Gluteal Tendinopathy

What is Gluteal Tendinopathy?

Gluteal tendinopathy can refer to both tendinitis and tendinosis of all the gluteal muscles (gluteus maximus, gluteus medius and gluteus minimus) together or in isolation, such as a gluteus medius tendinopathy. It is the most common cause for lateral hip pain and greater trochanteric pain syndrome ( the greater trochanter can be felt on the outside of the hip and is the location of the attachments of all the gluteal muscles).

Gluteal tendinopathy is most commonly seen in the inactive population, runners and hikers, and affects people predominantly over the age of 40 and females more than males (Grimaldi and Fearon, 2015).

Signs and symptoms of gluteal tendinopathy present very similarly between individuals.

Signs usually include:

• Mild limping when walking.
• Rubbing the outside of the hip and gluteal area after a short walk or after getting up from sitting.
• Difficulty lying onto the affected side, especially in hard and non-cushioned surfaces.
• Difficulty ascending stairs.

Common symptoms include:

• Pain and tenderness when palpating the outside of the hip (greater trochanter) and when pressing on the glutes.
• Pain with walking, running, ascending or descending stairs.
• Irritation of gluteal area with prolonged sitting or standing
• Red, hot and swollen gluteal area and greater trochanter.
• Pain during the night, especially when lying on the affected side.
• Stiffness in the morning, usually lasting less than 30 minutes.
• Pain when crossing legs.

The gluteal muscles are a powerful group of muscles that are used constantly to allow us to move, stand and sit. Abnormal loading due to individual skeletal differences, other underlying pathologies or biomechanical changes and overloading of these muscles can lead to irritation and pain.

Common causes:

• Each person has a slightly different skeleton with different structure and muscle mass. A hypermobile individual or someone with leg length discrepancy can end up loading those muscles in different ways, making them work harder which can eventually lead to some tendon irritation.
• Underlying pathologies such as ankle, knee, hip or pelvic problems following injuries or operations or some kind of instability in these joints can lead to abnormal or excessive loading in the gluteal tendons leading to irritation.
• Biomechanical changes which can alter the gait cycle, running mechanics and even daily movements in individuals, along with certain muscle imbalances secondary to those biomechanical changes can lead to excessive loading in the glutes which can irritate the tendon.
• Finally, purely muscle imbalances arising from less use of certain muscles in the lower extremities or excessive loading to other muscles due to high demand (especially in elite athletes) can once again lead to imbalances putting the gluteal muscles in excessive stress which are unable to withstand, leading to tendon irritation.

To diagnose gluteal tendinopathy a detailed case history must be taken to obtain information about the duration of the discomfort or pain and its progression, any previous or new injuries that could be referring to or causing pain to the lateral side of the hip and finally anything that relieves or aggravates it.

Following the case history, a physical examination will be carried on. The practitioner will palpate the area of discomfort or pain and the surrounding tissues to check for any tissue change and try to recreate the symptoms experienced. The practitioner will then observe you standing and will ask you to do a few active movements to check for any restriction or pain. Finally, a passive physical examination will take place to once again check for any joint restriction or abnormality, activate, stretch and put the muscle under stress to recreate the symptoms.

In certain occasions and when dealing with elite athletes a gait and running analysis may be needed to identify the reason that leads to the irritation of the gluteal tendons.

Gluteal tendinopathy treatment options may vary depending on the severity and the needs of the individual. For elite athletes a careful rehabilitation program will be formed, aiming to work on the areas of weakness that cause the gluteal tendons to work harder and return the athletes back to sports as soon as possible. For the general population a suitable rehabilitation and treatment program will be formed to help decrease pain and allow the individual to return to their hobbies and daily activities.

Treatment options may include:

• Rest and contrast bath therapy (hot and cold therapy) followed by rehabilitation of the tendon using progressive loading (starting with isometrics followed by eccentric and concentric loading).
• Physical therapy such as osteopathy and physiotherapy can help release the tension in the muscles and improve mechanics of the joints in order to reduce the tension going through the gluteal tendons.
• Dry needling or acupuncture along with osteopathy and massage may help speed up the healing process of the injured or irritated tissues and reduce the rehabilitation and recovery time needed.
• Steroid injection can be used if symptoms and inflammation are severe.
• Surgery is the last option if all the above treatment approaches have not made a sufficient change in the tissues and a reduction in the symptoms experienced.

