Marc Darrow, MD, JD

A patient may come into my office with hip pain, an X-ray showing arthritis, and a recommendation for hip replacement. Sometimes the arthritic joint is truly the main problem and replacement is the appropriate treatment. Sometimes it is not.

Pain near the hip can arise from the hip joint, but it can also come from the gluteal tendons, ligament and tendon attachments, the sacroiliac joint, or the lumbar spine. Several of these problems can exist at the same time. This is why I do not treat an X-ray or MRI by itself. I treat the patient.

Before deciding on surgery—or on an injection—the essential question is: Which structure is actually generating the pain?

This article grew from a discussion on my Living Pain-Free radio program. A listener asked about shoulder arthritis, low-back pain, and hip pain with walking. My response emphasized a principle I have followed throughout my career: pain felt around a joint does not necessarily originate inside that joint.

Hip osteoarthritis is only one possible source of hip-region pain

Hip osteoarthritis develops as articular cartilage and other joint tissues change over time. It can cause groin pain, stiffness, reduced range of motion, difficulty putting on shoes or socks, and pain with walking, standing, or getting up from a chair. Symptoms are often worse after inactivity or prolonged loading.

An X-ray can show joint-space narrowing, bone spurs, cysts, and changes in the bone beneath the cartilage. These findings are useful, but they are not a complete diagnosis. The severity of an image and the severity of a patient’s pain do not always match.

One patient can have significant radiographic arthritis and remain active. Another can have relatively modest imaging changes but severe pain. The difference may reflect inflammation, muscle weakness, joint mechanics, pain sensitivity, or a second problem outside the joint.

When the history, examination, and imaging all point to advanced symptomatic hip arthritis—and nonsurgical care no longer provides acceptable function—total hip replacement can be an excellent operation. Regenerative injections should not be presented as a way to rebuild a severely collapsed joint or reliably prevent surgery in every patient.

Where do you feel the pain?

The location and behavior of the symptoms provide important clues, although they do not establish the diagnosis by themselves.

  • Groin or deep anterior hip pain: more suggestive of an intra-articular problem such as osteoarthritis, labral injury, or femoroacetabular impingement.
  • Pain over the outside of the hip: commonly associated with gluteal tendinopathy or greater trochanteric pain syndrome.
  • Buttock or posterior pelvic pain: may arise from the sacroiliac joint, lumbar spine, deep gluteal structures, or proximal hamstring attachment.
  • Pain traveling below the knee, numbness, tingling, or weakness: raises concern for lumbar nerve involvement.
  • Pain with lying on the affected side: frequently occurs with greater trochanteric pain syndrome.
  • Catching, clicking, or pain with pivoting: may occur with labral or other intra-articular pathology, although painless clicking is common.

These patterns overlap. A patient can have both hip osteoarthritis and lumbar stenosis, or both a labral tear and gluteal tendon disease. Research on hip-spine syndrome emphasizes that hip and lumbar disorders can produce overlapping pain in the groin, buttock, thigh, and even knee. A careful history, complete examination, imaging, and—in selected cases—diagnostic injections may be needed to identify the primary source. (1)

Gluteal tendinopathy and greater trochanteric pain syndrome

The large bony prominence on the outside of the upper femur is the greater trochanter. The gluteus medius and gluteus minimus tendons attach around this region and help stabilize the pelvis while standing and walking.

Pain in this area was historically labeled “trochanteric bursitis.” The term greater trochanteric pain syndrome, or GTPS, is now preferred because the problem often involves the gluteal tendons—with or without an irritated bursa—rather than an isolated inflamed bursa.

Sonographic research has found that gluteal tendinosis and tendon abnormalities are common in GTPS, while primary bursitis by itself is comparatively uncommon. (2) A systematic review likewise found that tendon pathology was frequently detected, although definitions and ultrasound methods varied considerably among studies. (3)

Typical findings include:

  • tenderness over the outside of the hip;
  • pain when lying on that side;
  • pain climbing stairs, walking uphill, or standing on one leg;
  • weakness or pain with resisted hip abduction; and
  • symptoms aggravated by crossing the legs or allowing the knee to fall inward.

