Gluteus Medius Syndrome

What is Gluteus Medius Syndrome

Gluteus medius syndrome causes pain on the outside of your hip due to repeated overstretching or overwork of the gluteus medius muscle. This muscle runs from the top, outer part of your pelvis to the top of your thigh bone (femur).

The gluteus medius muscle’s primary function is as a hip abductor, and the muscle also assists in medial and lateral rotation of the hip. The gluteus medius muscle originates at the dorsal ilium just below the iliac crest.

The gluteus medius muscle is susceptible to the development of myofascial pain syndrome. Such pain most often occurs as a result of repetitive microtrauma to the muscle from activities such as running on soft surfaces and overuse of exercise equipment or other repetitive activities that require hip abduction. Blunt trauma to the muscle may also incite gluteus medius myofascial pain syndrome.

This muscle helps you lift your leg to the side and rotate your leg. It also keeps your hip stable and aligned when you are standing, walking, or running.

Myofascial pain syndrome is a chronic pain syndrome that affects a focal or regional portion of the body. The sine qua non of myofascial pain syndrome is the finding of myofascial trigger points on physical examination. Although these trigger points generally are localized to the regional part of the body affected, the pain of myofascial pain syndrome often is referred to other anatomical areas. This referred pain often is misdiagnosed or attributed to other organ systems, thereby leading to extensive evaluations and ineffective treatment. Patients with myofascial pain syndrome involving the gluteus medius often have primary pain along the posterior iliac crest that is referred down the buttocks across the sacroiliac joint and into the posterior lower extremity.

The trigger point is the pathognomonic lesion of myofascial pain and is thought to be the result of microtrauma to the affected muscles. This pathological lesion is characterized by a local point of exquisite tenderness in affected muscle. Mechanical stimulation of the trigger point by palpation or stretching produces not only intense local pain but also referred pain. In addition to this local and referred pain, often an involuntary withdrawal of the stimulated muscle, termed a jump sign, occurs. The jump sign also is characteristic of myofascial pain syndrome. Patients with gluteus medius syndrome will exhibit a trigger point along the posterior iliac crest.

Taut bands of muscle fibers often are identified when myofascial trigger points are palpated. Despite this consistent physical finding in patients with myofascial pain syndrome, the pathophysiology of the myofascial trigger point remains elusive, although many theories have been advanced. Common to all these theories is the belief that trigger points are the result of microtrauma to the affected muscle. This microtrauma may occur as a single injury to the affected muscle or as the result of repetitive microtrauma or chronic deconditioning of the agonist and antagonist muscle unit.

In addition to muscle trauma, a variety of other factors seem to predispose the patient to develop myofascial pain syndrome. The weekend athlete who subjects his or her body to unaccustomed physical activity often may develop myofascial pain syndrome. Poor posture while sitting at a computer keyboard or while watching television also has been implicated as a predisposing factor to the development of myofascial pain syndrome. Previous injuries may result in abnormal muscle function and predispose to the subsequent development of myofascial pain syndrome. All these predisposing factors may be intensified if the patient also has poor nutritional status or coexisting psychological or behavioral abnormalities, including chronic stress and depression. The gluteus medius muscle seems to be particularly susceptible to stress-induced myofascial pain syndrome.

Stiffness and fatigue often coexist with the pain of myofascial pain syndrome, increasing the functional disability associated with this disease and complicating its treatment. Myofascial pain syndrome may occur as a primary disease state or in conjunction with other painful conditions, including radiculopathy and chronic regional pain syndromes. Psychological or behavioral abnormalities, including depression, frequently coexist with the muscle abnormalities associated with myofascial pain syndrome. Treatment of these psychological and behavioral abnormalities must be an integral part of any successful treatment plan for myofascial pain syndrome.

What are the causes?

This condition is caused by small injuries to the gluteus medius muscle over time. It happens from repetitive movements or a sudden increase in amount or intensity of activity that involves the legs. It starts with muscle inflammation and may lead to small tears and scarring in your muscle.

What increases the risk?

