Gluteal Tendinopathy

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Wendy Snyders, Tarina van der Stockt, Kim Jackson and Hannah Hassell
Page Owner - Wendy Snyders as part of the One Page Project


Introduction

  • Gluteal Tendinopathy (GT) is defined as moderate to severe disabling pain over the Greater Trochanter (lateral hip pain) with marked palpation tenderness over the greater trochanter[1]. The pain can at times prefer into the lateral thigh[2].
  • It is often referred to as Greater Trochanter Pain Syndrome (GTPS) and was traditionally diagnosed as Trochanteric Bursitis.
  • However, recent research defines non-inflammatory tendinopathy of the gluteus medius(GMed) and/or gluteus minimus (GMin) muscles to be the main source of lateral hip pain[3].
  • This condition generally affects inactive people but can also be a problem in athletes, especially runners[3].
  • It is the most common tendinopathy in the lower limb[4][3] with one in four females over 50 years likely to be affected[5]. It is more common in females and outnumbers men 2.4 - 4: 1[6].
  • GT has significant impacts on the quality of life, with similar symptoms to those of hip OA and interferes with sleep (side lying) and common weight bearing tasks[3][1]
  • Sadly, there is no optimal treatment approach for this condition[1].

Pathoanatomy/Pathomechanics

  • Tendon structure and loading capacity are influenced by mechanical loading which triggers physiological responses within the tendon.
  • Under normal conditions, the tendon undergoes a cycle of balanced  catabolic and anabolic processes[3]. Changes in loading type, intensity or frequency of load disrupt this harmony.
  • Eccentric contractions in outer ranges (when the muscle is active and the tendon is lengthening simultaneously) and where potential compression can occur, represent the greatest form of loading[3].
  • Failure to adapt to loading, due to rapid increase in intensity and/or frequency with insufficient recovery time, results in a series of catabolic effects which in turn result in altering tenocyte behaviour, reducing load-bearing capacity and predisposing tendons to injury at relatively low tensile loads.
  • A combination of both tensile loading and compression are found to be the most damaging[7].
  • GMed and GMin tendons are subjected to compression due to several factors:
    1. Joint Position
      The Iliotibial Band (ITB) causes a compressive force on gluteal tendons that magnifies as the hip moves into further adduction[8]. Birnbaum et al. reported a change from 4N to 106N ITB compression as the angle of hip adduction increased from 0 to 40 degrees[9].  Based on this, adopting constant or repetitive hip adduction during static and dynamic tasks possibly contributes to the development of GT.
      ITB tension also exerts loads on the GMed and GMin tendons at higher degrees of flexion through the fascial confluence of the ITB with the gluteal fascia[8].  This suggests that combining adduction and flexion, such as in sitting with knees crossed or adducted in a low chair, can cause pronounced compression on the GMed tendon[8]. People with GT may also experience pain after sitting for an extended period of time, especially if their hips were flexed above 90 degrees[8].

      Examples of activities and positions that cause compression at the gluteal tendons[8]:
      • Standing with one hip in adduction
      • Sitting with knees together
      • Sitting with knees crossed in adduction
      • Excessive lateral pelvic tilt or shift during dynamic single leg loading tasks.
      • Running on a cambered road or in the same direction on an athletics track with a midline or cross-midline foot-ground contact pattern
    2. Muscle Force
      Kummer (1993) found that pelvic control in a single leg stance position was controlled 70% by the abductor muscles and that the ITB tensioners (GMax, TFL and vastus lateralis) then accounted for the remaining 30%[3]. This is seen as the abductor mechanism. It has also been shown that people with gluteal tendinopathy tend to have GMed and GMin atrophy and TFL hypertrophy. Weakness and/or muscle bulk changes impact the balance of the abductor mechanism and increase the compression of the gluteal tendons[3].
    3. Bony Factors
      A biomechanical study using cadaveric modelling showed increased compressive force associated with reduced femoral neck-shaft angle[10][3]. Another study related the severity of GT to lower femoral neck-shaft angle compared with pain-free subjects with hip OA[11]. Lower neck-shaft angle is likely to contribute to greater offset (the difference between the width of the iliac wings and that of the greater trochanters). All these bony factors are suggested to influence ITB compression against gluteal tendons[3]. It is postulated that women are more prone to GTPS because of pelvic biomechanics, different activity levels in the population and hormonal effects[12]. One study found that females have a smaller insertion of the GMed tendon, resulting in a smaller area across which tensile load could be dissipated. It also makes the moment arm shorter, causing reduced mechanical effeciency[6].

