Pilates for hip bursitis (gluteal tendinopathy): side-lying work and crossed legs, the moves to change, and a 25-minute class

Usually the tendons, not the bursa

On ultrasound in 877 people with outer hip pain, only about 1 in 5 had bursitis, while half had changes in the gluteal tendons. The tendons are what the advice and exercise aim at.

Sources 1, 2

No Pilates trial

We found no trial of Pilates for this pain (our searches, October 2026); the LEAP trial even excluded people who did Pilates regularly. The closest trial, in 60 women, found motor control exercise no better than general exercise.

Sources 3, 4, 5

Education plus exercise beat an injection

In LEAP, 204 people with at least 3 months of outer hip pain had 8 weeks of education and exercise, a steroid injection, or wait and see. At 8 weeks, 77% felt better with education and exercise, against 58% after the injection and 29% with wait and see; at a year it still led the injection on overall improvement, though pain had become similar.

Source 6

Stop squeezing the tendons

When the thigh moves across the body, the tight band down the outer thigh presses the tendons against the bone. An NHS trust's patient advice lists crossed legs, hanging on one hip, low chairs and lying on the sore side; in Pilates, clams, the side-lying inner thigh lift and letting the top leg drop in side-lying work do the same.

Sources 7, 8, 9

Load it standing and on one leg, and give it months

LEAP started with lying and standing presses, bridges, squats and side-steps, then moved weight onto one leg. Weight-bearing moves work the side-hip muscles hardest. One NHS trust says recovery with exercise can take 6 to 12 months.

Sources 4, 10, 8

Know the warning signs

Severe hip pain after a fall, or not being able to put weight on the leg, needs 999. A hot, swollen hip with a high temperature needs help the same day, and so does a child or teenager with hip pain or a limp. The full list, in the words of our hip pain guides, is below.

Sources 11, 12

Pain over the bony point

The pain sits over the greater trochanter, the bony point on the side of the hip, sometimes spreading down the outer thigh. It's often worse lying on that side, on stairs, standing on one leg and getting up after sitting with your legs crossed. The NHS hip pain page links pain that "may feel worse when moving or lying" on your side with bursitis. A doctor or physiotherapist can usually recognise it from where it hurts and a few simple tests.

Sources 11, 13

Usually the tendons, not just the bursaEmerging evidence

On ultrasound in 877 people, 79.8% had no bursitis, 49.9% had gluteal tendon changes and 28.5% a thickened IT (iliotibial) band; the authors wrote that "Bursitis is present in only the minority of patients". In 24 women on MRI (magnetic resonance imaging), a swollen bursa "did not occur in the absence of gluteus medius pathology". Reviews now call it gluteal tendinopathy, "previously referred to as trochanteric bursitis". The NHS's general bursitis page advises rest, but it covers bursitis anywhere in the body and doesn't mention the gluteal tendons.

Sources 1, 2, 14, 15

Who gets itStrong evidence

In 3,026 adults aged 50 to 79, 15.0% of women and 6.6% of men had it on one side, and 8.5% and 1.9% on both; women had over 3 times the odds, while body weight made no clear difference. In Dutch general practice it was the commonest tendon problem in the leg. It is especially common in women around and after the menopause.

Sources 16, 17, 14

How it usually goesEmerging evidence

In 164 people seen in general practice, at least 36% still had pain at a year and 29% at 5 years. In LEAP, 29% of the wait-and-see group felt better by 8 weeks and about half by a year. It often settles slowly on its own; exercise gets there faster and more reliably.

Sources 18, 6

No Pilates trialStrong evidence

Our searches of PubMed, Europe PMC and ClinicalTrials.gov (October 2026) found no trial of Pilates in greater trochanteric pain syndrome, gluteal tendinopathy or trochanteric bursitis. LEAP excluded anyone who had done "regular appropriate Pilates in the last 3 months". A clinical Pilates trial in hip arthritis finished in 2025 but hasn't posted results.

