Extra-Articular Hip Endoscopy: Minimally Invasive Treatment for Hip Pain Outside the Joint

About Dr. David Goodwin

David Goodwin, MD, is an award-winning, board-certified orthopedic surgeon at Arthritis & Sports Orthopaedics with expertise in sports medicine, hip arthroscopy, and joint-preservation procedures. His recent review in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) examines the latest evidence, indications, and techniques for extra-articular hip endoscopy—minimally invasive treatment for select conditions affecting the tissues surrounding the hip joint.

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Not all hip pain starts inside the hip joint. Sometimes the source is a tendon, muscle, bursa, or one of the structures surrounding the joint. Depending on the problem, pain may show up along the outside of the hip, deep in the buttock, at the top of the hamstring, or in the front of the hip.

Years ago, surgery for many of these conditions often meant making a larger incision to reach the affected area. Today, some can be treated with extra-articular hip endoscopy, a minimally invasive technique that uses a small camera and specialized surgical instruments.

Dr. David Goodwin, an orthopedic surgeon with Arthritis & Sports Orthopaedics, recently reviewed the latest research on these procedures in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). His review looks at when hip endoscopy may be appropriate, how different procedures are performed, and what current evidence tells us about patient outcomes.

At a Glance: What Could Be Causing Your Hip Pain?

Condition	Where Pain Is Often Felt	Common Clues	When Endoscopy May Be Considered
Greater trochanteric pain syndrome (GTPS)	Outside of the hip	Pain with activity or when lying on the affected side; may involve the gluteal tendons rather than the bursa alone	Persistent symptoms despite appropriate nonsurgical treatment
Gluteus medius or minimus tear	Outside of the hip	Lateral hip pain, weakness, and sometimes a limp or Trendelenburg gait	A symptomatic partial or full-thickness tear that hasn't improved with nonsurgical care
External snapping hip	Outside of the hip	A snapping sensation as the IT band or gluteus maximus moves over the hip; may be painless or painful	Painful snapping that continues despite conservative treatment
Proximal hamstring tear	Buttock or back of the upper thigh	Pain, bruising, weakness when bending the knee, or pain while sitting	Certain significant tears, particularly complete three-tendon injuries in active patients
Ischiofemoral impingement	Buttock or groin	Deep pain that may sometimes travel down the leg or include tingling	Persistent symptoms with supportive imaging and diagnostic testing
Iliopsoas disorder or internal snapping hip	Front of the hip or groin	Pain with hip flexion; snapping may occur in the front of the hip	Persistent painful symptoms that haven't responded to nonsurgical treatment
Subspine impingement	Front of the hip or groin	Pain or limited motion with deeper hip flexion; symptoms may resemble FAI	Symptoms that continue despite nonsurgical care, sometimes treated along with FAI or a labral tear

Hip conditions can cause overlapping symptoms, and this chart isn't meant to diagnose the source of your pain. A physical examination, imaging, and sometimes a diagnostic injection may be needed to determine what's causing your symptoms.

Key Article Takeaways

• Extra-articular hip endoscopy treats certain problems outside the hip joint. Traditional hip arthroscopy focuses on problems inside the joint.

• Conditions that may be treated this way include greater trochanteric pain syndrome, gluteal tendon tears, snapping hip, proximal hamstring tears, iliopsoas disorders, and certain types of hip impingement.

• Surgery usually isn't the first step. Depending on the condition, treatment may begin with physical therapy, activity changes, medication, or injections.

• Endoscopic surgery can provide a less invasive alternative to open surgery for some patients, but it isn't automatically the better choice for every hip problem.

• Treatment decisions depend on the diagnosis, severity of the injury, tissue quality, activity level, and how the patient has responded to nonsurgical care.

• Research on extra-articular hip endoscopy is encouraging, but more studies are needed to determine which patients and procedures benefit most.

What Is Extra-Articular Hip Endoscopy?

Extra-articular hip endoscopy is a minimally invasive surgical technique used to treat certain problems in the tissues surrounding the hip joint. Through small incisions, the surgeon uses a camera and specialized instruments to reach the affected area without the larger incision typically needed for open surgery.

The term extra-articular simply means “outside the joint.” That distinction matters because there are many structures around the hip that can cause pain. These include muscles, tendons, bursae, and areas where bones can make abnormal contact during movement.

