by Niamh Rafter, Physiotherapist. BSc. (Hons) (Physiotherapy)
Gluteal Tendinopathy is a condition affecting the hip and lumbo-pelvic region. Symptoms can include pain and dysfunction at the outside of your hip and thigh. Many different terms have been used to describe it, some of them including: Gluteal Tendinitis, Greater Trochanteric Pain Syndrome, Trochanteric Bursitis. Recent studies have supported the use of the term ‘gluteal tendinopathy’ in scientific literature, based on pathophysiological mechanisms and MRI findings. Tendinopathy (pathology of a tendon) occurs at the tendon attaching to your hip bone- the greater trochanter. People will most often complain of a sharp, localised pain at this bony point, palpable on the outside of your hip joint. The tendon is the structure causing localised pain, which can also radiate and extend to the lateral (outside) thigh. A variety of anatomical factors contribute towards this condition, so first let's have a look at the anatomy of the region: Here is the greater trochanter (hip bone!), and those suffering with this condition will experience varying proportions of pain at this region. It has been described as a similar pain to arthritic hip pain, a.k.a osteoarthritis, in terms of pain severity and disruption to normal daily activities.
So what exactly is happening?
Most people will have an understanding of what your ‘glute muscles’ are. You have three glute muscles, those being gluteus maximus, medius and minimus (or big, medium, and small). They are powerful muscles, involved in hip extension, abduction, medial and lateral rotation. They are required to sit and stand, walk, run, go up and down stairs and control single leg activity.
The tendons of gluteus medius and minimus cause pain in gluteal tendinopathy.
Why do the tendons cause pain?
A tendinopathy refers to a pathological process which can occur within a tendon. Tendons attach muscle to bone, common examples of these being your achilles at your ankle or your rotator cuff in your shoulder.
Tendons are structures which are designed to withstand load and force, and are highly organised structures which adapt according to the conditions under which they are placed.
They are composed of connective tissue with fibro-elastic properties, meaning that they are can adapt according to compressive or tensile forces during your everyday activities. Think of them like a complex spring, which will change according to how its used (or trained!).
Collagen fibres make up a portion of the tendon, and in a healthy tendon they are highly organised. Physiological changes occur within a tendon when a new and unfamiliar demand (e.g. a sudden change in training pattern) is placed on it. The collagen fibres cannot fully adapt to this, and they become ‘disorganised’ in their pattern, altering the resilience and function of the tendon.
Every tendon is different
There are three stages of tendinopathy, and your physiotherapy management will depend on your ‘stage’ of tendinopathy. Cook’s Tendon Continuum Model describes what is happening intrinsically within a tendon in the following diagram:
A healthy tendon becomes a reactive tendon when it thickens in response to a sudden change in load or trauma. If the tendonopathy is managed at this early stage, the prognosis it very good, whereby the tendon can recover and return to its original state.
If this excessive load is continuously applied, the tendon will enter a stage of tendon dysrepair, where internal changes to tendon structure occur: collagen disorganisation, scar tissue formation, new growth of nerves and vascularisation. If this continuously occurs, the final stage of tendon pathology is a degenerative tendon, where the natural recovery function is further compromised.
The Role of Gluteus Medius and Minimus Muscles (Glute med and min!)
Your smaller glutes muscles play a key role in the biomechanics of your pelvis, hips and lower limbs. Specifically,
- Keeping your pelvis stable and level
- Providing support to your core and lower back
- Control of your leg in any unilateral leg work
Factors which contribute to gluteal tendinopathy
So when symptoms of gluteal tendinopathy begin, it is likely that your muscle stability and control will be lacking in some of these areas. A common finding with gluteal tendinopathy is the ‘Trendelenburg sign’, an altered pattern during the gait cycle - seen below. Pelvic stability is a key component of interest for any conditions of the lumbar spine, pelvis and hip regions.
This video explains the Trendelenburg Sign in a bit more detail:
Excessive hip adduction on the affected side is another risk factor for developing symptoms of gluteal tendinopathy. When the pelvic drop occurs, the angle of your femur (thigh bone) in relation to your pelvis will change, as seen on the left leg in the left hand side picture below:
This inward movement of the thigh places greater force on the muscles and tendons on the affected leg. When weakness is present in these stabilising muscles, the pelvis cannot level off fully, and so an excessive load will occur at that point.
One final factor to consider is the iliotibial band (ITB). This is a band of connecting tissue which lies close anatomically to the glute med and min tendons, and runs down the lateral aspect of your thigh. . Compression of these tendons under the ITB is thought to be a significant contributing factor in developing gluteal tendinopathy. Again, this relates back to hip adduction movement, where your leg crosses the midline (i.e. crossing your legs). Over prolonged periods of time, when a number of individual factors are present, symptoms of tendinopathy may occur.
The condition is most commonly seen in women, aged 40-60; 23% of females in this age bracket will experience this condition. Research has stated that 1 in 4 women over the age of 50 will experience gluteal tendinopathy.
Should you try physiotherapy? The evidence tells us YES!
Physiotherapy management of this condition has been proven to be effective. Evidence based physiotherapy management of this condition is supported, as stated in a number of systematic reviews and high quality randomised control trials.
