. This is important. We are not looking at a capsular pattern. Passive movement does not reproduce her pain.

Neurological screening: Myotomes and dermatomes within normal limits. No radicular signs. Straight leg raise negative. This is not coming from her back, even though plenty of lateral hip pain does.

Palpation: Exquisite tenderness directly over the greater trochanter, specifically over the facets where the gluteus medius and minimus tendons insert. The gluteus medius muscle belly is ropey and tender about a hand-width above the trochanter. The gluteus minimus, deeper and harder to reach, reproduces her deep lateral ache when I press into it.

Orthopedic tests:

Single-leg stance test (30 second): Positive. She reproduces her lateral hip pain at about 20 seconds standing on the right leg.

Resisted hip abduction in side-lying: Positive. Pain over the trochanter, not in the muscle belly.

FADER test (flexion, adduction, external rotation with resistance): Positive. Reproduces lateral hip pain.

Ober test: Tightness noted, but the key is that the adducted position provoked her lateral pain.

FABER test: Negative for groin or posterior pain. No intra-articular signs.

Sport-specific assessment: I watch her do a single-leg squat on the right. Her pelvis drops and her knee dives into valgus almost immediately. Her abductor control under load is poor, and that is the engine that has been driving this for three months. Every stride she takes on that five-mile loop is a single-leg loading event, and her hip cannot control the frontal plane.

Diagnostic Statement

This is not bursitis. This is gluteal tendinopathy with greater trochanteric pain syndrome.

The tendons of her gluteus medius and minimus are degenerating and, more importantly, they are being compressed against the greater trochanter every time her hip drops into adduction. Stairs, single-leg stance, side-lying, the pillow at night. Every one of her aggravating factors is a compression position.

If we do not address this, she keeps running on a hip that cannot stabilize itself, the tendon keeps getting compressed and overloaded, and she joins the large group of patients who carry lateral hip pain for years.

Time to fix it.

The Trap: Calling it "trochanteric bursitis" and treating the bursa.

For decades, lateral hip pain got one label. Bursitis. The reasoning seemed sound. The pain is over the trochanter, there is a bursa over the trochanter, therefore the bursa is inflamed. Rest it, inject it, move on.

The problem is that the bursa is rarely the primary problem. Imaging studies of patients with lateral hip pain consistently show that the dominant pathology is tendon, not bursa. The gluteus medius and minimus tendons are the real story. The bursa, when it is inflamed at all, is usually reacting to the tendon problem underneath it. According to PubMed, a review of greater trochanteric pain syndrome by Pianka and colleagues describes the condition as a spectrum that includes abductor tendon pathology, trochanteric bursitis, and external coxa saltans, with careful clinical examination being essential because the tendon is so often the driver (DOI).

Why This Happens:

The name is sticky. "Bursitis" has been the default term for so long that it is the first word out of most clinicians' mouths when a patient points to the side of their hip.

The bursa is easy to blame. It is a simple, satisfying story. Inflammation in a sac, drain or inject the sac, done.

Tendinopathy is harder to treat. A degenerative, compression-driven tendon problem requires load management and a progressive program. That is more work than handing someone an anti-inflammatory.

Compression gets missed. Most providers never identify that adduction is the mechanical villain here. They tell the patient to stretch the IT band, which pulls the hip into more adduction, which compresses the tendon more.

The Cost:

When you treat this as bursitis, you usually reach for a corticosteroid injection. It feels effective because it calms the pain for a few weeks. D already lived this. The steroid dose pack from urgent care gave her a week of relief and then the pain returned, because nothing about the underlying tendon load or her abductor control had changed.

Worse, repeated corticosteroid injections into a degenerative tendon are not benign. The landmark LEAP trial, which I will come back to, found that education plus exercise outperformed corticosteroid injection at every time point that mattered. Patients who got the injection felt better fast and worse later.

And for D specifically, the cost is her running. Every week she spends being treated for the wrong diagnosis is another week of compressing and overloading that tendon on a five-mile loop. The longer this runs, the longer the rehab.