This condition is more likely to develop in people who:

  • Run on soft or uneven surfaces, such as sand or grass.
  • Have weakness in their hips and core muscles.
  • Run long distances.
  • Increase their time, distance, or intensity of their sport over a short period of time.

What are the symptoms?

The main symptom of this condition is pain on the outside of your hip with activity. Typically, pain will gradually increase the longer you play sports or run, and it will decrease with rest. Your hip may also be tender to the touch and you may have muscle spasms.

The trigger point is the pathological lesion of gluteus medius syndrome, and it is characterized by a local point of exquisite tenderness in gluteus medius muscle. Mechanical stimulation of the trigger point by palpation or stretching produces both intense local pain in the medial and lower aspects of the muscle and referred primary pain along the posterior iliac crest that is referred down the buttocks across the sacroiliac joint and into the posterior lower extremity. In addition, the jump sign is often present.

How is this diagnosed?

This condition is diagnosed based on your symptoms, medical history, and physical exam. During the exam, your health care provider will touch different areas of your hip to test for pain. You may also have imaging studies such as X-rays and MRI to rule out other causes of pain.

Biopsies of clinically identified trigger points have not revealed consistently abnormal histological findings. The muscle hosting the trigger points has been described as “moth eaten” and as containing “waxy degeneration.” Increased plasma myoglobin has been reported in some patients with gluteus medius syndrome, but this finding has not been corroborated by other investigators.

Electrodiagnostic testing has revealed an increase in muscle tension in some patients, but again, this finding has not been reproducible. Because of the lack of objective diagnostic testing, the clinician must rule out other coexisting disease processes that may mimic gluteus medius syndrome

Differential Diagnosis

The diagnosis of gluteus medius syndrome is based on clinical findings rather than specific laboratory, electrodiagnostic, or radiographic testing. For this reason, a targeted history and physical examination, with a systematic search for trigger points and identification of a positive jump sign, must be carried out in every patient thought to have gluteus medius syndrome. It is incumbent on the clinician to rule out other coexisting disease processes that may mimic gluteus medius syndrome, including primary inflammatory muscle disease, primary hip pathological processes, gluteal bursitis, and superior cluneal and gluteal nerve entrapment.

The use of electrodiagnostic and radiographic testing can identify coexisting pathological conditions such as rectal or pelvic tumors or lumbosacral nerve lesions. The clinician must also identify coexisting psychological and behavioral abnormalities that may mask or exacerbate the symptoms associated with gluteus medius syndrome.

How is this treated?

Treatment for this condition includes:

  • Decreasing mileage or time spent doing sports.
  • Having a coach help you with your running form.
  • Stretching or strengthening exercises (physical therapy).
  • Icing painful areas.

Treatment is focused on eliminating the myofascial trigger and achieving relaxation of the affected muscle. It is hoped that interrupting the pain cycle in this way will allow the patient to obtain prolonged pain relief. The mechanism of action of the treatment modalities used is poorly understood, so an element of trial and error is involved in developing a treatment plan.

Conservative therapy consisting of trigger point injection with local anesthetic or saline is the initial treatment of gluteus medius syndrome. As an alternative, dry needling may be considered. Because underlying depression and anxiety are present in many patients, antidepressants are an integral part of most treatment plans. Pregabalin, gabapentin, duloxetine, and milnacipran may also provide symptomatic relief.

Other methods, including physical therapy, therapeutic heat and cold, transcutaneous nerve stimulation, and electrical stimulation, may be helpful on a case-by-case basis. For patients who do not respond to these traditional measures, consideration should be given to the use of botulinum toxin type A. Although not currently approved by the Food and Drug Administration for this indication, the injection of minute quantities of botulinum toxin type A directly into trigger points has been successful in the treatment of persistent gluteus medius syndrome.