Dr. Goodwin's review separates extra-articular hip problems into three general areas: the lateral, or outside, part of the hip; the posterior area near the buttock and hamstrings; and the anterior, or front, of the hip.

What Is the Difference Between Hip Arthroscopy and Hip Endoscopy?

The terms sound almost interchangeable, but they describe different things.

Hip arthroscopy is used to treat problems inside the hip joint. Hip endoscopy is used to treat certain conditions outside the joint. Both approaches use a small camera, specialized instruments, and small incisions.

Hip arthroscopy is commonly used for conditions such as labral tears and femoroacetabular impingement, or FAI. Extra-articular hip endoscopy extends minimally invasive treatment to structures around the joint, including the gluteal and hamstring tendons.

Dr. David Goodwin states: “One of the challenges with hip pain is that the hip joint itself isn't always the source. Understanding exactly where the pain is coming from is critical because the right treatment for a tendon problem may be very different from the right treatment for a problem inside the joint.”

What Conditions Can Hip Endoscopy Treat?

Extra-articular hip endoscopy isn't a single operation. Rather, it's an approach that surgeons can use to treat several different conditions around the hip.

According to Dr. Goodwin's JAAOS review, these include:

• Greater trochanteric pain syndrome

• Gluteus medius and minimus tendon tears

• External snapping hip

• Proximal hamstring tears

• Ischiofemoral impingement

• Iliopsoas tendinitis and painful internal snapping hip

• Iliopsoas impingement

• Subspine impingement

These problems don't all feel the same. Symptoms can change quite a bit depending on which part of the hip is involved.

Greater Trochanteric Pain Syndrome and Pain on the Outside of the Hip

Greater trochanteric pain syndrome, often shortened to GTPS, is a common cause of pain along the outside of the hip. It may become worse with activity, and many people notice it most when lying on the painful side.

You may have heard this problem called trochanteric bursitis. That term doesn't always tell the whole story.

Research using imaging has shown that GTPS often involves the gluteus medius or minimus tendons, rather than inflammation of the bursa alone.

Treatment usually begins without surgery. Physical therapy, anti-inflammatory medication, and injections may be considered depending on the patient's symptoms and diagnosis.

If lateral hip pain continues despite an appropriate period of nonsurgical care, an endoscopic procedure may become an option. Exactly what the surgeon does depends on the source of the pain.

Can a Gluteus Medius Tear Be Repaired Endoscopically?

Yes. Some gluteus medius and gluteus minimus tendon tears can be repaired endoscopically.

These tendons help stabilize the pelvis and provide strength when you move your leg away from your body. When a significant tear occurs, it can lead to pain along the outside of the hip, weakness, and sometimes an abnormal walking pattern called a Trendelenburg gait.

Treatment often begins with options such as physical therapy, anti-inflammatory medication, and injections. If a symptomatic tear continues to cause problems despite appropriate nonsurgical care, surgery may be considered.

Published studies have found that endoscopic repair can produce outcomes comparable to open repair while giving appropriately selected patients a less invasive surgical option.

That doesn't mean every gluteal tendon tear can or should be repaired endoscopically. Severe tendon retraction or advanced fatty degeneration of the muscle may affect whether a repair is possible or likely to succeed.

What Is Snapping Hip Syndrome?

A hip that pops or snaps from time to time isn't necessarily injured.

External snapping hip happens when the iliotibial band, or IT band, or part of the gluteus maximus moves across the greater trochanter on the outside of the hip. For many people, the snapping doesn't hurt at all. In those cases, treatment may not be necessary.

Pain changes the picture.

If the snapping becomes painful and continues despite nonsurgical care, an endoscopic procedure may sometimes be considered.

In other words, the sound or sensation itself isn't usually the deciding factor. Persistent pain and limitations in activity matter much more.

Can Hamstring Tears Be Repaired Endoscopically?

Some proximal hamstring tears can also be repaired using an endoscopic approach.

The proximal hamstring tendons attach near the bottom of the pelvis. Injuries often happen when the hip is flexed while the knee extends, placing a sudden load on the tendons.

A more significant proximal hamstring injury may cause:

• Pain in the buttock or back of the upper thigh

• Bruising

• Weakness when bending the knee

• Pain while sitting

Complete injuries involving all three proximal hamstring tendons are more likely to be considered for surgical repair in active patients. Partial tears are often treated without surgery, although the right approach depends on the individual injury and the patient's needs.