Sources 3, 4, 19

Education plus exercise beat an injectionEmerging evidence

In LEAP, 204 people aged 35 to 70 (82% women) with at least 3 months of outer hip pain had 14 physiotherapy sessions of education and exercise over 8 weeks with 4 to 6 daily home exercises, one steroid injection, or one session of advice. At 8 weeks, 51 of 66, 38 of 65 and 20 of 68 reported success. At a year, education plus exercise still beat the injection on overall improvement, though pain no longer differed. "No participant or practitioner reported a serious adverse event." One trial, and the people taking part knew their group.

Source 6

The advice may matter as much as the exercisesMixed evidence

Strength didn't differ between LEAP's groups, so its authors think the benefit "might well be more in the education aspect of the programme"; a later analysis found it worked through better function, less constant pain and more confidence. In 132 postmenopausal women all taught to avoid squeezing the tendons, tendon exercise did no better than sham exercise, and everyone improved. An earlier trial of 94 women from the same group found the same; whether the two share participants isn't stated, so don't count them as two.

Sources 6, 20, 21, 22

Motor control exercise was no better than general exerciseEmerging evidence

In 60 women, 8 weeks of supervised motor control exercise, the approach closest to clinical Pilates, did no better than general exercise that included stretching, at 8 or 60 weeks; the authors suggest "patient (and therapist) preferences should be considered". Choose exercise you'll keep doing, and keep the squeeze out of it.

Source 5

Reviews put exercise first, on thin evidenceEmerging evidence

A review of the better trials found "moderate strength evidence of a medium effect on pain" from exercise and education in the short term, with smaller effects later, and says they "can be cautiously recommended as the core approach". Others rate the certainty low to very low, or rank exercise first from few trials. There is no Cochrane review or treatment guideline.

Sources 23, 24, 25, 26, 27

Injections help for weeksEmerging evidence

In 120 general practice patients, a steroid injection helped more people recover at 3 months (55% against 34%) but not at a year (61% against 60%). Platelet-rich plasma did no better than a placebo injection in 79 people. Injections are a GP's or specialist's decision; this guide is about exercise.

Sources 28, 6, 29

Which moves work the side-hip musclesEmerging evidence

In healthy people, weight-bearing moves (standing presses, one-leg bridges, step-ups, side-steps) and side-lying leg lifts worked the gluteus medius and minimus hardest, and the clam was among the weakest for gluteus medius, though one fine-wire study found it the most selective for the gluteal muscles. With outer hip pain, the case against clams is that they squeeze a painful tendon, not that they don't work the muscles. All of this was measured in people without pain.

Sources 10, 30, 31, 9

Menopause and hormone therapyMixed evidence

Hormone therapy cream made no clear difference overall in 132 postmenopausal women; only women with a body mass index (BMI) under 25 did better with it on top of exercise and advice. Menopausal status didn't change who benefited in LEAP. Talk to your doctor about hormone therapy for its own reasons; our hip pain in menopause guide covers it.

Sources 21, 20

The idea: squeezing plus loadEmerging evidence

Tendon researchers think "The combination of excessive compression and high tensile loads within tendons are thought to be most damaging", and that the thigh moving across the body is a key factor. In cadavers and during surgery, the pressure of the IT band on the bony point rose as the hip moved across the body. People with this pain let the hip drop and shift more when they stand on one leg, and their gluteal muscles are smaller. It's the leading explanation, not a proven fact.

Sources 7, 32, 33, 34

What LEAP left out

The programme left out the usual piriformis and IT band stretches because they hold the hip "in forced adduction, which is a position of high compressive loads on the gluteal tendons", and limited how far the thigh crossed the body in its exercises. The trial papers say the education covered tendon load, with handouts and a DVD, without listing everyday positions.

Sources 4, 6

Everyday positions to avoid

An NHS trust's patient advice says to avoid hanging on one hip, sitting with your legs crossed, low chairs, and lying with the painful leg across the other one; to sleep on your back with a pillow under your knees, or on your good side with a pillow between your legs; and that "Exercise is safe and pain does not mean harm."