Follow these instructions at home:

  • Take over-the-counter and prescription medicines only as told by your health care provider.
  • If directed, apply ice to the injured area.
    • Put ice in a plastic bag.
    • Place a towel between your skin and the bag.
    • Leave the ice on for 20 minutes, 2–3 times a day.
  • Do exercises as told by your physical therapist.
  • Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
  • Keep all follow-up visits as told by your health care provider. This is important.
  • Try not to lie on your painful side. When lying on your other side, put a pillow between your knees to decrease strain on your top hip muscles.


Trigger point injections are extremely safe if careful attention is paid to the clinically relevant anatomy. Sterile technique must be used to avoid infection, along with universal precautions to minimize any risk to the operator. Most complications of trigger point injection are related to needle-induced trauma at the injection site and in underlying tissues. The incidence of ecchymosis and hematoma formation can be decreased if pressure is applied to the injection site immediately after injection. The avoidance of overly long needles can decrease the incidence of trauma to underlying structures. Special care must be taken to avoid trauma to the sciatic nerve.

How is this prevented?

  • Warm up and stretch before being active.
  • Cool down and stretch after being active.
  • Give your body time to rest between periods of activity.
  • Include a variety of exercises and activities in your routine to avoid overuse injuries.
  • Maintain physical fitness, including:
    • Strength.
    • Flexibility.
    • Cardiovascular fitness.
    • Endurance.

Contact a health care provider if:

  • Your pain does not get better or it gets worse.

Gluteus Medius Syndrome Rehabiliation

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do notbegin these exercises until told by your health care provider.

Stretching and range of motion exercise

This exercise warms up your muscles and joints and improves the movement and flexibility of your hip and pelvis. This exercise also helps to relieve pain and stiffness.

Exercise A: Lunge (

hip flexor stretch)

  1. Kneel on the floor on your left / right knee. Bend your other knee so it is directly over your ankle.
  2. Keep good posture with your head over your shoulders. Tuck your tailbone underneath you. This will prevent your back from arching too much.
  3. You should feel a gentle stretch in the front of your thigh or hip. If you do not feel a stretch, slowly lunge forward with your chest up.
  4. Hold this position for __________ seconds.
  5. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Strengthening exercises

These exercises build strength and endurance in your hip and pelvis. Endurance is the ability to use your muscles for a long time, even after they get tired.

Exercise B: Bridge (

hip extensors)

  1. Lie on your back on a firm surface with your knees bent and your feet flat on the floor.
  2. Tighten your buttocks muscles and lift your bottom off the floor until the trunk of your body is level with your thighs.
    • You should feel the muscles working in your buttocks and the back of your thighs. If this exercise is too easy, cross your arms over your chest or lift one leg while your bottom is up off the floor.
    • Do notarch your back.
  3. Hold this position for __________ seconds.
  4. Slowly lower your hips to the starting position.
  5. Let your muscles relax completely between repetitions.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise C: Straight leg raises (

hip abductors)

  1. Lie on your side with your left / right leg in the top position. Lie so your head, shoulder, knee, and hip line up. Bend your bottom knee to help you balance.
  2. Lift your top leg up 4–6 inches (10–15 cm), keeping your toes pointed straight ahead.
  3. Hold this position for __________ seconds.
  4. Slowly lower your leg to the starting position and let your muscles relax completely.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise D: Hip abductors and external rotators, quadruped

  1. Get on your hands and knees on a firm, lightly padded surface. Your hands should be directly below your shoulders, and your knees should be directly below your hips.
  2. Lift your left / right knee out to the side. Keep your knee bent. Do nottwist your body.
  3. Hold this position for __________ seconds.
  4. Slowly lower your leg.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise E: Single leg stand

  1. Stand near a counter or door frame to hold onto as needed. It is helpful to look in a mirror for this exercise so you can watch your hip.
  2. Squeeze your left / right buttock muscles then lift up your other foot. Do not let your left / right hip push out to the side.
  3. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Clinical Pearls

Although gluteus medius syndrome is a common disorder, it is often misdiagnosed. Therefore in patients thought to have gluteus medius syndrome, a careful evaluation to identify underlying disease processes is mandatory. Gluteus medius syndrome often coexists with a variety of somatic and psychological disorders.


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