Clinical Presentation

Lateral Thigh Pain.jpg

Lateral hip pain with an insidious onset, that gradually worsens overtime[3] with different loads and tasks[13] is the main feature of GT. Other symptoms include:

  • Tender lateral hip when palpated, especially near the greater trochanter[12][6]
  • Pain with side-lying on the problematic side[6][12][14]. Pain at night when lying on the painful side is the hallmark sign for GT[15].
  • Pain with weight-bearing activities such as walking, climbing stairs, standing and running[6][12][14]
  • Pain may refer to the lateral thigh and knee[6][12]
  • Pain with prolonged sitting[3]
  • Sitting with crossed legs increases pain[3]
  • Pain can also occur when lying on the non-painful side if the painful hip falls into adduction
  • Weak hip abductors[3]

Fearon et al. (2012) proposed that being able to manipulate socks and shoes without pain differentiates GTPS (or gluteal tendinopathy) from hip osteoarthritis (OA)[16]

Diagnostic Procedures

A thorough hip examination is needed basically by obtaining patient's history to understand the nature of the symptoms and rule out Red Flags. Then the assessor should go into the physical exam with a hypothesis that to be confirmed with clinical tests. The tests below, although they have weak diagnostic properties, are commonly used in musculoskeletal settings to confirm GT diagnosis. Their diagnostic accuracy can be improved when the patient is able to report the site of symptoms during testing[6].

  1. Palpation: Palpation has been shown to be most sensitive (0.83), but least specific (0.43) for clinically diagnosing GT[17] and is seen as the cardinal sign of gluteal tendinopathy [18]. Palpation should be done over the anterior, lateral or posterosuperior facets of the greater trochanter (GMed and GMin tendon insertions) bilaterally. The patient should assume a side-lying position with the asymptomatic side at the bottom, hips flexed 60°and knees together. A positive test indicates pain and tenderness.
  2. FABER test: Flexion/Abduction/External Rotation. Tension in this test is specific to the anterior portions of the GMed and GMin. The test is positive when pain is experienced over the lateral hip. It assists with differentiating between hip OA and GTPS[16].
  3. (30 second) single leg stance test: The person being tested must stand, unassisted, on one leg with their eyes open and one finger on a wall. As soon as the person’s foot is lifted of the floor, the 30 seconds start.  This test has been shown to have a specificity of 100%, sensitivity of 38% and positive predictive value of 100%, indicating that if the test was positive there was an extremely high likelihood that GT was present on MRI[19].Grimaldi and Fearon (2015) suggest holding the position for 30 seconds or until reproduction of symptoms[6].
  4. Resisted external de-rotation test and modified external de-rotation test:The patient lies in supine and the examiner then passively flexes the hip to 90° with external rotation. The hip should be in neutral abduction/adduction. Slightly reduce the external rotation to decrease the compression of the tendon. The patient then actively rotates their leg to neutral against the therapist’s resistance. The modified test is exactly the same, but done in full hip adduction[20].
  5. Hip FADER: (FADER=Flexion/Adduction/External Rotation)[19][17]. The therapist passively takes the limb into 90° hip flexion, adduction and external rotation to end of range. This test aims to position the ITB over the greater trochanter, and positions the GMed and GMin tendons under tension with the ITB fascia against the greater trochanter. Test is positive if the patient experienced pain (≥2/10) on the Numeric Rating Scale (NRS) over the lateral hip. The reported specificity and positive predictive value (PPV) of this test are 86.67% and 88.24% respectively when compared with an MRI imaging[21].
  6. Hip FADER-R: Flexion/Adduction/External Rotation with static resisted internal rotation of the hip. Grimaldi et al. (2014) found this test to have a sensitivity of 0.48 and a specificity of 0.86[17]
  7. Passive end-of-range hip adduction in side lying (ADD) test[19]: In the side lying position, the lowermost hip and knee flexed 80-90°, and the uppermost leg supported by the examiner with the knee extended, in neutral rotation, and the femur in line with the trunk. The anterior superior iliac spines are aligned vertically in the frontal plane. The examiner passively moves the hip into end range hip adduction with overpressure, while maintaining the pelvis stable with the other hand. This test compresses the lateral insertions of the gluteal tendons, and a positive response is felt over the lateral hip. It has been found to have a very low sensitivity but a high specificity (0.79)[17]
  8. ADD with resisted isometric abduction (ADD-R)[19][17]: In the end range of the previous test position (ADD test), the participant is asked to push the thigh up, against the resistance of the examiner’s hand at the lateral knee. This further compresses the tendons with pain experienced over the lateral hip. Similar to the FADER test, adding manual resistance has been shown to improve the the sensitivity, specificity, PPV and negative predictive value (NPV) of both of this test.
  9. Resisted hip abduction: A systematic review by Reiman et al. (2012) found this test to have a 71% sensitivity and 84% specificity[22]. Assessing active abduction in a position of hip adduction may be more useful.

