Hip Pain Lying on Your Side at Night: Why It Happens and What Helps
Pain on the outside of the hip that wakes you when you roll onto it is common, is often labelled bursitis, and is usually something else. This is what the evidence suggests is going on, and what tends to help.
Peek Practice, Grey Lynn, Auckland, New Zealand
Most outer-hip pain that wakes people at night is not bursitis. Hip pain lying on your side at night more often reflects irritation of the gluteal tendons, where the buttock muscles attach to the bony point on the outside of the hip. The distinction sounds academic. It is not: it changes what helps, and what is likely to be a waste of time and money.
What causes hip pain lying on your side at night?
Two muscles, gluteus medius and gluteus minimus, run from the pelvis to the greater trochanter — the bony bump you can feel on the outside of the upper thigh. Their tendons wrap over that bump. When those tendons become sensitive and less tolerant of load, the condition is called gluteal tendinopathy. It is the most common tendon problem in the lower limb and the most common cause of pain in this area.
These tendons are thought to be particularly sensitive to compression — being squashed against bone. Lying directly on the sore side compresses them. Less obviously, so does lying on the other side, when the top knee drops towards the mattress and the tendon is pulled tight across the bone. Crossing the legs, standing with weight hitched onto one hip and sitting in low chairs can do the same.
This is why the pain so often shows up at night, on first standing, on stairs and when getting out of the car, rather than mid-walk. The ache may spread down the outer thigh, and pressing on the bony point is usually tender.
Isn’t this just bursitis?
For decades this was called trochanteric bursitis — inflammation of a small fluid-filled cushion (a bursa) that sits near the tendon. Contemporary thinking favours a different picture. Imaging and tissue studies find that the tendon is usually the primary problem, and that bursal swelling, when present, is mostly a secondary feature. The tendon changes themselves are largely degenerative rather than inflammatory.
The label matters because it shapes the treatment. “Inflammation of a bursa” points towards anti-inflammatories and injections. A tendon that has lost tolerance to load points towards changing how it is loaded, then gradually rebuilding that tolerance. Many people arrive having had one or two cortisone injections, several weeks of relief, and then a return of pain. That pattern is consistent with the research below.
Who tends to get it?
Women in their 40s, 50s and 60s are affected several times more often than men. In one large US study of adults aged 50 to 79, close to one in four women had tenderness of this kind, compared with fewer than one in ten men.
It is thought that falling oestrogen after menopause may reduce tendon resilience, which could partly explain the timing. The evidence here remains thin: no trial has yet shown that hormone therapy improves gluteal tendon outcomes. Other possible contributors include a sudden increase in walking, hills or stairs, a wider pelvis, higher body weight, and a lower back that is already sensitive.
What else could it be?
Not every pain on the outside of the hip comes from the tendon. Several conditions can look similar, and they can coexist:
Referred pain from the lower back. Spinal joints and nerves can refer pain into the buttock and outer hip. Between a fifth and a third of people with low back pain also have tenderness over the outer hip, so both may be contributing.
The hip joint itself. Hip osteoarthritis more often causes pain in the groin and front of the thigh, with stiffness turning the leg inwards, rather than tenderness on the outside.
An irritated skin nerve (meralgia paraesthetica). This tends to produce burning or numbness over the front and outer thigh rather than an ache on movement.
Rarer but important causes. A stress fracture in someone with low bone density, infection, or a tumour. Night pain unchanged by position, fever, unexplained weight loss or a history of cancer warrant prompt medical review.
The clinical task is not simply to name one condition. It is to work out which structures may be contributing, and by how much.
Do I need a scan?
Usually not to make the diagnosis, which is clinical — built from the history and examination. Imaging can help when the picture is unclear, when weakness is marked, or when symptoms are not improving with good care.
When scans are done, they can be hard to interpret. In the LEAP trial, the largest randomised trial in this condition, 42% of participants had tears in the gluteal tendons on MRI. Yet how severe the tendon changes looked was not associated with how much pain or disability people reported. A reported “tear” therefore does not automatically mean an injection or surgery. As discussed in our post on whether you need an MRI for back pain, scan findings are part of a process of determining how the tissue may be contributing to the problem — not a verdict on their own.
What actually helps?
On balance, the literature supports education about load combined with a graded exercise programme as the first-line approach.
The LEAP trial compared three options in 204 people: 14 sessions of education and exercise over eight weeks, a single corticosteroid injection, or wait-and-see. At eight weeks, 77% of the education-and-exercise group rated themselves at least moderately better, compared with 58% after injection and 29% with wait-and-see. The advantage held at one year. Systematic reviews since then broadly agree: injection offers a small, short-term reduction in pain, while education and exercise produce larger and more durable gains in pain and function. Shockwave therapy and platelet-rich plasma injections show some promise, but the evidence is less settled.
Interestingly, a separate trial in post-menopausal women found that education about avoiding compression, paired with a minimal exercise programme, did as well as a targeted strengthening programme. One could infer that understanding the problem, and changing daily habits accordingly, does much of the work.
In practical terms, the changes that tend to matter most are:
Sleeping on your back, or on the good side with a pillow between the knees so the top knee stays level with the hip.
Avoiding crossed legs and standing with weight hitched onto one hip.
Choosing higher chairs, and rebuilding walking, hills and stairs gradually rather than all at once.
Strengthening that begins with gentle held contractions and progresses over weeks.
How we assess and help at Peek Practice
At Peek Practice, our Chiropractic Orthopaedist in Auckland begins with the history: where the pain sits, what provokes it, how it behaves at night, and what has already been tried. The examination then tests the tendon directly — standing on one leg for 30 seconds, resisted hip movements, and careful pressure over the bony point. We also examine the lower back, sacroiliac joint and hip joint, so that a coexisting source is not missed.
From there, we explain what is going on in plain terms, adjust the loads that are aggravating the tendon, and set a graded exercise plan with regular check-ins. Months of broken sleep can leave the nervous system more sensitive to incoming damage signals, which is part of why pain is an output, not an input; easing night pain early is therefore a priority. Manual therapy may help settle pain in the short term while capacity rebuilds. If progress stalls, or a significant tear with marked weakness is suspected, we coordinate imaging and referral to a sports physician or orthopaedic surgeon.
Gluteal tendinopathy in Auckland is common, rarely serious and often slow to settle without a plan: in the LEAP trial, fewer than a third of people who simply waited felt better at eight weeks. With the right explanation and the right loading, most people sleep better and move more freely within a few months.
Nigel Peek, MSc Chiro (SA) | DIANM, Chiropractic Orthopaedist | PGDip HealSc Pain & Pain Management – Dist. (Otago) — Peek Practice, Grey Lynn, Auckland
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