Gluteal Tendinopathy

Firstly, what is it?

Tendinopathy is a broad term used for changes at a tendon that can produce pain and/or reduced function (Millar et al., 2021). It is usual a result of overloading of the tendon (Millar et al., 2021) however it can also result from other factors such as genetics, metabolic conditions, medication, and others (Millar et al., 2021).

It has replaced terms such as tendinitis, tenosynovitis and tendinosis

What are the signs and symptoms?

Symptoms that are often reported include pain with:

• Sitting (Grimaldi & Fearon, 2015)

• Standing (Grimaldi & Fearon, 2015)

• Walking (Grimaldi & Fearon, 2015)

• Climbing up stairs (Grimaldi & Fearon, 2015)

• Lying on the affected side (Grimaldi & Fearon, 2015)

How is it diagnosed?

Within the clinic, a physiotherapist, doctor or orthopedic surgeon can perform a number of tests which when combined with your history can lead them to have a reasonable suspicion of gluteal tendinopathy (Dancy et al., 2023)(Grimaldi & Fearon, 2015)(Grimaldi et al., 2024). This is referred to as a clinical diagnosis, it is important to note that the accuracy does depend on the clinicians expertise, competence and training in this area.

For further confirmation imaging can be used. There are two main options which are ultrasound and MRI, both having limitations and benefits for their use (Grimaldi & Fearon, 2015), with MRI considered the gold standard (Grimaldi et al., 2024). Abnormal findings are common in these scans even for people without pain (Register et al., 2012), so they need to be matched to the clinical picture to be relevant.

What are the treatment options?

A high quality research trial found that supervised exercise therapy and education improves pain and physical function at 8 weeks and 1 year when compared to no treatment and a corticosteroid injection (Mellon et al., 2018). Corticosteroid injection was more beneficial than no treatment however, treatment effect are mainly short term (Ladurner et al., 2021). A recent larger research paper that included several studies found that exercise is considered superior to corticosteroid injections (Patricio Corrdeiro et al., 2024). Additionally, there is some evidence that corticosteroid injections are actually harmful to the tendon itself in the long term (Grimaldi et al., 2024).

Platelet rich plasma injections have shown mixed results in research trials (Dancy et al., 2023).

Shockwave therapy is seen as a promising treatment however, there is very limited high quality research available (Dancy et al., 2023). One higher quality trial did find it outperformed corticosteroid injection in the long-term but was inferior to a home exercise program (Rompe et al., 2009).

Surgery is another option (Ladurner et al., 2021). However, it is usually reserved for more severe cases (e.g., full thickness tears, larger partial thickness tears)(Dancy et al., 2023)(Grimaldi & Fearon, 2015). It may also be an option if conservative options fail(Grimaldi & Fearon, 2015).

There are numerous factors to consider when deciding on the appropriate treatment for you. Including, the extent of the tendinopathy, your age, medical conditions, finance, etc. These are best discussed with your GP or physiotherapist.

Where does exercise physiology (EP) and physiotherapy come in?

Gluteal tendinopathy is a condition where load is very important. With load we refer to how much we use the tendons. For gluteal tendinopathy too little or too much can both be contributing factors to pain persisting. This is where EP/physio’s can assist in ensuring you are avoiding either of these.

An exercise program can also assist in the rehabilitation process and EP/physio’s are again most appropriate in prescribing these. Occasionally symptom modifying techniques like massage, dry needling, and others can be useful in the short term as an add-on treatment (Millar et al., 2021).

Tips to help management

1. Rest can be helpful but does not fix the problem and will likely only provide temporary relief. Being less physically active is actually a risk factor for the development of gluteal tendinopathy.

2. Stretching is not the answer. As with all tendinopathies, stretching can actually be problematic (Grimaldi & Fearon, 2015).

3. Temporarily avoid painful movements if possible or reduce the amount you are doing these

4. Temporarily avoid sitting cross-legged or standing with legs crossed.

5. If possible sleep with a pillow positioned under your leg

References

1. Dancy, M. E., Alexander, A. S., Clark, C. J., Marigi, E. M., Hevesi, M., Levy, B. A., Krych, A. J., & Okoroha, K. R. (2023). Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments. JBJS reviews, 11(10), e23.00101. https://doi.org/10.2106/JBJS.RVW.23.00101

2. Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. The Journal of orthopaedic and sports physical therapy, 45(11), 910–922. https://doi.org/10.2519/jospt.2015.5829

3. Ladurner, A., Fitzpatrick, J., & O'Donnell, J. M. (2021). Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthopaedic journal of sports medicine, 9(7), 23259671211016850. https://doi.org/10.1177/23259671211016850

4. Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., & Vicenzino, B. (2018). 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. British journal of sports medicine, 52(22), 1464–1472. https://doi.org/10.1136/bjsports-2018-k1662rep

5. Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., Murrell, G. A. C., McInnes, I. B., & Rodeo, S. A. (2021). Tendinopathy. Nature reviews. Disease primers, 7(1), 1. https://doi.org/10.1038/s41572-020-00234-1

6. Patricio Cordeiro, T. T., Rocha, E. A. B., & Scattone Silva, R. (2024). Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis. Scientific reports, 14(1), 3343. https://doi.org/10.1038/s41598-024-53283-x

7. Register, B., Pennock, A. T., Ho, C. P., Strickland, C. D., Lawand, A., & Philippon, M. J. (2012). Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. The American journal of sports medicine, 40(12), 2720–2724. https://doi.org/10.1177/0363546512462124

8. Rompe, J. D., Segal, N. A., Cacchio, A., Furia, J. P., Morral, A., & Maffulli, N. (2009). Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. The American journal of sports medicine, 37(10), 1981–1990. https://doi.org/10.1177/0363546509334374 

9. Grimaldi, A., Mellor, R., Nasser, A., Vicenzino, B., & Hunter, D. J. (2024). Current and future advances in practice: tendinopathies of the hip. Rheumatology advances in practice, 8(2), rkae022. https://doi.org/10.1093/rap/rkae022

This blog was written by Samuel Bulten