The Hip - Gluteal Tendinopathy

Gluteal tendinopathy, a common cause of lateral (outside) hip pain, occurs when the tendons that attach the gluteal muscles to the hip bone become irritated due to excessive or imbalanced loading. This condition is frequently observed in middle-aged women and individuals involved in repetitive activities like running or walking. Luckily, with a well-structured rehabilitation program your physiotherapist can help you recover. 

Anatomy 101 

Muscles attach to bone via tendons, a strong, relatively non-elastic material that is excellent at transferring the contraction force of a muscle into movement (or stability) across a joint. Under normal conditions, healthy tendon tissue responds to the cycle of overload and adequate rest by increasing its load capacity. 

In the gluteal region there are three primary muscles — gluteus maximus, gluteus medius, and gluteus minimus. The gluteus medius and gluteus minimus muscles play a critical role in hip and pelvis stability. They originate from the outer surface of the pelvis, and their tendons attach to the greater trochanter, the bony prominence on the side of the hip. When standing on one leg, these muscles ensure that your hip doesn’t drop down on the other side.

Who gets it? 

A relatively common condition, gluteal tendinopathy is estimated to affect between 10-25% of the population. Women aged 40-60 years of age are more frequently affected, with high levels of pain and dysfunction affecting physical activity and quality of life.

In individuals with variations in pelvic or femoral anatomy, such as a wide pelvis or increased femoral anteversion, the tendons may be subjected to higher mechanical loads, increasing the risk of tendinopathy.

Causes of Gluteal Tendinopathy 

Tendinopathy is referred to as an overuse injury, as the tendon has undergone pathological changes due to exposure to excessive load over time. When localised tendon cells are exposed to repeated tensile (stretching) and compressive forces beyond their capacity with inadequate recovery time, they start to break down, with gradual development of pain and dysfunction.

Tendinopathy can occur in any tendon, commonly the heel, knee, shoulder, elbow and hip. In the gluteal region, causes include:

• Repetitive overloading: High levels of repetitive activity, such as running, prolonged standing, or walking long distances, can strain the tendons.
• Compressive forces: Positions that press the tendon against the bone, such as lying on one side or crossing the legs, can exacerbate symptoms.
• Muscle weakness or poor activation: Insufficient strength or control of the gluteal muscles places additional stress on the tendons.
• Suboptimal biomechanics: Some movement patterns, such as excessive hip adduction during walking or running (Trendelenburg gait), can lead to overloading of the tendons.
• Systemic or metabolic factors: having diabetes or cardiovascular health problems, or being overweight can increase systemic inflammation and raise the risk profile for tendinopathy.

Symptoms of Gluteal Tendinopathy

Slow onset pain over the outside of the hip that gradually worsens over time is the main feature of gluteal tendinopathy. Patients will often report:

• Pain or tenderness on the outer hip, especially when standing on one leg, climbing stairs, or walking.
• Difficulty sleeping on the affected side due to pain.
• Increased discomfort after prolonged periods of activity or sitting with legs crossed.
• Tip: If you get pain when you manipulate socks and shoes (either on or off) then it is more likely that you have hip osteoarthritis than gluteal tendinopathy.

Diagnosing Gluteal Tendinopathy

Diagnosis is primarily clinical, with specific tests designed to provoke symptoms and assess functional limitations. Your physiotherapist will palpate the painful area and assess your movement and strength. There are some specific tests that are helpful including standing on one leg and putting your hip in certain positions. It is important to rule out problems like hip joint arthritis or low back problems which can refer pain to the outer hip.

Imaging, such as ultrasound or MRI, may be used in persistent cases to confirm the diagnosis or rule out other conditions, but it is not usually necessary.

Management and Treatment

Effective management of gluteal tendinopathy requires a wholistic approach addressing pain, range of motion, strength and load. 

1. Load Management.  Reducing provocative activities is essential to allow the tendon to recover. Your physio will help you modify activities like stair climbing, prolonged standing, or sitting in positions that compress the tendon. Importantly, complete rest is not advised, as tendons require a certain level of load to maintain their health.
2. Exercise Therapy. A progressive exercise program tailored to the individual is the cornerstone of treatment. Exercises must be tailored to the individual, incorporating isometric (static), concentric (shortening under load) and eccentric (lengthening under load). Graduated load exposure is essential to build the capacity of the tendon under a variety of conditions, with progression towards meaningful functional activities.
3. Optimizing Movement Patterns.  Correcting biomechanical issues can be helpful. Strategies may include changes to your gait (walking and running) such as widening your step width, increasing your cadence, or strengthening calf muscle power.

Incorporating functional movement patterns like single-leg step-ups, squats, lunges and lifting tasks helps prepare the tendons for daily demands.

What about an injection?

Corticosteroid injections (CSI) are not recommended as a first line treatment for gluteal tendinopathy. While studies indicate they can provide short term pain relief, they are less effective than a good quality exercise and education program in terms of both pain and function. Corticosteroids are harmful to tendon cells and reduce their capacity to heal, which may delay healing and prolong recovery. They should only be considered in recalcitrant cases and only when combined with a high-quality therapeutic exercise program that accounts for the detrimental effects on tendon cell health.

Recovery Timeframe

Recovery varies based on the severity of the condition and adherence to the rehabilitation program. Tendons adapt slowly, so a consistent, graded approach over several months is often required. Early intervention typically results in better outcomes.

The Take Home 

While Gluteal Tendinopathy can be challenging, many people successfully manage it with the right combination of treatment, load management, and lifestyle adjustments. GT requires a tailored program designed around the specific goals of the patient. Early assessment and diagnosis, careful planning around activity modification and therapeutic exercise, full recovery from GT is achievable.

Got lateral hip pain and want to get it sorted? Give us a call now.

At Movement for Life Physiotherapy, we can assess and diagnose the cause of your hip pain and let you know whether you have gluteal tendinopathy, hip joint osteoarthritis, or if there is something else going on. With a clear diagnosis and tailored management plan, we'll help get you back to the things you love sooner.

Call us now on 08 8945 3799 or click on BOOK AN APPOINTMENT to book online.

Sources

1. Allison, K., Hall, M., Hodges, et al. (2018). Gluteal tendinopathy and hip osteoarthritis: different pathologies, different hip biomechanics. Gait & Posture, 61, pp.459-465.
2. Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416.
3. Fearon, A.M., Scarvell, J.M., Neeman, et al. (2013). Greater trochanteric pain syndrome: defining the clinical syndrome. British journal of sports medicine, 47(10), pp.649-653.
4. Ganderton, C., et al. (2018). Gluteal tendinopathy: Clinical diagnosis, management, and pathophysiology. Journal of Orthopaedic & Sports Physical Therapy, 48(4), 239–249.
5. Grimaldi, A., & Fearon, A. (2015). Hip-related pain in adults—Clinical assessment and management. British Journal of Sports Medicine, 49(22), 1397–1404.
6. Grimaldi, A. (2023). Injections for hip pain: Options, benefits, and risks. Dr. Alison Grimaldi. https://dralisongrimaldi.com/blog/injections-for-hip-pain-options-benefits-risks/
7. 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
8. Rio, E., et al. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283.
9. Wilson, R., Abbott, J.H., Mellor, R., et al. (2023). Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial. Journal of Physiotherapy, 69(1), pp.35-41.