Pain provocation and reproduction of symptoms by loading abductors are the aims of these tests.

  • The traditional Trendelenburg sign is useful in diagnosing partial and complete abductor tendon[21][3] and is considered positive when a drop of the pelvis on the contralateral side of the stance leg is seen.
  • The combination of several tests is advisable because one positive clinical test helps in confirming diagnosis but doesn't necessarily refute it.
  • There will be many times where doing only 2 or 3 tests will be inadequate for correctly diagnosing gluteal tendinopathy[18].
  • Performing a combination of tests that include sensitive tests, like palpation, as well as specific tests such as tests 3,4,5 and 8 as listed above, can help prevent the risk of incorrect diagnosis[18].
  • Please note that this is only one possible option for a combination of test and that the available literature has not yet provided a clear combination of diagnostic tests to confirm GT diagnosis. Further research is required to reach accurate and objective set of criteria and/or tests.
  • Cook and Purdam[23] suggest functional loading tests to assess and track a tendon's response to therapy.
  • Reduced pain on single leg standing (low-load test) and hopping on the affected leg (high-load test) indicates improved loading tolerance of the gluteal tendons[23].
  • Inadequate eccentric pelvic control in single leg loading tasks indicates a greater hip adduction moment arm and possible gluteal tendons compression. Video analysis of is suggested for athletes to observe pelvic tilt and femoral adduction in running and changing direction[3].
[24]
  • Imaging is only suggested in the following situations:
    • When it comes to diagnosing gluteal tears, ultrasound or MRI should be used to confirm the diagnosis if it is suspected clinically[25][12]. Cook (2020) reports that ultrasound is the most accurate when assessing a tendon where MRI is helpful for differential diagnosis[26].
    • When conservative treatment has failed[6][12]
    • When diagnosis is unclear[6][12]

Outcome Measure

The Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G) can be used to assess and track pain intensity and functional limitation[27].

Differential Diagnosis

Management Strategies

Dr Allison Grimaldi reports that correct diagnosis is essential for the correct management[18]. The wrong exercise or rehabilitation may delay recovery or confound an optimal outcome[18].

Management of GT includes[3]:

  • load management strategies
  • tendon rehabilitation
  • shockwave therapy
  • corticosteroid injections
  • platelet-rich plasma injections
  • tenocyte injections
  • surgery .

Please see the Tendon Rehabilitation page for more information.