Gluteal Tendinopathy vs. Hip Osteoarthritis vs. Lumbar Referred Pain

Lateral hip pain has three big sources you have to separate before you treat anything. The hip joint itself. The lumbar spine referring laterally. And the abductor tendon complex. Get this wrong and you treat the wrong structure for months.

Diagnostic Tests Performed:

Single-Leg Stance Test (30 second): Positive Finding: Lateral hip pain reproduced at approximately 20 seconds of standing on the affected leg. Clinical Significance: This is one of the most useful tests for gluteal tendinopathy. Single-leg stance loads the abductors and compresses the tendon against the trochanter. Reproduction of lateral pain points strongly to the tendon, not the joint.

Resisted Hip Abduction (side-lying): Positive Finding: Pain localized over the greater trochanter with resisted abduction, not pain in the muscle belly. Clinical Significance: Loading the abductor tendon reproduces the patient's pain at the insertion. This separates a tendon problem from a muscle strain.

FADER Test: Positive Finding: Lateral hip pain with the hip held in flexion, adduction, and external rotation under resistance. Clinical Significance: This position both compresses and loads the gluteal tendons. A positive test supports tendinopathy and helps rule in the compression component.

FABER Test: Negative Finding: No groin pain, no posterior pain, no reproduction of intra-articular symptoms. Clinical Significance: A negative FABER makes hip joint pathology and sacroiliac involvement less likely. If this were osteoarthritis, we would expect groin pain and a capsular ROM pattern.

Lumbar Screen and Neurodynamics: Negative Finding: Straight leg raise negative, no radicular signs, myotomes and dermatomes within normal limits. Clinical Significance: This clears the lumbar spine as the primary driver. Lower lumbar pathology can refer to the lateral hip, so this has to be ruled out, not assumed.

Trendelenburg / Single-Leg Squat: Positive for control deficit Finding: Pelvic drop and knee valgus on single-leg loading of the affected side. Clinical Significance: This identifies the abductor control deficit that is feeding the tendinopathy. It is not diagnostic on its own, but it tells you what the rehab has to fix.

DECISION FRAMEWORK:

The mixed presentation row matters here. Plenty of 52-year-old runners have a little lumbar contribution and a tendinopathy at the same time. You treat both. You do not have to choose.

Immediate Emergency Referral:

Sudden inability to bear weight after acute trauma, with suspicion of fracture.

Signs of septic arthritis: hot, red, swollen joint with fever and severe pain.

Progressive neurological deficit in the lower limb.

Night pain that is unrelenting, not positional, combined with unexplained weight loss or a history of malignancy.

Urgent Medical Referral (Same Day):

Acute, severe pain with a palpable defect suggesting a full-thickness abductor tendon tear.

Rapidly worsening function with constitutional symptoms.

Suspected deep vein thrombosis presenting as limb pain and swelling.

Co-Management Referral:

Concurrent hip osteoarthritis where the joint is contributing significantly to the pain. I continue managing the tendon and abductor control while the orthopedic or primary team addresses the joint.

Failure to progress after a well-executed eight to twelve week loading program, which raises the question of a high-grade tendon tear that may need imaging and a surgical opinion.

Suspected inflammatory arthropathy that needs rheumatology input.

Imaging Referral:

Persistent symptoms not responding to conservative care, where MRI helps grade tendon pathology and rule out a full-thickness tear.

Suspicion of a tendon tear over degeneration, particularly with marked weakness on testing.

Clinical uncertainty between tendinopathy and intra-articular pathology, where plain radiographs and MRI clarify the picture. Imaging is not required to make the diagnosis of gluteal tendinopathy, which is clinical, but it earns its place when the case is not behaving.

Here is what gets my attention with D. The gluteus medius muscle belly is ropey and full of active trigger points, and the deeper gluteus minimus reproduces her exact lateral ache when I press into it. The tendon is the pain generator at the trochanter, but the muscle driving that tendon is dysfunctional, guarded, and not firing well. We can change that.