Gluteal tendinopathy can last from a few weeks up to a year or more. An acute state is considered to be anything less than 8 weeks and a chronic state is anything more than 8 weeks.

Depending on how quickly and accurately the problem is picked up by a healthcare practitioner, it can change the rehabilitation program and the recovery time. Understanding what exactly is causing the symptoms and seeking the appropriate help and advice can speed up the process by following a guided treatment and rehabilitation plan formed by a trained professional. Changes in symptoms and pain reduction can be seen following a few treatments and an overall recovery can be achieved once the causation of the problem has been resolved and the individual is able to return pain and symptom free to their activities and sports.

Like any other muscle injury, gluteal tendinopathy can be prevented from happening if the body is functioning well. For every individual and most importantly for athletes in both recreational and elite level a check-up is recommended a few times a year in order to check the body for areas that might be compensating for certain reasons, which may eventually, if left untreated, cause further problems and complications such as gluteal tendinopathy. An osteopath or physiotherapist will carefully examine, check and compare both sides and your spine to detect any restrictions that may eventually lead to problems. Through manual therapy and with the right advice these problems could potentially be prevented.

A structured rehabilitation program formed by your osteopath or physiotherapist along with hands-on treatment including mobilizations, manipulations, stretches, massage, dry needling, shock-wave therapy and K-tape and further advice can help with the overall recovery time.

According to recent evidence from studies on tendon rehabilitation, loading of the tendon as opposed to rest has been proven to lead to better overall management with less pain and quicker recovery and return to functional movements.

The rehabilitation program follows a specific order of loading the tendon starting with isometric contractions, followed by eccentric and concentric, finally going into low and high velocity loading and full functional loading. Some of the exercises will be described below:

• Isometric hip internal rotation: Either standing or seating next to a wall bring the hip closer to the wall to 90 degrees and push for 20 seconds. Relax for 10 seconds and repeat for 5 times.
• Isometric gluteus medius activation: Stand on one leg with your opposite knee bent to 90 degrees and touching the wall. With the bent knee push the knee against the wall, making sure to keep the rest of the body still. Hold for 20 seconds, Relax for 10 seconds and repeat for 5 times.
• Eccentric contraction of gluteus medius: Using an elastic band over your knees abduct both legs until you feel the tension in the band. Then slowly balance on one leg whilst bringing the opposite leg off the floor. Counteract the pull from the band whilst slowly abducting the hip that is off the floor. Repeat 5 times on each side for 3 sets.
• Concentric contraction of gluteus medius: With an elastic band over your knees lie onto your side with hips at 45 degrees and knees at 90 degrees. Both ankles and feet maintain contact with each other. Begin by lifting the top knee up making sure there is no rotation at the pelvis. Return the top knee to the starting position. Repeat on each side for 3 sets of 10-12 repetitions.
• Functional loading of gluteal muscles: Squats, lunges, glute bridges and hip thrusts all work the gluteal muscles in different planes giving strength, mobility and flexibility. These exercises can be done with and without weights, with varying repetitions and sets but the importance is the form and progression.

*It is recommended to get the go ahead from your physical therapist or GP before carrying out any of these exercises.

The best action for someone who is suspected to have gluteal tendinopathy is to consult their osteopath or physiotherapist and in severe cases a musculoskeletal specialist. However, if the onset of the pain is sudden, if there has been a traumatic event that initiated the pain or there are underlying risk factors such as severe osteoporosis or osteopenia then it is recommended to talk to your GP or go to A&E.

Grimaldi, A., Mellor, R., Hodges, P., Bennell, K., Wajswelner, H. and Vicenzino, B., 2015. Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Medicine, 45(8), pp.1107-1119.

Grimaldi, A. And Fearon, A., 2015. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. Journal of Orthopaedic & Sports Physical Therapy, 45(11), pp.910-922