Just one example of successful outcomes from physiotherapy is demonstrated in The LEAP study, a high quality RCT from 2018. This study compared physiotherapy management - evidence and exercise (EDX) vs corticosteroid injection (CSI) vs wait and see approach (WS). A 14 week program was designed for people with confirmed diagnosis of gluteal tendinopathy.
The physiotherapy group received education regarding avoiding aggravating factors and management of symptoms, as well as a structured exercise program, involving 14 sessions over 8 weeks. After 8 weeks, and also at 52 week follow up, 77% of participants in the group reported being at least moderately better, whereas the injection and wait and see populations being less improved (58% and 29% respectively). The physiotherapy groups pain scores were also lower, and at the one year follow up they had the best outcomes in all categories still.
Getting a diagnosis
If you are experiencing pain around the hip region, you should book in for a physiotherapy assessment. Based on what you describe, we can assess and plan the most appropriate management plan. Often, people are unsure of whether to visit their local doctor, physio, chiro, massage therapist etc. The most important thing is to appropriately diagnose the problem, which your physiotherapist is an expert in!
An MRI or ultrasound scan will show specifically what is happening pathologically with the tendons, however based on your symptoms and stage this may not be necessary.
Quite often, with gluteal tendinopathy, there will be a co-existing condition of problem, relating to the complexity of the lumbo-pelvic region. The most common complaint associated with gluteal tendinopathy is lower back pain, another presentation which physiotherapists deal with on a daily basis.
During your appointment
Your physiotherapist will take a subjective history, seeking to find out the nature and pattern of your symptoms - duration, pain intensity, daily activities and what your goals for recovery are.
The physical examination will focus on your lumbar spine, pelvis, hip and groin region, so bringing a pair of shorts is always helpful.. Here at bounceREHAB, we keep some very stylish pairs!
Diagnosis of gluteal tendinopathy is based on clinical findings, and can be confirmed by scans where indicated.
But what should i ACTUALLY do?
Management of gluteal tendinopathy will depend on individual factors, but principles of management in tendinopathies will certainly involve a progressive resistance (strengthening) program.
Based on your lifestyle, current activities and pain levels, the physiotherapists at bounceREHAB will devise an appropriate exercise plan - initially to improve your pain levels. Activation exercises for key muscle groups will be the starting point, and over the course of treatment, as pain subsides, your program can involve further hip stability and strength training, moving from isolated to more functional and complex movements with time.
They key factor here is pain and tendon loading - tendons have the capacity to heal and adapt over time, given the right circumstances and environment. Time is key here, building strength takes time and consistency with training. We commonly advise our patients here to expect 3-6 month timeframe for rehabilitation.
Pain relief
In the acute phase of pain, using ice or taking appropriate anti-inflammatory medications may be appropriate for you. One of the key management strategies we recommend is to avoid aggravating activities.
Common examples of aggravating activities include:
● Sitting cross legged
● Lying on the painful side (try lying on the opposite side with a pillow between legs)
● Continuing to take part in high level activity, which causes pain during or after
● ‘Hip Hanging’ - standing with weight on the affected leg, allowing the pelvis to drop
Avoid this where possible:
If the pain does not subside with the appropriate management above, referral for imaging may be beneficial to outrule associated bursitis. A cortisone injection may be beneficial as an addition to the management protocol. Cortisone is an anti-inflammatory agent, but in fact only 8% of gluteal tendinopathy cases have coexisting bursitis with inflammation.
How can bounceREHAB can help you to get back on track?
Physiotherapy will be an important initial phase of management, to relieve pain with hands on therapy. Working on surrounding muscle tissue (hip, lower back, buttock and groin) will help in the acute stage of pain. Your therapist will of course remain professional and ensure you are comfortable during the session. We will advise you on specific activity modifications, things to avoid in the short term- regarding your gym program, ergonomics set up or sleep position for example.
Next, in the sub-acute phase of pain, local core and hip exercises will be provided in an individualised program, based on your assessment findings. These can be completed in a home or gym setting, or within a group exercise setting in our Physio Rehab classes. Based on your lifestyle and preferences, we can discuss which of these are most appropriate to get the most out of your rehabilitation and recovery.
Options available at bouceREHAB:
One to One therapeutic exercise sessions, using rehab space equipment.
Progressing to Group Rehab Classes - small group sessions with focus on individual programs.
Progressing to Fundamental / Basic / Reformer classes for progressive maintenance of whole body strength.
Equipment?
Trigger point ball - to relieve myofascial trigger points. Instruction from your physio will be necessary so to not aggravate symptoms.
Resistance bands (Light, Medium, Heavy) - for progressive strength loading of hip and lower limb muscle groups.
PainPod - local micro-current device to alleviate local pain symptoms.
Supplements?
Take home message
Gluteal Tendinopathy is a condition that requires physiotherapy management, and is individual to each person. To begin your rehabilitation, the best starting point is to book in for an initial physiotherapy assessment!
Before physiotherapy:
During physiotherapy:
After physiotherapy:
Niamh Rafter
Bsc. Physiotherapy
Physiotherapist @ bounceREHAB