This distinction matters. Repeatedly treating a presumed “bursa problem” may not correct an overloaded or degenerative gluteal tendon.

Hip labral injury

The acetabular labrum is a ring of fibrocartilage around the rim of the hip socket. It contributes to joint stability and helps maintain the joint’s fluid seal. Labral changes can develop after trauma, repetitive twisting, hip impingement, dysplasia, or degeneration.

A symptomatic labral injury may produce deep groin pain, pain with rotation, or catching and clicking. Yet a labral abnormality on MRI does not automatically prove that it is causing the symptoms. Labral findings can coexist with osteoarthritis, tendon problems, and referred pain from the spine.

The physical examination may include range-of-motion testing and maneuvers intended to reproduce symptoms from inside the joint. MRI or MR arthrography may be useful when the result would change management. In uncertain cases, a carefully performed diagnostic anesthetic injection into the joint can help determine how much of the pain is intra-articular.

The sacroiliac joint and lumbar spine can refer pain toward the hip

The lumbar spine, sacroiliac joint, and hip function as a connected mechanical system. A problem in one region can change movement and loading in another.

Lumbar disc disease, facet-joint pain, or nerve compression may be perceived in the buttock, lateral hip, groin, or thigh. Sacroiliac-joint pain can also be felt near the posterior hip and may worsen with transitions, uneven loading, or prolonged positions. Conversely, a stiff arthritic hip can alter pelvic and lumbar mechanics and contribute to back symptoms.

There is no single examination maneuver that answers every case. I look at how a patient walks, how the pelvis moves, whether hip rotation is restricted, where direct pressure reproduces pain, and whether neurologic findings suggest lumbar nerve involvement. When two regions remain plausible, targeted diagnostic injections may help clarify which structure is contributing most.

Ligament, tendon, and enthesis injuries

An enthesis is the location where a tendon or ligament attaches to bone. Injury or degeneration at that attachment is called enthesopathy.

Around the hip, painful attachment sites may include the gluteal tendons at the greater trochanter, the proximal hamstring tendons at the sitting bone, the adductor tendons near the groin, and other capsular or ligamentous structures. These tissues may be injured by a sudden event or overloaded gradually through altered mechanics, weakness, training errors, or repetitive activity.

In my clinical experience, these attachment injuries are sometimes overlooked when attention is focused entirely on an arthritic X-ray or a labral finding on MRI. That observation does not mean that every case of hip pain is an enthesis problem. It means the examination should ask whether the patient’s familiar pain can be reproduced at a specific soft-tissue structure.

Why the physical examination remains essential

Imaging provides anatomy. The examination helps connect that anatomy to the patient’s symptoms.

My evaluation generally begins with the history: where the pain is felt, what triggers it, whether it travels, whether the patient has weakness or numbness, and what previous treatments have or have not accomplished. I then evaluate gait, hip and lumbar motion, strength, neurologic findings, and the specific areas of tenderness.

The examination also helps identify situations that require a different pathway. Fever, unexplained weight loss, inability to bear weight after trauma, progressive weakness, loss of bowel or bladder control, a history of cancer, or concern for fracture, infection, inflammatory disease, or osteonecrosis requires prompt conventional medical assessment.

What diagnostic ultrasound can—and cannot—show

Musculoskeletal ultrasound allows us to evaluate many soft tissues dynamically. Around the lateral hip, it may show gluteal tendon thickening, disorganization, calcification, partial tearing, or fluid around the trochanteric bursa. It can also guide a needle to a selected structure without relying on surface landmarks alone.

