Hip pain at night: you lie down, find a position, and two hours later you are awake with that pain in your side. Or you struggle to fall asleep because every time you put weight on that side you feel sharp pains.
It is a very common complaint and in the great majority of cases it has a simple, treatable cause. But "almost always" does not mean always: night pain at rest is one of the signs clinicians check. That is why the first thing to do is not to buy a pillow. Let us start there.
Before reading the rest: the warning signs to check straight away
Mechanical night-time hip pain changes when you change position, is worse on one specific side and is also felt during the day on stairs or standing for long periods. That is treatable, and further on you will find how.
There are, however, situations in which night pain is not a mattress problem and needs to be assessed by a doctor before you try any exercise or adjustment:
- The pain wakes you and does not change in any position: you turn over, lie on your back, get up, and it stays exactly the same.
- You have fever, shivers or night sweats, or the hip is hot, swollen and every movement is unbearable.
- You have unexplained weight loss, or significant tiredness that appeared in the same weeks.
- You have had cancer, at any point in your life, even many years ago and even if considered cured.
- You take cortisone for prolonged periods, or have had radiotherapy on the pelvis or femur.
- The pain gets progressively worse week after week, whatever you do.
- After a fall you can no longer put weight on that leg.
If you recognise yourself in any of these points, see a doctor promptly, and immediately if there is fever with a hot, swollen hip. Not a new pillow, not a course of exercises, not "let us wait two weeks". A joint infection and a bone lesion are treated better the sooner they are recognised, and no adjustment to sleep makes them go away.
The opposite is also true, because alarmism does harm as much as underestimation. Night pain on its own is not proof of anything.
In a study of 482 people who came to a triage clinic for back pain, 213 had night pain and 90 had it every night: in none of them was a serious condition found. The authors concluded that the mere presence of night pain is not a useful indicator of serious disease. It concerned the back, not the hip, but the concept holds.
What shifts the probability is not the isolated symptom, but the context. A systematic review published in the BMJ measured how much the individual warning signs are worth in back pain: most of them change the probability of fracture or cancer very little.
The two that really matter are a personal history of cancer and prolonged use of cortisone, and the probability rises sharply when several signs appear together.
Put simply: if you only have night pain, it hurts when you sleep on that side and improves when you turn over, you are almost certainly in the large group. If you have night pain plus a cancer history, or plus fever, or plus long-term cortisone, that combination needs checking. The rest of this article speaks to the first group.
Why at night in particular
The first reason is compression. Lying on your side, the weight of the pelvis presses the gluteal tendons against the bony prominence of the greater trochanter, the one you feel under your hand. An already irritated tendon does not tolerate this pressure for hours.
The second is leg position. If you sleep on your side with nothing in between, the top leg falls inwards: the hip goes into adduction, and it is precisely excessive adduction that compresses the gluteal tendons against the bone. This is not a hypothesis: it is the mechanism that the literature identifies as key, together with excessive load.
The third is prolonged immobility. During the day you change position dozens of times an hour without noticing; at night you can stay still for an hour or more, and irritated tissues do not like that.
The fourth is lack of distractions: at night, in the dark, the pain has the whole stage to itself.
The causes, in order of frequency
Lateral hip pain and gluteal tendinopathy
This is by far the most common cause of night-time hip pain, and also the one most often misdiagnosed. It involves the tendons of the gluteus medius and gluteus minimus, which attach to the greater trochanter. It mainly affects people in midlife, and women more than men.
The picture is recognisable: pain on the side of the hip, at a point you can indicate with one finger, that is worse when lying on that side, when standing on one leg, when climbing stairs, when crossing your legs.
Many people say that the symptom that brought them to the physiotherapist was not pain when walking: it was no longer being able to sleep on that side. The literature describes precisely this interference with side-lying sleep as a typical feature.
The term you will often hear is greater trochanteric pain syndrome, an umbrella label that includes gluteal tendinopathy, trochanteric bursitis and other conditions in the same area. It is now thought that the tendon is the main player, much more than the bursa.
If you want to explore further, the full picture is in gluteus medius tendinitis: symptoms, causes and effective treatment.
Hip osteoarthritis
Hip osteoarthritis typically causes pain in the groin, not on the side, and often radiates to the front of the thigh as far as the knee. Stiffness in the morning and after being still for a while is a characteristic feature.
Night-time pain in osteoarthritis appears mainly in more advanced stages and is often linked to position: sleeping with the hip very flexed or rotated puts already suffering structures under strain.
If the pain is in the groin and putting on socks and shoes has become difficult, osteoarthritis needs to be on the table. We discuss it in hip osteoarthritis: exercises for mobility and pain.