Dry needling the gluteal complex does two things. It reduces the trigger point activity and tone in the muscle so the patient can actually load it through rehab. And it creates a local response in the tissue that, paired with loading, supports the program rather than replacing it. According to PubMed, a double-blind randomized trial by Karamiani and colleagues found that adding gluteus medius trigger point dry needling to conventional physiotherapy produced greater improvement in physical function than physiotherapy alone in women with anterior knee pain, which speaks directly to the role of the gluteus medius as a treatable driver (DOI). Needling is the door opener. Loading is the room you walk into.

TARGET MUSCLES:

Gluteus Medius (Unilateral, right) Anatomical Landmarks: Palpate the iliac crest and the greater trochanter. The muscle belly sits in the upper outer quadrant of the buttock, roughly a hand-width above the trochanter, between the crest and the trochanter. Needle Specifications: 0.30mm x 50mm. Depth: Approximately 20 to 40mm into the muscle belly. Note: Depth is patient-dependent based on body composition, muscle development, and tissue response. Always assess tissue resistance and patient feedback to determine appropriate depth for each individual. Technique: Pistoning into taut bands to elicit a local twitch response, then a brief twirl to maintain engagement. Expected Response: A reproducible local twitch and the patient's familiar lateral ache, followed by a release in muscle tone. Safety Notes: Stay above and posterior to the trochanter to avoid the trochanteric region itself. Angle away from the sciatic notch. Keep needling in the muscle belly, not into the tendon insertion.

Gluteus Minimus (Unilateral, right) Anatomical Landmarks: Deeper and anterior to the medius, closer to the anterior superior iliac spine and the trochanter. Needle anterior in the upper outer quadrant. Needle Specifications: 0.30mm x 50mm, occasionally 60mm in a larger patient. Depth: Deeper than the medius, often 30 to 50mm, again patient-dependent. Note: Depth is patient-dependent based on body composition, muscle development, and tissue response. Always assess tissue resistance and patient feedback to determine appropriate depth for each individual. Technique: Slow, controlled advancement with gentle pistoning to find the deep taut band that reproduces the patient's referral. Expected Response: Reproduction of the deep lateral hip ache, which confirms you are in the right tissue, followed by a reduction in that referral. Safety Notes: This is a deep muscle near the hip joint and the path of the superior gluteal neurovascular bundle. Know your anatomy. Advance slowly, never force against firm resistance, and stay in the safe upper outer quadrant.

Tensor Fasciae Latae (Unilateral, right, optional adjunct) Anatomical Landmarks: Anterolateral hip, just distal and lateral to the ASIS. Needle Specifications: 0.30mm x 40mm. Depth: 15 to 30mm, patient-dependent. Note: Depth is patient-dependent based on body composition, muscle development, and tissue response. Always assess tissue resistance and patient feedback to determine appropriate depth for each individual. Technique: Gentle pistoning into taut bands. Expected Response: Local twitch, reduction in anterolateral tension that often feeds the compression pattern. Safety Notes: Superficial muscle, straightforward, but stay aware of the lateral femoral cutaneous nerve.

A note on what we do NOT needle. We do not needle into the trochanter, the bursa, or the tendon insertion itself. The pathological tendon does not need a needle driven into it. We needle the muscle to change tone and pain, then we load the tendon to remodel it.

TREATMENT FREQUENCY:

Phase 1 (Initial, Week 1): One to two sessions. Calm the muscle down, reduce trigger point activity, and get her able to tolerate the first loading exercises. This is the window where needling buys the most.

Phase 2 (Stabilization, Weeks 2 to 3): Once per week alongside the loading program. As her abductor control improves, the muscle needs less help.

Phase 3 (Maintenance, Weeks 4 and beyond): Every two to three weeks as needed, tapering off. By this point the loading program is doing the heavy lifting and needling is a tune-up, not the treatment.