Is Endoscopic Hamstring Repair Better Than Open Surgery?

Not necessarily.

Endoscopic hamstring repair has produced promising results, but studies comparing open and endoscopic techniques have found similar patient outcomes and failure rates.

That's why the decision shouldn't come down to which approach sounds newer or less invasive. Patient selection matters.

Dr. Goodwin states: “Minimally invasive doesn't automatically mean it's the right operation for every patient. The goal is to choose the approach that gives us the best opportunity to repair the problem safely and help that individual patient return to the activities that matter to them.”

What Is Ischiofemoral Impingement?

Ischiofemoral impingement is a less common source of hip pain. It develops when a muscle called the quadratus femoris becomes compressed between two nearby bones.

The resulting pain may be felt in the buttock or groin. Some people can also experience symptoms that travel into the leg, including tingling or other nerve-like sensations.

Those symptoms can look a lot like other hip or spine problems, so making the right diagnosis is important. Imaging and a diagnostic injection may help determine whether ischiofemoral impingement is actually responsible for the pain.

If symptoms continue despite nonsurgical treatment, endoscopic decompression may be considered in carefully selected patients.

What Iliopsoas Problems Can Cause Pain in the Front of the Hip?

The iliopsoas is one of the major muscles responsible for flexing the hip. Problems involving this muscle and its tendon can cause pain in the front of the hip or groin.

Common iliopsoas-related conditions include:

• Iliopsoas tendinitis

• Iliopsoas bursitis

• Internal snapping hip

• Iliopsoas impingement

The discomfort often becomes more noticeable when the hip is flexed. Activities that repeatedly involve hip flexion, including certain sports like ballet dancing and soccer, may contribute to iliopsoas problems.

Treatment generally starts conservatively. Rest, activity modification, and physical therapy may help. A guided injection can sometimes serve two purposes: helping confirm the source of the pain and providing symptom relief.

If symptoms remain persistent, an endoscopic procedure to lengthen or release part of the iliopsoas tendon may be considered.

That decision comes with important tradeoffs. Research reviewed by Dr. Goodwin found that some patients experienced decreases in iliopsoas muscle size and hip-flexion strength after the procedure. Careful patient selection is important for that reason.

Can Iliopsoas Pain Occur After Hip Replacement?

Yes. Iliopsoas tendinitis or impingement can occur even after a total hip replacement.

In some patients, irritation may be related to the position or prominence of a hip replacement component or to a change in leg length. When implant prominence is suspected, CT imaging may help with the evaluation.

Treatment depends on what's actually causing the problem. An iliopsoas procedure may be appropriate in some situations. If the symptoms are related to a prominent implant, however, a different surgical approach may be needed.

What Is Subspine Hip Impingement?

Subspine impingement occurs when part of the pelvis called the anterior inferior iliac spine, or AIIS, makes abnormal contact with the upper femur as the hip moves.

It may cause pain in the front of the hip and limit motion, particularly when the hip moves into deeper flexion.

How Is Subspine Impingement Different From FAI?

Subspine impingement and femoroacetabular impingement syndrome (FAI) involve different areas of abnormal contact around the hip. Their symptoms, however, can look very similar.

The two conditions can also occur at the same time.

If subspine impingement doesn't improve with nonsurgical treatment, a surgeon may sometimes address it during the same procedure used to treat FAI or a labral tear. Research reviewed by Dr. Goodwin found improvements in patient-reported outcomes after subspine decompression, although much of the published evidence involves patients who also underwent other procedures.

When Is Hip Endoscopy Considered?

For most people with hip pain, hip endoscopy isn't the first step.

First, the source of the symptoms has to be identified. That's not always straightforward. Several different conditions can cause pain in similar areas, which means the location of the discomfort alone usually isn't enough to make a diagnosis.

Depending on the suspected problem, an evaluation may include a physical examination and imaging. A diagnostic injection can also be useful for certain conditions.

Initial treatment may include:

• Activity modification

• Physical therapy

• Anti-inflammatory medication when appropriate

• Injections in selected cases

Surgery may become an option when a specific structural problem has been identified and symptoms continue despite appropriate nonsurgical care.

How long someone should try conservative treatment depends on the diagnosis. For example, Dr. Goodwin's review discusses several months of nonsurgical treatment before surgery is considered for persistent greater trochanteric pain syndrome and gluteal tendon problems.