Load Management

Loading management for GT should include education on positions and activities that can increase compressive load on the gluteal tendons. Patients with GT should:

  1. Avoid sitting with their legs crossed[6]
  2. Avoid sitting with knees together[6]
  3. Avoid standing while hanging on one hip[6]
  4. Avoid lying on the affected side[6]
  5. Place a pillow between their knees and shins when lying on the unaffected side to limit adduction of the affected hip[6]
  6. Stop adduction stretching (for glutes and ITB) to limit compression of the gluteal tendons[6]
  • Avoiding side-lying on the affected side or hip adduction when lying on the unaffected side will greatly help with reducing the common problem of night pain.
  • High tensile loads should be managed by teaching the patient not to rapidly increase activity.
  • Sport and recreational activity volumes should be carefully monitored to prevent aggravation of pain. For the elderly, small changes like reducing walking distances, avoiding hills when walking and avoiding stairs may be sufficient in reducing the load on the gluteal tendons[6].
  • In athletes, complete rest is detrimental to tendon function. Training should be modified; activities combing high tensile and compressive loads should be avoided and quick changes in training should be restricted[3].
  • It is assumed that most tendinopathies that develop in season are due to a reactive response on an existing degenerative tendinopathy and based on this, removing high loads prevents further disruption of the matrix of the tendon if given enough time[23].
  • It is also important to progressively load the tendon to aid matrix remodeling[23].
  • An example of managing load would be to reduce training in the outer muscle range and in so doing reduce the compression on the tendon. This will allow the patient to then continue the existing tensile load as they will not be combining compressive and high tensile loads[23]. To reduce tensile loads, running over long distances, plyometric training and hill running should be stopped temporarily[6].
  • Very importantly, there are loads that can reduce pain in tendons.  Sustained isometric contractions with a degree of load have been shown to activate the descending inhibitory pathways resulting in a mechanical analgesic effect in the tendon[23]. Isometric exercises will be discussed further in the tendon rehabilitation section below.
Activity modifications in GT.jpg
Running modifications in GT.jpg

Tendon Rehabilitation

Isometric Loading

  • Isometric contractions are now commonly used as they release cortical inhibition targeting both peripheral and central pain drivers.
  • This cortical inhibition causes immediate pain reduction and for 45 minutes afterwards[14].
  • Cook (2020) reported that the analgesic effect can last for 4 to 8 hours after isometrics[26].
  • Isometric contractions must be heavy to effectively achieve pain relief in the tendon[26][31].  
  • The exact duration of the contraction is unknown, but 5 repetitions of 45 seconds has been found to be very effective[6][26][31].
  • A rest period of 2 minutes must occur between each of the isometric contractions[26].
[32]
[33]

Isotonic Loading

  • This phase is to commence once pain is under control and should include slow, progressive isotonic loading and strength endurance.
  • Establishing a graduated strengthening programme from early on is helpful to reduce pain and improve the tendon’s load-bearing capacity[6].
  • Eccentric training is not sufficient on its own and can at times aggravate pain and should be replaced by high load, slow velocity exercises that are initially done in positions of minimal hip adduction[6]
  • Reducing the amount of adduction helps prevent compression of the gluteal tendons and places the ITB tensioners at a mechanical disadvantage[6].
  • Isolated hip abductor strengthening must be included and is best activated in weight-bearing positions, should this be possible for the person[6].
  • Grimaldi and Fearon (2015) advised that these high-tensile load exercises should be limited to 3 times per week, where Prof Jill Cook (2020) did not limit isotonic strengthening to a certain number of times per week[26].
  • During this isotonic strengthening phase, functional strengthening and endurance training should also included[26].
  • Should modifiable comorbidities and risk factors be present, they should also be addressed during this phase[6].
  • In patient’s with GT, there is often weakness or poor movement control at the lumbar spine, hip and knee and this should also be addressed[6].
  • Cook (2020) reported that patients with GT frequently have weak calves and so this should also be assessed and addressed if necessary[26].