I pair electrical stimulation with the needling in this case for two reasons. First, to drive a stronger, more comfortable contraction of the gluteus medius during the early phase when D's voluntary activation is poor. Second, to use it as a sensory tool for pain modulation between loading sessions.

Electrical Stimulation to Needles (during CDNP): Parameters: Low frequency, 2 to 4 Hz, intensity to a strong but comfortable visible contraction, 10 to 15 minutes. Leads connected to the gluteus medius needles. When to use: During the needling session in Phase 1 and early Phase 2. Expected outcome: A stronger local twitch response and improved post-treatment muscle activation, making the first loading exercises more accessible.

Neuromuscular Electrical Stimulation (NMES) for abductor activation: Parameters: 35 to 50 Hz, 10 seconds on, 50 seconds off, intensity to a strong contraction, surface electrodes over the gluteus medius, 10 to 15 contractions per session. When to use: Early rehab, when she struggles to volitionally recruit the abductors during a side-lying or standing isometric. Expected outcome: Improved voluntary recruitment and a quicker transition to load-bearing exercise. NMES is a bridge to active loading, not a destination.

TENS for pain modulation: Parameters: Conventional high frequency, 80 to 100 Hz, comfortable sensory intensity, 20 to 30 minutes over the lateral hip. When to use: At home on high-symptom days, particularly to help with night pain. Expected outcome: Short-term pain relief that helps her sleep and stay consistent with the program. It manages symptoms, it does not treat the tendon.

Mobilization (Manual Therapy): Parameters: Lumbar and hip mobilization as indicated. Posterior-to-anterior glides to the lower lumbar segments to address any minor spine contribution, and gentle hip mobilization to maintain pain-free joint mechanics. Soft tissue work to the gluteal complex and TFL. When to use: Early sessions to reduce guarding and address the lumbar contribution that often rides along in this age group, and as needed through the program. Expected outcome: Reduced protective tone, better movement tolerance, and a hip that loads more comfortably. Manual therapy is the on-ramp. It is not the program. The mistake is making it the whole visit.

A word on what we deliberately avoid. No aggressive IT band stretching. No foam rolling directly over the trochanter. Both drive the hip into adduction or directly compress the painful tendon. They feel productive and they make the problem worse.

This is where the case is won or lost. Needling opens the door. Electrical stimulation and manual therapy support the early phase. But the tendon only remodels under progressive load, and the abductors only learn to control the hip if we train them to.

REHABILITATION SAFETY PRINCIPLES:

Avoid compression early. No exercises in hip adduction during the first phase. That means no clamshells with the hip flexed and adducted, no crossing the leg over midline, no side-lying on the painful hip without support, and no IT band stretching.

Use pain as a guide, not an enemy. According to PubMed, a systematic review of load progression criteria in lower limb tendinopathy by Escriche-Escuder and colleagues found that pain-based progression is the most commonly used approach, allowing low and acceptable levels of pain during loading as long as it settles (DOI). A pain level up to about 3 out of 10 during exercise that settles within 24 hours is acceptable. Pain that climbs and lingers means we backed off too little.

Isometrics first. Start with isometric abduction in neutral, which loads the tendon without the compression of end-range movement and gives early pain relief.

Phase 1. Foundation (Weeks 1 to 2):

Isometric hip abduction in standing against a wall, neutral hip, 5 holds of 30 to 45 seconds, once or twice daily. This loads the abductors without adduction.

Side-lying hip abduction with a pillow between the knees to keep the hip out of adduction, slow and controlled, 2 to 3 sets of 10 to 12.

Standing hip hitch (pelvic control drill) to retrain the abductors to hold the pelvis level, 2 to 3 sets of 10 per side.

Double-leg bridge to engage the posterior chain without single-leg compression, 2 to 3 sets of 12 to 15.

Goal of Phase 1: Reduce pain, restore basic abductor activation, and educate D thoroughly on load management. The education piece is not optional. It is the highest-value intervention we deliver.