Dr. David Goodwin states that “the MRI is only one part of the picture. We want the imaging, examination, symptoms, and response to treatment to point toward the same problem before deciding whether surgery makes sense.”

What Are the Potential Benefits of Hip Endoscopy?

Extra-articular hip endoscopy is designed to reach the affected area through a minimally invasive approach.

Depending on the condition and procedure, potential benefits may include:

• Smaller incisions than traditional open surgery

• Improved visualization of certain structures

• More targeted treatment of the affected tissue

• Less disruption to surrounding tissues

• Reduced morbidity for some procedures

Overall, Dr. Goodwin's review found that many extra-articular hip conditions can be treated endoscopically while maintaining favorable clinical outcomes.

There's an important caveat, though: that doesn't mean endoscopic surgery is always the better option.

Is Endoscopic Hip Surgery Better Than Open Surgery?

There isn't a single answer that applies to every hip condition.

For some procedures, researchers have found similar results with open and endoscopic surgery. For others, there simply aren't enough high-quality comparative studies to say that one approach is clearly superior.

Dr. Goodwin's review specifically notes the need for more comparative research on conditions including gluteal tendinopathy, iliopsoas tendinitis, and subspine impingement.

Open surgery may still make more sense when an injury is severe, a tendon has pulled far away from its attachment, tissue quality is poor, or the surgeon needs wider access to safely complete the repair.

Who May Not Be a Candidate for Hip Endoscopy?

Candidacy depends heavily on the diagnosis. There isn't one list that applies to every extra-articular hip procedure.

For certain conditions, factors that may make endoscopic treatment less appropriate include:

• Severe tendon retraction

• Poor tissue quality

• Advanced fatty degeneration of a damaged muscle

• Severe hip arthritis

• Significant bone deformity

• Hip instability

• Poor bone quality

These aren't universal rules. A finding that matters a great deal for one condition may have little importance for another.

That's why the decision has to be individualized.

What Are the Risks of Extra-Articular Hip Endoscopy?

Like any operation, hip endoscopy carries risks.

Those risks aren't identical for every procedure. They depend on the area being treated and what the surgeon needs to do.

Dr. Goodwin's review highlights several issues surgeons have to consider, including nerve injury, weakness, persistent symptoms, instability, and incomplete correction of the underlying problem.

For example, operating near the proximal hamstring requires careful attention to the sciatic nerve. Iliopsoas procedures may affect hip-flexion strength. In other procedures, removing too much tissue can create new problems, while removing too little may leave the original symptoms unresolved.

Before surgery, your surgeon should explain the specific risks, expected benefits, and alternatives for the procedure being considered.

What Is Recovery Like After Hip Endoscopy?

There's no standard recovery timeline that applies to every hip endoscopy procedure.

Someone having a small area of impingement treated may recover very differently from a patient who has a gluteal or hamstring tendon repaired.

Recovery can depend on:

• The condition being treated

• Whether a tendon was repaired

• The severity of the injury

• Whether other procedures were performed at the same time

• The patient's general health and activity goals

Physical therapy may also be an important part of recovery, depending on the procedure.

For that reason, it isn't very helpful to compare your recovery with someone who simply says they “had hip endoscopy.” The underlying procedures may have been completely different.

Patients should follow the rehabilitation plan provided for their specific operation.

What Does Current Research Say About Extra-Articular Hip Endoscopy?

Dr. Goodwin's JAAOS review examined the current evidence on the indications, surgical techniques, and outcomes associated with extra-articular hip endoscopy.

Overall, the findings are encouraging.

Certain procedures that once commonly required open surgery, including some gluteal and hamstring tendon repairs, can now be performed endoscopically in selected patients. Surgeons are also using minimally invasive approaches to treat greater trochanteric pain syndrome, iliopsoas disorders, and several types of extra-articular hip impingement.

At the same time, there are limits to what the research can tell us today.

More well-designed studies are needed to compare open and endoscopic techniques, identify which patients are most likely to benefit, and better understand long-term outcomes. Dr. Goodwin's review also notes that newer approaches such as biologic augmentation with dermal allografts or collagen patches haven't yet shown a clear advantage over standard repair techniques.

That's an important distinction. Newer doesn't automatically mean better, and a minimally invasive procedure isn't necessarily the right choice for every patient.