Trochanteric bursitis
It exists, but it is much less frequent than the word suggests. For years every lateral hip pain was called bursitis; today we know that in most cases the tendon is involved, and when the bursa is inflamed, it is often secondary. The night-time symptoms and the initial management are practically the same as for gluteal tendinopathy.
Pain referred from the lower back
A problem in the lumbar spine can project pain into the buttock and side of the hip, and be felt at night.
What points towards the back is that the pain changes with trunk movements more than with hip movements, that it comes with symptoms down the leg, or that the hip moved passively does not hurt. We discuss it in the link between hip and back.
Less common causes
Inflammatory arthritis, such as rheumatoid arthritis and ankylosing spondylitis, often causes night-time pain with morning stiffness lasting more than thirty to forty minutes, and involves several joints.
Avascular necrosis of the femoral head causes deep groin pain even at rest. In older people or those with osteoporosis, a fragility fracture can cause constant groin pain and difficulty bearing weight.
How to sleep: what is clinical practice and what has evidence
Here honesty is needed. The adjustments to sleeping position are sensible mechanical reasoning and we use them every day, but there are no robust studies showing that a position cures hip pain. They serve to help you sleep while you treat the cause. Confusing the two is why many people buy three pillows and solve nothing.
If the pain is lateral, sleep on the side that does not hurt, with a thick pillow between the knees and possibly also between the ankles. The point is not generic comfort: it is to stop the top leg falling inwards, that is, to avoid the adduction that compresses the tendons against the bone. A thin pillow that flattens is of little use.
Lying on your back often works even better, because it removes lateral compression altogether. Put a pillow under the knees to soften the tension on the hip flexors and the lower back.
If the pain is in the groin, lying on your back with a pillow under the knees is usually the best tolerated position. On your side, the pillow between the knees is still useful to keep the pelvis aligned.
What to avoid with lateral pain: the tight foetal position, with knees drawn to the chest and legs crossed, which is exactly the most compressive combination. And also lying on your front with one leg rotated outwards.
On the mattress, the evidence is thinner than sellers claim. A systematic review of 39 studies concludes that a medium-firm mattress favours comfort, sleep quality and spinal alignment, but the same authors note that the literature is inconsistent and that it concerns mainly back pain, not the hip.
In practice: if the mattress is very firm, a soft topper may reduce pressure on the trochanter and is worth trying; if it is so soft that the pelvis sinks, the problem is the opposite. There is no therapeutic mattress you need to buy urgently.
If night pain also affects the back, the same principles are in how to sleep with back pain.
What really works during the day
Positions get you through the night. What changes the problem is done while awake.
For gluteal tendinopathy the evidence is good and comes from a randomised trial published in the BMJ in 2018 involving 204 people with lateral hip pain lasting more than three months. It compared three routes: education on managing load plus exercise guided by a physiotherapist, a single cortisone injection, or waiting without treatment.
At eight weeks, improvement was reported by 51 people out of 66 in the exercise and education group, by 38 out of 65 in the injection group and by 20 out of 68 in those who waited. At 52 weeks the exercise group was still ahead of the injection on overall improvement, while on pain intensity the two were equivalent and both did better than waiting.
A 2024 meta-analysis of six randomised trials and 733 patients reaches the same conclusion: a strong recommendation for exercise as first-line treatment, superior to injection in perceived long-term improvement.
The authors specify, however, that the results rest on few studies and that compared with no treatment the effect on pain is small. No serious adverse event was reported.
The content matters. The work involves progressive loading for the hip abductors, avoiding compression positions: isometrics and then dynamic strengthening with the hip in a neutral position. Not aggressive stretching of the glute by bringing the knee to the chest or the leg past the midline, which is precisely the manoeuvre that squeezes the tendon against the bone.
This is the most common mistake we see: the person feels lateral tension, stretches, feels better for ten minutes and gets worse during the night.
For hip osteoarthritis, a Cochrane review of nine randomised trials and 549 participants classifies as high-quality evidence the finding that land-based exercise reduces pain and improves function. The effect is modest in absolute terms, about 8 points on a 0 to 100 scale, but it is maintained for three to six months after the end of the supervised programme.
On cortisone injections it is worth being clear, because it is the choice many people make first. They often give real and rapid relief: in the BMJ study they beat waiting at eight weeks. The problem is the distance.
A systematic review of 41 randomised trials involving over 2,600 people with tendinopathies in various sites showed a strong short-term benefit and an effect that reverses in the medium and long term, with better outcomes in those who had not been injected. The most solid data concern lateral epicondylalgia of the elbow, so it is not transferable to every tendon without caution.
Added to the 52-week result on the hip, the practical message is this: an injection may make sense to break through an unbearable acute phase, not as a single strategy.
Want to understand which of these causes applies to you? Start with the questionnaire with a physiotherapist registered with the Albo: twenty minutes on a video call to distinguish the lateral picture from the groin one and understand where to start.