Energy-Storage Loading

  • Phase 3 is commenced once there is sufficient strength.
  • This is appropriate to a certain extent when the person in question is a middle-aged, inactive person.
  • Far more energy storage should be done if the patient is an athlete.
  • During this phase, both inactive people and athletes should continue the exercises from stage 1 and stage 2, where Stage 2 exercises should be continued twice per week[26].
  • Phase 3 should be done 2 to 3 times per week and the exercises given should be broken up into an energy absorption phase and an energy propulsion phase.
  • Also consider starting to gradually load into compression during this phase[26].

Return to Sport

  • This phase is only relevant to athletes and specifically athletes who have not been able to continue with their sport due to pain and/or dysfunction[26].
  • During this phase, phase 1 and 2 should be continued and the exercises in phase 3 should systematically be replaced with return to sport drills and activities[26].
  • Change one thing at a time and continue to monitor the tendon’s response[26].

Very importantly:

  • 24 hour re-assessment is essential to prevent loading the tendon too much while rehabilitating it.
  • In people with GT, night pain will improve if the load is correct, but will get worse if the load is too much[6][26].
  • Morning stiffness is an indication of overloading the tendon[26]

"Every tendon is different. Every person is different. Every starting point is different. Every end point is different. You cannot standardise exercise in tendons" (Prof Jill Cook, date unknown).

  • Because of the above-mentioned, there is no one rehabilitation programme that can be given to people with GT.
  • There have been some studies showing effective exercise programmes for people with GT, and one of these, called the LEAP trial, compared exercise plus education to corticosteroid injection to a wait and see approach. The study revealed that exercise plus education and corticosteroid injection resulted in greater pain reduction than the wait and see approach and that exercise plus education was also superior to corticosteroid injection[5].
  • The LEAP study has shown that treatment can be successful if[18]:
    • clinicians understand the condition
    • screening is done properly with a battery of tests that have been shown to have diagnostic utility
    • management of the condition is evidence-based
  • Below is the list of exercises used in the LEAP trial:
LEAP trial pg 1. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license Rebecca Mellor,Kim Bennell, Alison Grimaldi, Philippa Nicolson, Jessica Kasza, Paul Hodges, Henry Wajswelner, Bill Vicenzino Supplementary appendix for Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial The BMJ DOI: 10.1136/bmj.k1662 2018;361:k166 Published online: 2 May 2018 https://www.bmj.com/content/361/bmj.k1662
LEAP trial pg 2. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license Rebecca Mellor,Kim Bennell, Alison Grimaldi, Philippa Nicolson, Jessica Kasza, Paul Hodges, Henry Wajswelner, Bill Vicenzino Supplementary appendix for Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. The BMJ DOI: 10.1136/bmj.k1662 2018;361:k166 Published online: 2 May 2018 https://www.bmj.com/content/361/bmj.k1662
LEAP trial pg 3. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license Rebecca Mellor,Kim Bennell, Alison Grimaldi, Philippa Nicolson, Jessica Kasza, Paul Hodges, Henry Wajswelner, Bill Vicenzino Supplementary appendix for Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial The BMJ DOI: 10.1136/bmj.k1662 2018;361:k166 Published online: 2 May 2018 https://www.bmj.com/content/361/bmj.k1662
LEAP trial pg 4. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license. Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;360:1-9. https://www.bmj.com/content/361/bmj.k1662
LEAP trial pg 5. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P, Wajswelner H, Vicenzino B. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;360:1-9.https://www.bmj.com/content/361/bmj.k1662

Summary of progression of exercises in the LEAP study[5]:

  • Week 1-2
    • Static abduction in supine against an elastic band (1-2 sets of 10 reps) and standing "imagine sliding your legs apart" (hold 5-10sec, 1 set of 3-5 reps) *Twice a day
    • Double leg bridge > Offset bridge > Single foot hover bridge > Single leg extension bridge > Single leg bridge with dips (1 sets, 5 reps) *Daily
    • Functional retraining: Double leg squats > Offset squats > Single leg standing > Single leg squats > Step ups (1 sets, 5 reps) *Daily
  • Week 3-8
    • Continue with week 1-2 static abduction exercises for low load activation as part of the warm up
    • Continue with Double and single leg biased exercises (1-2 sets, 5-10 reps) *Daily
    • Continue with Functional retraining: Double leg squats > Offset squats > Single leg standing > Single leg squats > Step ups (1-2 sets, 5-10 reps) *Daily
    • Weight bearing abductor loading: Side stepping, Doorway side slides against elastic band (1-2 sets, 5-10 reps) *Daily
    • Exercises supervised by physiotherapist in the clinic
      • Abductor loading via frontal plane movement on an abductor slide against spring resistance with body upright > mini squat (1 set, 5-10 each way) *Twice a week
      • Pelvic control during functional loading

(">" means progression of previous exercise) 

  • Fear and uncertainty are associated with Achilles[34] and gluteal tendinopathies[35].
  • A study by Plinsinga et al. (2018) revealed that people struggling with severe GT have a poorer quality of life, greater psychological anguish and they tend to present with higher BMI when compared to people whose pain is not as severe,
  • These findings support the need for utilising a bio-psychological management approach and this can be achieved by being empathetic; addressing their concerns of returning to basic levels of activities; helping them identify their barriers to recovery; explaining tendinopathy in a positive way and knowing when to refer to other specialised healthcare professional[36].

Shockwave Therapy

A small study conducted in 2018 found that shockwave therapy was effective in providing short-term pain relief in chronic GTPS where gluteal tendinopathy was confirmed on MRI[37]. A systematic review published in 2014 found the following[38]

  • Shockwave therapy is superior to interventions such as rest, non-steroidal anti-inflammatories and corticosteroid injections and stretching exercise when the aim is to reduce pain and improve function.
  • It is more effective than exercise at home at 4 months
  • It is more effective than corticosteroid injections in the long-term for pain relief

It is worth mentioning that the studies included in the above-mentioned review were old (published in 2009).

Corticosteroid Injections

  • Corticosteroid injection is very effective for providing short-term pain relief in the early stages of GT[3].
  • It however is not effective in the long-term and leads to high recurrence rates[3].
  • GT is seen to be a degenerative condition rather than an inflammatory condition and the short-term analgesia of corticosteroids is most likely due to its interaction with neurotransmitters and local neuropeptides[3].
  • Corticosteroids may also carry the negative effect of down-regulation of collagen production by fibroblasts, impacting the tendon's ability to respond appropriately to load[3].

Tenocyte Injections

  • A pilot study released in 2017 found that autologous tenocyte injection was safe and effective for managing pain in chronic gluteal tendinopathy, that had not responded to other conservative treatments.
  • There were no persistent complications and improvement in clinical scores was still noted at 24 months post-intervention[39]

Surgical Intervention

  • Surgery is considered in patient's with persistent pain and who have failed conservative treatment[3] and when MRI and clinical findings are consistent with a tendon tear.
  • A retrospective study by Davies et al. (2013) revealed that in most cases, substantial improvement in abductor tendon strength and clinical performance occurred with gluteal tendon repair[40].
  • A study published in 2016 found that a double-row endoscopic technique allowed the surgeon to visualize, debride and repair the tendon effectively[41]. There have also been cases where a GMax tendon transfer has been done to manage the tear[42].
  • A very recent study (2019) found that reinforcing the repair with an allograft increased the structural strength of the repaired tendon, preventing suture pullout. The authors also reported that this approach allowed for better graft compression to the bone, potentially allowing for an increased healing rate[42].
  • While open repairs are used for large tendon tears and tears where the tendon has retracted, endoscopic repairs are preferred as they are less invasive and allow for rehabilitation to begin sooner[3].
  • When there is no tendon tear and conservative management has failed, endoscopic arthroscopic bursectomy together with an ITB release as been shown to be effective by Mitchell et al. (2016)[42].
  • Please see Table 2 on the GTPS page for a rehabilitation protocol for gluteal tendon repair.
[43]
[44]

References

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  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. The American journal of sports medicine. 2019 Apr;47(5):1130-7.
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