Source 8

In Pilates

Side-lying series put you on one hip, and if the top knee drops, the top thigh crosses the body. A hip physiotherapist and researcher advises leaving out clams with outer hip pain, because "As the knees come together the ITB is wrapped firmly around the greater trochanter, compressing the gluteal tendons and bursae against the underlying bony trochanter"; she also warns against letting the top ankle drop to the bottom one on every lift, and against long-lever leg circles in the reformer straps. This is expert advice, not trial evidence.

Sources 9, 35

What the trial used

Up to 6 exercises at home every day, and physiotherapy once a week for 2 weeks, then twice a week for 6. Week 1 was gentle presses of the knees outwards lying down (holds of 5 to 10 seconds) and standing (5 to 15 seconds), 3 to 5 at a time, twice a day, plus bridges, squats and side-steps. From week 2 it moved weight onto one leg, then added heavier, slower strengthening.

Sources 4, 6

The pain rule

The LEAP programme accepted no increase in outer hip pain during squats, bridges and side-stepping, because pain there suggested the tendon was being squeezed. During heavier strengthening, pain up to about 5 out of 10 was fine if it eased afterwards and was no worse that night or the next morning.

Source 4

Our editorial starting point

Week 1: our 20-minute Pilates for hip pain class 2 or 3 times a week, with the lying and standing presses on other days. From about week 2 or 3, when those bring on no extra outer hip pain, the 25-minute class below. Give it 8 to 12 weeks before you judge it; the full recovery can take months.

Sources 4, 8

Lying in class and in bed

In class, lie on your back or on your good side with a pillow between your knees so the top leg stays level, and never on the sore side. At night, the same: on your back with a pillow under your knees, or on your good side with a pillow between your legs. Our hip pain at night guide covers getting back to lying on the sore side.

Source 8

Clams

Leave them out while the outside of your hip hurts, as our hip pain and hip bursitis guides do. The clam's own page says to leave them out "while it hurts at night"; we'd leave them out for as long as the outer hip hurts, day or night, and use the belt press and standing wall press instead.

Sources 9, 4

The side-lying series

The inner thigh lift's page says "With pain on the outside of the hip, our suggestion is to leave this one out". Do the side-lying leg circles and side kick only on your good side, with a pillow between your knees, and don't let the top ankle drop to touch the bottom one, as their pages say.

Outer hip stretches and rolling

Leave out the lying IT band stretch and the knee-across-the-body stretch (both pages say skip them with outer hip pain), foam rolling the outer thigh (its page says "skip it if the bony point on the outside of your hip is sore"), and figure-four stretches that pull the knee across the body.

Sources 8, 4

Legs crossing the middle of the body

The corkscrew and hip twist carry the legs across the middle of the body, as their pages say: leave them out for now. Keep single-leg circles small and on your own side (our suggestion).

Sitting on the sore hip

For the mermaid, the page says "If side-sitting bothers your knees or hips, sit cross-legged, on a block or on a chair." Leave the side bend and kneeling side kick off the sore side, and leave out the crab, which crosses the legs (our suggestion).

On the reformer

Footwork and bridging are fine. Avoid side-lying work on the sore side, and long-lever leg circles in the straps that carry the leg across your body; a hip physiotherapist advises against those circles for hip pain. Tell the teacher which side hurts (our suggestion).

Source 35

Call 999 or go to A&E

• Call 999 or go to A&E: severe hip pain after a fall or injury, or you cannot stand, walk or put weight on the leg. In an older adult this can be a broken hip; the leg may be at an odd angle or look shorter. Don't drive yourself.
• Call 999 or go to A&E: tingling or loss of feeling in the hip or leg after an injury.
• Call 999 or go to A&E if you have sciatica on both sides, weakness or numbness in both legs that's severe or getting worse, or numbness around or under your genitals, or around your bottom (anus); if you find it hard to start peeing, cannot pee or cannot control when you pee; or if you do not notice when you need to poo or cannot control when you poo, and this is not normal for you. These could be symptoms of a serious back problem that needs to be treated in hospital as soon as possible.

Source 11

The same day: a hot, swollen hip

Ask for an urgent GP appointment or get help from NHS 111 if you have severe hip pain that started suddenly but you've not had a fall or injured your hip, your hip is swollen and feels hot, the skin around your hip has changed colour, or you have hip pain, feel generally unwell and have a high temperature (or feel hot, cold or shivery). A hot, swollen hip with a high temperature can be a joint infection.

