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)
With the help of our advisors, ChiroUp is pleased to release our 96th protocol that details the current best practice management of gluteal tendinopathy. We thought that you might appreciate a quick summary of our top 10 tips, including video demonstrations of the most appropriate tests, treatments, and exercises.
1. 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. 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) Hypothetically, if excessive tensile load were the primary mechanical trigger, tears of the outermost fibers would predominate. While the deeper fibers carry the least tensile load, they are also exposed to the highest compressive loads at their bony insertion. (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. Clinical evaluation will demonstrate tenderness to palpation over the greater trochanter. Lack of tenderness over the greater trochanter suggests an alternate diagnosis. (23)
4. The following tests show high sensitivity & specificity (>90%) for gluteal tendinopathy.
5. 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.
6. ADL advice 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. “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:
8. 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)
9. Gluteus medius rehab might include a combination of the following:
10. 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).
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About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.