Phase 2. Loading (Weeks 3 to 4):

Progress isometrics to slow, heavy, controlled abduction with resistance band, neutral to slight abduction range, 3 sets of 8 to 12.

Step-ups to a low step, focusing on keeping the pelvis level and the knee tracking over the foot, 3 sets of 8 per side. This is functional single-leg loading.

Single-leg balance progressions, building toward the 30-second single-leg stance she failed at evaluation.

Hip airplane or controlled single-leg deadlift pattern to load the abductors in rotation control, 2 to 3 sets of 6 to 8 per side.

Goal of Phase 2: Build abductor strength and single-leg control under progressively heavier load, with pain staying within the acceptable window.

Phase 3. Sport-Specific Integration (Weeks 5 and beyond):

Heavy slow resistance abduction work, progressing load as tolerated.

Single-leg squats and lateral step-downs with clean pelvic control, 3 sets of 8 to 10 per side.

Running-specific loading: lateral bounds, controlled hops, and progressive return to running starting with a walk-run interval program on flat ground.

Hill and stair reintroduction last, since these are her highest compression demands.

RETURN-TO-SPORT CRITERIA:

Single-leg stance held for 30 seconds without reproducing lateral hip pain.

Symmetrical single-leg squat with no pelvic drop and no knee valgus.

Pain-free stair climbing and side-lying.

Successful completion of a graded walk-run progression with no symptom flare in the following 24 hours.

VISA-G score improved substantially from baseline, ideally into the 80s or better.

The evidence here is strong and worth saying plainly to your patients. According to PubMed, the LEAP trial by Mellor and colleagues, a single-blinded randomized clinical trial of 204 people with gluteal tendinopathy, found that education plus exercise produced better global improvement than corticosteroid injection at both 8 weeks and 52 weeks (DOI). A more recent narrative review by Gill and colleagues reached the same conclusion, that targeted physiotherapy offers superior long-term outcomes compared to shockwave therapy and corticosteroid injection (DOI). Load is the medicine. Earlier work by Ganderton and colleagues using the VISA-G to track gluteal loading outcomes reinforces that exercise and education move the needle on this condition over a full year of follow-up (DOI).

Managing Expectations Against the Quick Fix

D came to me having already been offered the fast answer. A steroid dose pack, and the implicit promise that it would handle things. It did not, and the evidence tells us why. Here is the ethical tension. The patient in pain wants relief now, and a corticosteroid injection delivers it. But the best available evidence shows that injection leads to worse outcomes at a year than education plus exercise. We have an obligation to tell patients the truth even when the truth is "this will take eight to twelve weeks of work." The principle is honest informed consent, including the uncomfortable timeline. We do not sell the slow road as fun. We sell it as the road that actually gets her back to running.

Scope of Practice and the Injection Conversation

Patients will ask you about cortisone. They will ask whether they should get the shot. We can and should explain what the evidence says, and we can co-manage with the physician who would perform an injection. But we have to stay in our lane. We do not tell a patient to refuse a medical procedure their physician recommended. We give them the evidence, we frame the trade-offs, and we respect that the decision is shared between the patient and the prescriber. Offering evidence is our job. Overriding another provider is not.

Treating the Whole Athlete, Not Just the Tendon

D's running is part of her mental health and identity. There is an ethical pull to either be overly cautious, telling her to stop running entirely, or overly permissive, clearing her too soon to keep her happy. Neither serves her. The ethical center is shared decision making grounded in objective criteria. We use the return-to-sport markers to make the call together, so the decision is based on her hip's actual capacity rather than on her frustration or my desire to be the clinician who got her back fast.

Lateral hip pain that hurts in single-leg stance, on stairs, and lying on that side at night is gluteal tendinopathy until proven otherwise. The bursa is rarely the main event.

Every aggravating position in this condition is a compression position. If you understand adduction is the enemy, your whole treatment plan organizes itself.

Do not needle the tendon or the bursa. Needle the muscle to change tone and pain, then load the tendon to remodel it.

Kill the IT band stretch and the trochanter foam roll. They feel productive to the patient and they drive compression into an already irritated tendon.