Source 11

Children and teenagers

Call 999 or go to A&E if your child gets sudden pain in their hip, knee or thigh (hip problems can sometimes be felt in the thigh or knee) or cannot put any weight on their leg. If your child is limping, ask for an urgent GP appointment or get help from NHS 111 the same day. This applies to teenagers too, and in some children knee pain is the only sign.

Hip bursitis is rare in children, so outer hip or thigh pain with a limp in a child or teenager needs checking rather than a Pilates class (our suggestion).

Source 12

See a GP or physiotherapist soon

• Hip pain that stops normal activities or disturbs sleep, keeps getting worse or keeps coming back, or has not improved after 2 weeks of looking after it at home.
• Stiffness lasting more than 30 minutes after waking.
• Bone pain that is constant or worse at night, especially with a lump, unexplained weight loss, fever or tiredness, or a past history of cancer.
• Outer hip pain that hasn't improved within 6 weeks of following this advice, or that gets worse: talk to a GP or physiotherapist. In many areas you can refer yourself.
• No improvement after 3 months of good rehabilitation, or sudden weakness walking (a tendon tear is possible).
• See a GP if you have pain and stiffness for more than a week, especially if you're over 50, it's in both shoulders (often the neck and hips too) and the stiffness lasts longer than 45 minutes in the morning. It can be polymyalgia rheumatica.

Source 11

During Pilates

The LEAP programme accepted no increase in outer hip pain during squats, bridges and side-stepping, because pain there suggested the tendon was being squeezed. During heavier strengthening, pain up to about 5 out of 10 was fine if it eased afterwards and was no worse that night or the next morning.

Stop the move for a sharp pinch at the front of the hip in deep bends or circles, a catching or locking feeling, or outer hip pain that builds during side-lying work, and swap to the versions on this page (our suggestion).

Source 4

Chest pain or fainting while exercising: call 999

Call 999 if:

• You get sudden pain or discomfort in your chest that doesn't go away; it can feel like squeezing or pressure, burning or indigestion.
• The pain spreads to your left or right arm, or your neck, jaw, stomach or back.
• You have chest pain and feel sweaty, sick, light-headed or short of breath.
• Someone faints while exercising, can't be woken within 1 minute, or has chest pain or a pounding, fluttering or irregular heartbeat.

Sources 36, 37, 38

Unusual breathlessness

Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.

Source 39

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 40

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

Source 40

"Stretch the IT band to fix hip bursitis"Mixed evidence

No trial tests it, and LEAP left those stretches out because they squeeze the tendons; an NHS trust says stretching "can irritate it if done repeatedly". The US surgeons' patient page still suggests IT band stretches, so the advice differs; we follow the trial and the NHS trust.

Sources 4, 8, 41

"It's an inflamed bursa, so rest it"Emerging evidence

Most people with this pain have tendon changes rather than bursitis, and the trial that helped combined education with progressive exercise. A 2025 expert review says it's time to put aside rest and steroid injections as the first treatment.

Sources 1, 2, 6, 42

"Clams are the best exercise for the side of the hip"Mixed evidence

In healthy people, clams worked the main side-hip muscle less than side-lying or standing moves, though one study found them selective for the gluteals. With outer hip pain, a hip physiotherapist advises leaving them out because they squeeze the tendons.

Sources 30, 10, 31, 9

"An injection is the quickest fix"Emerging evidence

It helps for weeks. At a year, education plus exercise did better on overall improvement, and injections did no better than usual care.

Sources 6, 28

"Strong glutes are all that matters"Mixed evidence

In LEAP, strength didn't differ between groups, and in postmenopausal women taught to avoid squeezing the tendons, sham exercise did as well as tendon exercise. The advice and steady loading seem to matter as much as strength.

Sources 6, 20, 21

"You need a reformer"

No trial has tested any kind of Pilates for this pain. The same rules apply on a mat, at a wall or on a reformer: no squeezing, and weight onto one leg over time.

Source 3