Ultrasound is not a replacement for every other study. It does not evaluate the deep articular cartilage, labrum, or bone marrow as comprehensively as MRI, and the quality of the examination depends on the operator. Research also shows that ultrasound definitions for GTPS are not yet fully standardized. (3) I therefore use ultrasound as part of the diagnostic picture—not as a stand-alone answer.

Conservative care comes first for many patients

Treatment should match the actual diagnosis. Depending on the problem, initial care may include:

  • modifying activities that repeatedly compress or overload the painful tissue;
  • progressive strengthening of the hip abductors and surrounding muscles;
  • improving gait, balance, and lumbopelvic mechanics;
  • weight management when appropriate;
  • short-term medication when medically safe;
  • addressing lumbar or sacroiliac contributors; and
  • allowing adequate time for a tendon-loading program to work.

Exercise is particularly important for gluteal tendinopathy. An injection should not be used as a substitute for correcting the loading problem that continues to irritate the tendon.

When PRP may be considered

Platelet-rich plasma is prepared from the patient’s own blood. After processing, the platelet-containing portion is injected into a selected joint or soft-tissue target. Platelets release signaling proteins involved in inflammation and tissue repair, but PRP formulations and treatment protocols vary considerably.

For chronic gluteal tendinopathy or GTPS that has not improved with an appropriate rehabilitation program, ultrasound-guided PRP may be considered after discussing the uncertainty in the evidence. Earlier randomized studies reported longer-lasting improvement with leukocyte-rich PRP compared with corticosteroid injection in selected patients. (4) However, a 2025 placebo-controlled randomized trial found no significant advantage for leukocyte-rich PRP over placebo for GTPS. (5)

A 2026 systematic review of 11 randomized trials involving 581 hips reported that PRP produced comparable or superior outcomes to controls across several extra-articular hip conditions, including GTPS, but also emphasized substantial heterogeneity in PRP preparations, comparison treatments, outcomes, and follow-up. (6)

The practical conclusion is not that PRP always works or never works. It is that patient selection, diagnosis, injection target, PRP composition, and rehabilitation likely matter—and that the evidence remains mixed.

When bone marrow concentrate may be considered

Bone marrow concentrate is collected from the patient’s bone marrow, commonly from the pelvis, and processed to concentrate platelets, signaling molecules, nucleated cells, and a small population of progenitor cells. It is often called “stem cell therapy,” but that shorthand can be misleading: bone marrow concentrate is a mixed autologous product, not a purified or culture-expanded stem-cell drug.

For selected patients with symptomatic mild-to-moderate hip osteoarthritis who have not improved adequately with exercise and other nonsurgical care, bone marrow concentrate may be discussed as an investigational orthobiologic option. A small prospective cohort of patients with early hip or knee osteoarthritis reported improved patient-reported outcomes after treatment, but it included only 19 patients and had no placebo control. Two patients proceeded to hip replacement within eight months. (7)

A 2024 systematic review concluded that bone marrow aspirate concentrate appeared safe and potentially beneficial for pain and function in hip osteoarthritis, while stressing that the available studies were limited and that better randomized trials are needed. (8)

These treatments should therefore not be promoted as proven cartilage restoration or as a guaranteed alternative to hip replacement. The more advanced the joint collapse, deformity, loss of motion, and disability, the less realistic it is to expect an injection to reverse the mechanical problem.

Who may be a reasonable candidate for regenerative treatment?

A possible candidate generally has:

  • a specific, clinically supported pain generator;
  • persistent symptoms despite appropriate conservative treatment;
  • a condition for which PRP or bone marrow concentrate has a plausible role;
  • realistic expectations about pain and function rather than promises of complete regeneration;
  • the ability to participate in post-procedure rehabilitation; and
  • no infection, uncontrolled illness, or other contraindication identified during medical screening.

The choice between PRP and bone marrow concentrate is not determined simply by which treatment sounds more powerful. The tissue involved, severity of disease, quality of the supporting research, overall health, cost, and procedural burden all matter.