Isometric abduction in neutral is your best early tool. It loads the tendon, calms the pain, and avoids the compression that movement-based exercises create.

Tell the patient the timeline up front. Education plus exercise beats the injection over a year, but it is slower in week one. Set the expectation and they will trust the process.

For the older recreational runner, screen the lumbar spine every time. A mixed tendon-plus-spine presentation is common in this age group, and you treat both.

Subjective: 52-year-old female recreational runner presents with insidious onset right lateral hip pain, 3-month duration, no acute mechanism. Pain localized to the right greater trochanter, rated 6/10 at worst. Aggravated by single-leg stance, stair ascent, and side-lying on the right at night, with secondary discomfort lying on the left due to hip adduction. Prior course of oral corticosteroid provided one week of relief with return of symptoms. Goal is return to recreational running. No bowel or bladder changes, no constitutional symptoms, no history of malignancy.

Objective: Observation: Subtle right pelvic drop in stance, mild Trendelenburg pattern in gait. ROM: Hip flexion, extension, and rotation symmetrical and within normal limits, pain-free with passive movement. Neurological: Myotomes and dermatomes within normal limits, straight leg raise negative. Palpation: Marked tenderness over the right greater trochanter at the gluteus medius and minimus insertions, taut bands and active trigger points in the gluteus medius belly, deep gluteus minimus tenderness reproducing the lateral referral. Orthopedic testing: Single-leg stance test positive at 20 seconds, resisted hip abduction positive over the trochanter, FADER positive, FABER negative, lumbar screen and neurodynamics negative. Functional: Single-leg squat demonstrates pelvic drop and dynamic knee valgus, indicating abductor control deficit.

Assessment: Right gluteal tendinopathy with greater trochanteric pain syndrome, compression-driven, with associated abductor control deficit. Hip osteoarthritis and lumbar referred pain ruled out by negative FABER, full pain-free passive ROM, and negative lumbar and neurodynamic screen. Presentation, examination, and provocation testing are consistent and confident for gluteal tendinopathy. Plan addresses muscle tone and pain via CDNP with electrical stimulation, symptom and activation support via NMES and manual therapy, and tendon remodeling via a progressive, compression-avoidant loading program with objective return-to-sport criteria.

D bought in on day one, and that is half the battle.

The first two weeks were about taking pressure off the tendon and getting her muscles to talk to her again. We needled the gluteus medius and minimus with electrical stimulation, did the early isometrics, and I spent a real chunk of that first visit teaching her load management. No more lying on the painful side without a pillow. No more crossing her legs. No more IT band stretching, which she had been doing religiously and which had been quietly making everything worse.

By week three her night pain was mostly gone. That is the finding patients notice first, and it is a good early signal. She could lie on the hip with a pillow and sleep through the night.

We moved into loading. Step-ups, banded abduction, single-leg balance. Her single-leg stance climbed from 20 painful seconds to a full 30 seconds clean by about week six. The pelvic drop in her single-leg squat cleaned up as the abductors got stronger and smarter.

At week eight we started the walk-run progression on flat ground. She had one minor flare after she got excited and added a hill too early, which gave me a perfect teaching moment about her highest compression demand. We pulled the hills back, let it settle, and progressed again.

By week eleven she ran her five-mile loop. No lateral hip pain. Her VISA-G had climbed into the 80s from a baseline in the 40s.

Here is the lesson I want you to take from D. The fast answer she got first, the steroid pack, was not wrong because the provider was careless. It was wrong because it treated a name, bursitis, instead of a mechanism, compression and load. When you understand the mechanism, the whole plan writes itself.

Every patient is unique, and D taught me again that the runner in front of you is rarely looking for a shortcut. She is looking for someone who will tell her the truth and then walk the timeline with her.

That is the work.

The Clinical Coach is a clinical education publication produced by SmartCARE Education. Content is for educational purposes and CE credit. Always exercise independent clinical judgment with individual patients.

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