Two Hip Pain Mistakes All Chiropractors Must Avoid

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“Gluteal tendinopathy is one of the most common lower limb tendinopathies presenting to general practice, affecting approximately 10%–25% of the population.” - BMJ Open April 2021

A recent BMJ study (59) compared three different gluteal tendinopathy management strategies to define clinical outcomes for each.

% Reporting moderate  - very much improvement

🙁  Wait and see: 52%

🙁  Ultrasound-guided corticosteroid injection: 58%

😄  Education plus exercise: 78%

Problems

An April 2021 follow-up study by the BMJ authors revealed an even more telling story. Patients felt disappointed and disenfranchised when they did not receive two things:

1. Definitive Diagnosis

BMJ: “Participants emphasized the importance of having been provided a definitive diagnosis after being clinical examined. [One representative patient statement was]: ‘It was really quite a relief to see, that, yes, there is something wrong with it and I’m not just, making it up’ “ (58)

2. Appropriate Active Care

BMJ: “Participants almost always felt disenfranchised, disappointed or frustrated by being allocated to a wait-and-see approach rather than education plus exercise… [patient statements included] ‘I would rather feel like something was being done, rather than sort of, sitting back and feeling like nothing was being done,’ and ‘hoping I would be in a more proactive group.’ “(58)

Solutions

What Can We Learn?

While this study focused on gluteal tendinopathy, evidence-based chiropractors can apply two lessons to almost any MSK management:

1. Provide a Definitive Diagnosis

An educated patient is an empowered patient (who is also much more likely to comply with your care plan). Ensure that your report of findings consistently delivers clear answers to:

• What’s wrong with me?

• What can you do to help?

• How long will this take?

2. Deliver Appropriate Active Care

Lesson two is that patients want to play an active role in their recovery. So, ensure that you’re providing appropriate recommendations for their often unspoken question:

• What will I need to do?

Oh, and one more thing I almost missed—don’t forget that people forget stuff. Patients rarely remember everything you tell them about their exercises, what activities they’re supposed to avoid, how many treatments will be necessary, or even their diagnosis. So, stay a step ahead by consistently providing a written outline of these compliance, satisfaction, and outcome killers.

There’s a Vast Difference Between Treating Someone and Consistently Applying Best Practices

The foundation of appropriate care is staying up-to-date with the best practice assessment and management for each condition. Fortunately, you’ve got a clinical partner who can help with that. We hope you’ll enjoy this updated version of our Top 10 Tips for Hips: Assessment & Management of Gluteal Tendinopathy

Clinical Question

A post-40-year old female presents with insidious-onset, persistent lateral hip pain that extends slightly into the buttock and upper lateral thigh. Symptoms are exacerbated by walking, climbing stairs or hills, standing on one leg to dress, and following prolonged sitting. Nighttime pain interferes with sleep. What is your most likely diagnosis?

Answer: Tendinopathy involving the gluteus medius or gluteus minimus is the most common cause of lateral hip pain. (1, 2) Gluteal tendon tears have been dubbed “rotator cuff tears of the hip” because of their similar prevalence, anatomy, etiology, and management. (3-5)

Here’s a quick summary of our top 10 tips for gluteal tendinopathy, including video demonstrations of the most appropriate tests, treatments, and exercises.

1. It’s Not Bursitis

While the greater trochanteric bursa was once a focal point for lateral hip pain, current thought deemphasizes the concept of “bursitis.”  Evidence now suggests that true “bursitis” is rare, and if present, generally occurs secondary to another underlying dysfunction, like gluteal tendinopathy. (6, 7)

2. Compression/Ischemia

Gluteal tendinopathy (GT) develops from a combination of excessive tension or compression. (12) Similar to rotator cuff tendinopathy, the primary trigger for gluteus medius tendinopathy seems to be compression of the undersurface of the tendon – as most tears begin in this region.  (12) Long-term compressive loads lead to a predictable continuum of ischemia, failed healing, matrix degradation, diminished load-bearing capacity, and failure. (12, 13)

3. Palpation

Clinical evaluation will demonstrate tenderness to palpation over the greater trochanter.  Lack of tenderness over the greater trochanter suggests an alternate diagnosis. (23)

4. Orthopedic Assessment

The following tests show high sensitivity & specificity (>90%) for gluteal tendinopathy.

Hip Lag Sign

Single Leg-Stance Test

Resisted External De-Rotation Test

5. Predisposing Functional Deficits

Patients with gluteal tendinopathy may demonstrate frontal plane movement imbalances. (6, 29) Hip abductor weakness is the most common muscle imbalance disorder in GT patients.  Functional orthopedic testing for hip abductor weakness would include the Trendelenburg sign, overhead squat test, and single-leg squat test. 

Hip Abductor Weakness Cluster

6. ADL Advice

ADL recommendations should include advising patients to:

• Avoid “hanging on one hip” and sitting or standing with their knees crossed.

• Avoid prolonged periods of sitting, particularly on low-height seats.

• Keep their knees spread (like sitting on a horse) to ease the tension when transitioning in and out of a chair.

• Avoid side-lying sleep postures, as this triggers ipsilateral bed-side compression and contralateral traction-induced compression from thigh adduction. Placing a pillow between the knees can minimize excessive adduction traction. 

• Sleep in a ¾ prone position or use a memory foam or egg-shell mattress toppers to reduce bed-side compression.

• When walking, patients should land softly on the front of their heels and take shorter, quicker steps to avoid “over-striding.”

7. Isometric “Analgesics”

“Sustained, low-intensity isometric contractions may provide analgesic benefit for tendinopathy patients.” (38, 39) While there is no standard isometric exercise protocol for gluteal tendinopathy, a patellar tendinopathy protocol has demonstrated high success by performing four, 45-second contractions held at 70% maximum (MVC), repeated multiple times per day. (40, 41) Here’s an isometric option for the gluteal muscles:

Isometric Gluteal Contractions

8. Eccentric Rehab

Once the patient can tolerate isometric tensile loading, they may progress to eccentric exercises with low repetitions of moderate effort. (34) Clinicians may use “change in nighttime pain” as a gauge for advancing or retreating exercise intensity. (34)

Seated Clam

Glute Bridge with Band

Standing 3-Point Tap

9. Hip Abductor Strengthening

Gluteus medius rehab might include a combination of the following:

10. Modalities & Manual Therapy

As with other degenerative tendinopathies, clinicians should employ treatments that initiate a controlled inflammatory response and trigger healing, including IASTM, therapeutic taping, soft tissue manipulation, myofascial release, dry needling, and extracorporeal shockwave therapy (ESWT).

ChiroUp subscribers can access the complete Gluteal Tendinopathy protocol (and tutorial videos) anytime in the My Clinical Skills tab in your ChiroUp account.

Are you ready to implement these tips into your treatment and patient education? Consider ChiroUp your “easy button” to do just that. Now, with 100+ condition protocols & seamless patient education for each of our conditions, improving your clinical outcomes is just a click away.

See for yourself what all the hype is about & get started with your free ChiroUp trial, today!

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