When hip replacement may be the better treatment

Regenerative treatment cannot reverse every case of advanced arthritis. Hip replacement deserves serious consideration when pain and stiffness are severe, function is substantially limited, imaging confirms advanced joint destruction that matches the symptoms, and reasonable nonsurgical care has failed.

The purpose of a careful diagnostic evaluation is not to delay necessary surgery. It is to reduce the chance of performing major surgery for pain that is primarily arising somewhere else.

If the pain is actually being generated by gluteal tendinopathy, a lumbar nerve, the sacroiliac joint, or another extra-articular structure, replacing the hip may not resolve it. Conversely, when the joint is clearly the principal pain generator and arthritis is advanced, continuing to pursue biologic injections may only postpone the treatment most likely to help.

The central question before treatment

Before hip replacement, PRP, bone marrow concentrate, or any other procedure, ask:

What specific structure are we treating, and what evidence shows that it is responsible for my pain?

At the Stem Cell Institute and Joint Rehab, our objective is to identify the most likely pain generator through the history, hands-on examination, appropriate imaging, and diagnostic testing when necessary. Only then can we have an honest discussion about rehabilitation, regenerative treatment, or surgical consultation.

The goal is not to avoid every operation. The goal is to avoid treating the wrong structure.

References

  1. Buckland AJ, Miyamoto R, Patel RD, Slover J, Razi AE. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management. J Am Acad Orthop Surg. 2017;25(2). doi:10.5435/JAAOS-D-15-00740.
  2. Long SS, Surrey DE, Nazarian LN. Sonography of Greater Trochanteric Pain Syndrome and the Rarity of Primary Bursitis. AJR Am J Roentgenol. 2013;201(5):1083-1086. doi:10.2214/AJR.12.10038.
  3. Hilligsøe M, Rathleff MS, Olesen JL. Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome: A Systematic Review. Ultrasound Med Biol. 2020;46(7):1584-1598. doi:10.1016/j.ultrasmedbio.2020.03.008.
  4. Fitzpatrick J, Bulsara MK, O’Donnell J, Zheng MH. Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med. 2019;47(5):1130-1137. doi:10.1177/0363546519826969.
  5. Atchia I, Ali M, Oderuth E, et al. Efficacy of Platelet-Rich Plasma Versus Placebo for the Treatment of Greater Trochanteric Pain Syndrome: A Double-Blinded Randomized Controlled Trial. J Bone Joint Surg Am. 2025;107(5):444-451. doi:10.2106/JBJS.24.00763.
  6. Kuhns BD, Becker N, Reyes-Cordova A, et al. Improved Outcomes With Platelet-Rich Plasma for Treating Extra-articular Hip Pathology Especially Greater Trochanteric Pain Syndrome and Hamstring Injury: A Systematic Review of Randomized Controlled Trials. Arthroscopy. 2026;42(1):310-325. doi:10.1002/arj.70024.
  7. Rodriguez-Fontan F, Piuzzi NS, Kraeutler MJ, Pascual-Garrido C. Early Clinical Outcomes of Intra-Articular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip and Knee: A Cohort Study. PM R. 2018;10(12):1353-1359. doi:10.1016/j.pmrj.2018.05.016.
  8. Chandrashekar S, Jeyaraman M, Mounissamy P, Jeyaraman N, Khanna M, Gupta A. Safety and Efficacy of Bone-Marrow Aspirate Concentrate in Hip Osteoarthritis: A Systematic Review of Current Clinical Evidence. Indian J Orthop. 2024;58(7):835-844. doi:10.1007/s43465-024-01183-7.

Medical disclaimer

This article is for educational purposes and is not a diagnosis or treatment recommendation. PRP and bone marrow concentrate procedures are not FDA-approved to treat a specific orthopedic disease. Individual risks, benefits, alternatives, and regulatory considerations should be discussed with a qualified physician. Seek urgent medical care for severe trauma, inability to bear weight, fever, rapidly worsening symptoms, progressive weakness, or loss of bowel or bladder control.