When Should You See an Orthopedic Hip Specialist?

An occasional ache or painless pop in the hip doesn't always require specialist care.

If the symptoms aren't going away, are getting worse, or are starting to interfere with daily life, however, an orthopedic evaluation may be worthwhile.

Consider scheduling an evaluation for:

• Persistent pain along the outside of the hip

• Hip pain that makes it difficult to sleep on one side

• Ongoing groin or front-of-hip pain

• Painful snapping or clicking

• Hip weakness or a noticeable limp

• Persistent buttock pain, especially while sitting

• Pain or weakness after a hamstring injury

• Sports-related hip pain that isn't improving

• Symptoms that continue despite physical therapy or other treatments

None of these symptoms points to one diagnosis on its own. Many hip, tendon, and even spine conditions can cause similar problems. Finding the source of the pain comes first.

Advanced Hip Care With Dr. David Goodwin

Dr. David Goodwin is an orthopedic surgeon at Arthritis & Sports Orthopaedics with expertise in sports medicine, hip arthroscopy, and joint-preservation techniques.

His recently published JAAOS review, Extra-articular Hip Endoscopy: Current Indications, Evidence, and Techniques, examines how advances in minimally invasive surgery are expanding the options available for treating certain conditions outside the hip joint.

If hip pain is making it harder to exercise, play sports, sleep comfortably, or get through normal daily activities, finding out what's causing it is the first step.

That doesn't automatically mean surgery. For many patients, nonsurgical care is still the right place to begin.

Learn more about hip conditions and treatment, or request an appointment with Arthritis & Sports Orthopaedics.

Frequently Asked Questions About Hip Endoscopy

What is extra-articular hip endoscopy?

Extra-articular hip endoscopy is a minimally invasive surgical approach used to treat certain problems in the tissues surrounding the hip joint. Through small incisions, a surgeon uses a camera and specialized instruments to reach tendons, bursae, and areas of impingement outside the joint.

What is the difference between hip arthroscopy and hip endoscopy?

Hip arthroscopy is used to treat conditions inside the hip joint. Hip endoscopy treats certain conditions outside the joint. Both techniques use small incisions, a camera, and specialized surgical instruments.

What conditions can hip endoscopy treat?

Hip endoscopy may be used to treat greater trochanteric pain syndrome, gluteus medius or minimus tears, painful snapping hip, proximal hamstring tears, ischiofemoral impingement, iliopsoas disorders, and subspine impingement. Whether the procedure is appropriate depends on the individual diagnosis.

Can a gluteus medius tear heal without surgery?

Some gluteal tendon problems can be treated without surgery. Physical therapy, medication, and injections may all be considered. Surgery may become an option when a symptomatic tear continues to cause problems despite appropriate nonsurgical treatment.

Can a torn hamstring be repaired with minimally invasive surgery?

Yes, some proximal hamstring tears can be repaired endoscopically. Complete three-tendon ruptures in active patients are more likely to be considered for surgery, while many partial tears are treated nonsurgically. The right approach depends on the severity and age of the injury as well as the patient's individual needs.

Does snapping hip always need treatment?

No. Snapping hip is often painless and may not require treatment at all. Surgery is generally considered only when the snapping is painful and continues despite appropriate nonsurgical treatment.

Is hip endoscopy better than open surgery?

Not always. Hip endoscopy can provide a less invasive option for some conditions, but research hasn't shown it to be superior to open surgery for every diagnosis. The best approach depends on the condition, severity of the problem, anatomy, tissue quality, and individual patient.

How long does it take to recover from hip endoscopy?

There isn't one recovery timeline for all hip endoscopy procedures. Recovery after treating an area of impingement may look very different from recovery after repairing a gluteal or hamstring tendon. Your surgeon can provide a timeline and rehabilitation plan based on the procedure you're having.

Is hip endoscopy always necessary for persistent hip pain?

No. Many hip conditions are first treated with nonsurgical options such as activity modification, physical therapy, medication, or injections. Surgery may be considered when symptoms continue and the examination and imaging identify a problem that can be treated surgically.

What type of doctor treats extra-articular hip problems?

An orthopedic surgeon with experience in hip arthroscopy, sports medicine, and hip-preservation procedures may evaluate and treat extra-articular hip conditions. Because hip, tendon, and spine problems can sometimes cause very similar symptoms, getting an accurate diagnosis is an important first step.