Working approach: Localise the dominant pain generator with a focused hip, groin/pelvic and lumbar neuromusculoskeletal assessment, while actively screening for stress fracture, intra-articular hip disease, athletic pubalgia, sacroiliac pathology, infection and referred spinal pain. NICE CKS
History: Clarify whether pain is predominantly lateral/posterolateral at the greater trochanter, deep anterior groin/adductor origin, buttock, lower back or anterior thigh; document radiation, onset, nature, severity, mechanical symptoms and aggravating or relieving factors. NICE CKS
Establish the relationship to running, hills, stride/loading, kicking, sit-ups, coughing/sneezing or Valsalva, weight bearing, prolonged standing or sitting, lying on the affected side, and any recent change in training load. NICE CKS
Ask about acute trauma, fall, prior hip disease or surgery, previous femoral fracture, corticosteroid exposure, alcohol misuse, systemic symptoms, known malignancy, and symptoms of lumbar radiculopathy. NICE CKS
Groin pain provoked by kicking, sit-ups, Valsalva or direct pressure, particularly with radiation to the inner thigh, supports athletic pubalgia/sports hernia rather than isolated trochanteric disease. NICE CKS
Gradual weight-bearing hip or groin pain with rest relief, limp and stiffness raises osteoarthritis, whereas sporting groin pain with pain or restriction in flexion and internal rotation suggests hip impingement. NICE CKS
Deep pain on weight bearing after repetitive loading, especially if reproduced by hopping, active straight-leg raise, leg roll or end-range hip movement, should prompt concern for femoral-neck stress fracture. NICE CKS
Posterior buttock pain radiating to the groin or posterior proximal thigh suggests sacroiliac joint dysfunction, while low-back symptoms or neurological features require a lumbar and neurological assessment and consideration of cancer, infection, trauma or inflammatory disease where clinically indicated. NICE CKS,NICE NG59
Examination: Observe gait and single-leg loading; an antalgic gait reduces stance time on the painful side, and a Trendelenburg gait with ipsilateral trunk lean supports impaired lateral hip abductor function. NICE CKS
Inspect and palpate systematically: greater trochanter/gluteus medius insertion, adductor muscle belly and proximal adductor origin, pubic tubercle and inguinal canal, femoral triangle, sacroiliac region, lumbar spine and hip joint line. NICE CKS
Focal tenderness over the greater trochanter, particularly near the gluteus medius tendon insertion, combined with lateral hip pain aggravated by activity, favours greater trochanteric pain syndrome. NICE CKS
For suspected greater trochanteric pain syndrome, assess pain with resisted hip abduction, resisted internal rotation and resisted external rotation, because tensioning muscles and tendons attached to the greater trochanter commonly reproduces symptoms. NICE CKS
For a probable adductor-related source, compare sides for focal adductor-origin tenderness and pain reproduced by resisted hip adduction; interpret this alongside absence or presence of the trochanteric findings above. NICE CKS
Assess active and passive hip range of motion, particularly flexion and internal rotation; painful restriction of internal rotation with the hip and knee flexed supports hip arthritis, and pain or restriction with flexion/internal rotation supports hip impingement. NICE CKS
Perform resisted sit-up and hip-flexion testing and examine for inguinal-canal, pubic-tubercle or adductor-origin tenderness if athletic pubalgia is suspected, noting that a clinically evident hernia may be absent. NICE CKS
Use sacroiliac stress testing, such as posterior shear, if the pain distribution is posterior buttock/groin/proximal posterior thigh. NICE CKS
Check for lateral-hip erythema, warmth, oedema or a tender palpable mass, which would raise concern for bursal or soft-tissue infection rather than uncomplicated greater trochanteric pain syndrome. NICE CKS
Likely working diagnoses: Greater trochanteric pain syndrome is most likely when lateral/posterolateral pain and focal greater-trochanter tenderness are reproduced by loading the hip abductors/rotators. NICE CKS
An adductor-related tendinopathy/strain is more likely when pain is centred at the adductor origin or medial groin and is reproducible with adductor loading, provided intra-articular hip pathology and athletic pubalgia are not suggested by the wider examination. NICE CKS
Investigations and safety net: Do not image routinely for an uncomplicated clinical presentation of greater trochanteric pain syndrome, but arrange a plain hip radiograph when acute fracture, dislocation or femoral-neck stress fracture is suspected. NICE CKS
If a hip fracture remains clinically suspected despite adequate negative radiographs, MRI is recommended; CT is an alternative when MRI is unavailable within 24 hours or contraindicated. NICE CG124
Arrange emergency assessment for sudden inability to bear weight, hip pain with systemic symptoms, clinical infection, a fall, or known primary malignancy with possible pathological fracture. NICE CKS
Arrange urgent orthopaedic assessment for severe pain unresponsive to analgesia with persistent loss of function. NICE CKS
Refer to secondary care or an MSK interface service when the diagnosis remains uncertain, symptoms may relate to prior hip surgery or femoral fracture, or there is failure of appropriate conservative care. NICE CKS
Initial primary-care management if no red flags or stress-fracture concern: Advise temporary relative reduction or modification of provocative running and repetitive hip-loading activity, avoiding lying on the affected side if this worsens lateral hip pain. NICE CKS
Offer paracetamol or an NSAID such as ibuprofen when appropriate, and advise ice application for 10–20 minutes several times daily for symptomatic relief. NICE CKS
Provide an early physiotherapy-led rehabilitation plan directed by the examination findings, with progressive hip abductor/pelvic-control work for greater trochanteric pain syndrome or graded adductor loading for an adductor-related presentation. NICE CKS
If a clinical greater trochanteric pain syndrome presentation has inadequate relief after initial conservative treatment, offer physiotherapy and consider peri-trochanteric corticosteroid injection where local expertise is available. NICE CKS
Review function, gait, pain location and response to load modification promptly; escalating pain, worsening weight-bearing tolerance or emergence of stiffness, systemic features or neurological symptoms should trigger reassessment for an alternative diagnosis. NICE CKS,NICE NG59