What not to do
Sleeping on the other side for months and considering the problem solved. It is the most common trap. Turning over works, the night pain drops, and so the cause stays there getting worse in silence while you keep loading it on the stairs and standing. When the pain comes back it is often worse and takes longer to resolve. The position is a useful plaster, not the cure.
Resting for long periods. Prolonged rest is not a treatment either for tendinopathy or for osteoarthritis: an unloaded tendon loses its capacity to tolerate load, and a stiff, osteoarthritic hip becomes stiffer and more painful.
The load that causes pain should be reduced, not movement in general. You stop crossing your legs and standing on one hip; you do not stop walking.
Stretching the glute aggressively. In lateral hip pain most classic stretches bring the hip into adduction, that is, into the compression position. Immediate relief, irritation a few hours later.
When imaging is needed and when it is not
Greater trochanteric pain syndrome is a clinical diagnosis: it is made from the history and the physical examination, that is, with tests that load and compress the tendon, reproducing the pain in the right place.
The reviews agree: X-rays and MRI are not necessary for diagnosis. They serve to exclude other causes or to guide treatment when something does not add up.
Imaging makes most sense in three situations: when the signs listed at the start are present, when there has been a trauma or a fracture is suspected, and when a conservative treatment carried out well for a couple of months has produced no change at all.
Outside these cases, a report can do more harm than good. After forty, images almost always show something, from early osteoarthritis to tendon suffering, even in people with no pain at all. Being labelled with a degeneration that was already there before leads to moving less out of fear, which is the opposite of what is needed.
The vicious circle between sleep and pain
There is a reason night pain weighs more than its intensity would suggest. The relationship between sleep and pain is two-way: pain breaks sleep, and sleep deprivation lowers the pain threshold.
The most recent literature indicates that insomnia is not just a consequence: it predisposes people to chronic pain and to the worsening of painful conditions already present.
So treating sleep is not a detail to sort out later. Reducing awakenings, even just with position and pillow, improves tolerance of pain the following day and makes it easier to do the exercises that really matter.
Simple things help: heat on the area for fifteen to twenty minutes before bed, regular times, a cool and dark room, no intense training in the two to three hours before. If you are considering an evening painkiller, talk to your doctor or pharmacist, especially if you would take it for more than a few days.
How long it takes
In the BMJ study the education and exercise programme lasted eight weeks and the benefits were already evident at the end, but the most interesting advantage was seen a year later. In osteoarthritis the improvement is maintained for months after the end of the supervised programme.
Expect weeks, not days. Fewer awakenings in the first two to three weeks is a good sign. No change after six to eight weeks of consistent work, on the other hand, is the moment to reconsider the diagnosis, not to push harder.
When to get assessed
Beyond the warning signs at the start, which remain the absolute priority, an assessment makes sense when the night pain has lasted more than a few weeks, when it limits your day too, between stairs, walks and work, when you cannot tell whether yours is lateral or groin pain, or when you have already tried something without result.
The value of a well-made assessment lies here: distinguishing the lateral picture from the groin one and from pain referred from the back completely changes the exercises to do. It is also the reason the same exercises work for one person and make another worse.
Need a consultation?
Start with the questionnaire on Ri-Hub: a few questions about your case, you register, and you see who will follow you: a physiotherapist registered with the Albo, whom you write to in chat whenever you like. If you prefer to talk it through by voice, the first consultation is free, lasts 20 minutes and commits you to nothing: they arrive having already read what you wrote, and together you decide whether and how to go on.
No credit card is needed: the first consultation does not commit you to anything.
If the pain that wakes you does not yet have a name, we have put the most common cases together in sleeping with pain: it helps you work out where to start.
Sources
- Mellor R, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: randomised clinical trial. BMJ 2018. PMID 29720374
- Kjeldsen T, et al. Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: systematic review and meta-analysis. Physiotherapy 2024. PMID 38295551
- Grimaldi A, et al. Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Medicine 2015. PMID 25969366
- Pianka MA, et al. Greater trochanteric pain syndrome: evaluation and management of a wide spectrum of pathology. SAGE Open Medicine 2021. PMID 34158938
- Fransen M, et al. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews 2014. PMID 24756895
- Coombes BK, et al. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: systematic review of randomised controlled trials. Lancet 2010. PMID 20970844
- Downie A, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013. PMID 24335669
- Harding IJ, et al. The symptom of night pain in a back pain triage clinic. Spine 2005. PMID 16135990
- Caggiari G, et al. What type of mattress should be chosen to avoid back pain and improve sleep quality? Review of the literature. Journal of Orthopaedics and Traumatology 2021. PMID 34878594
- Andersen ML, et al. Sleep Disturbance and Pain: A Tale of Two Common Problems. Chest 2018. PMID 30059677
Last source check: August 2026.
