Gluteal Tendinopathy
What is it?
Gluteal Tendinopathies were previously often referred to as trochanteric bursitis, which is inflammation of a fluid filled sac that sits over the trochanter. After research has been developing, it was brought to attention that the bursa may not be the issue and there may not be any inflammation. In an article by Bird et al. (2001), they examined MRI results of patients with Greater Trochanteric Pain Syndrome and found that nearly all patients had evidence of Glut Med Tendinopathy. Swelling of the bursa was present in only 8% of the patients and did not occur in the absence of gluteal tendinopathy.
The primary pathology of Gluteal Tendinopathy appears to be an insertional tendinopathy of the Gluteus Medius and/or Gluteus Minimus tendons and enlargement of the associated bursa.
The most common cause of glut med tendinopathy is due to poor hip and gluteal muscle control, which can lead to overstressing the gluteal tendons causing pain and hip-pelvis instability. If these issues are not addressed it can lead to continued instability causing you to walk or run with poor control, which causes friction loading into your hip bursa. This is when it is often diagnosed as trochanteric bursitis.
The most common cause of glut med tendinopathy is due to poor hip and gluteal muscle control #performbetter @pogophysio Click To TweetSigns and symptoms
Individuals with Glut med tendinopathy commonly present with pain over the greater trochanter (the big hip bone felt on your side), with symptoms spreading to the lateral thigh, knee and buttock and sometimes into the groin. It usually causes lateral hip pain, muscular stiffness and loss of strength in the hip muscles.
The following are common signs and symptoms:
- Pain may be worse when overloading or using the tendons for example, running and hopping.
- Hip pain and stiffness is worse during the night or when you get up first thing in the morning.
- Pain is worse when lying on the affected hip or side-lying, but can also be painful when lying on the non-affected side as the upper leg is adducting and causing compression.
- The outside of the hip may be tender to touch, red, warm or even swollen if there is inflammation within the hip bursa.
- Pain with crossing your legs, climbing stairs or hills.
- Pain trying to balance or stand on one leg, as your pelvic control may be lacking increasing tension through your ITB and increasing compression.
- Standing in a ‘hip hanging’ position leading to hip adduction causes discomfort.
- Sitting in low chairs as the hip is at an increased flexed position that increases tension on the fascia lata and ITB increasing compression, which can also lead to pain on rising from sitting.
Predisposing factors
- Gluteal tendinopathy is more common in women than men and more common in postmenopausal women. In an article by Fearon et al. (2012), they found an association between adiposity and gluteal tendinopathy in women and found that the lower neck shaft angle was a risk factor.
- Leg length discrepancy and spinal scoliosis with significant pelvic obliquity have also been associated with Glut med tendinopathy.
- Runners who run on a track or camber as this causes one leg to be always slightly adducted.
- Hormonal factors can also be a predisposing factor for example higher amounts of estrogen can affect the collagen fibres, increasing elasticity.
- Poor posture and movement patterns can lead to gluteal tendinopathies as there are potential changes in recruitment patterns or length tension relationships and can become less efficient at working in their inner range causing changes in movement patterns. This may then cause lateral shifting and lateral tilting of the superficial abductors (ie glut max and tensor fascia lata) leading to further compression.
Stages
There are two main stages of tendinopathy clinically seen through research from Cook and Purdam (2009). The two stages are known as reactive (and early dysrepair- failed healing) and degenerative (and late dysrepair).
The reactive stage is typically an acute response to excessive load when you usually have no issues before. For example if you have had an increase or change in training load leading to pain which is highly likely to be reactive tendinopathy. Cook and Purdam (2009) describe the reactive stage as “A short term adaptation to overload that thickens the tendon, reduces stress and increases stiffness”. The change in training may be longer distances, sprint work, adding hills or even incorporating step aerobic classes into your routine as these all lead to a combination of compressive and tensile load onto the gluteal tendons causing that reactive response. The good news is that since the tendon is structurally intact and there is minimal change to collagen integrity, this process is reversible with an emphasis on load management.
The degenerative stage is often seen in the older population, as it is a response of chronic overloading through the tendon. It is often associated with multiple tendon structure changes making it less efficient at managing load. In the degenerative stage, connective tissue becomes disorganized and can break down causing more increases in vascularity and neuronal ingrowth. The tendon can present as thickened and nodular, possibly leading to a risk of tendon rupture and advanced degeneration. Seeing as there are gluteal tendinopathies are quite complex, it is always best to have a thorough examination and appropriate imaging to confirm if you are in the degenerative stage.
Treatment
Understanding and being educated about gluteal tendinopathies are a huge part of the treatment process as it is important to understand what is going on and what factors are contributing to the overloading and compression causing the pain. Knowing what causes your symptoms will help tremendously as you can specifically focus on changing those factors. If certain daily habits can be addressed and corrected it can go a long way in preventing any recurrences in the future.
It is very important to know which stage you are in because this will affect how you are managed. In the reactive stage load management is crucial. It is necessary to reduce both tensile and compressive load on the tendons. As tendons connect muscle to bone they are placed under a great deal of tension during activities when the muscle is contracting or resisting stretching forces, therefore load needs to be managed. Your local physiotherapist can go over load tolerance and isometric exercises to help you out of that reactive stage and back to doing the activities you love.
When pain arises in the degenerative stage, a combination of load management, anti-inflammatories, eccentric work, isometric and strength exercises are likely to help. Due to the degenerative nature of the tendons some changes may be reversible, but it is reasonable to say that this type of gluteal tendinopathy will need to be managed in the long term.
As gluteal tendinopathy is a complex condition is important to see a healthcare professional or physiotherapist who can perform a detailed examination and guide you on the right path to address load management and rehab movement control.
Just remember that gluteal tendinopathies can be managed and it will get better!
Natasha Chan (APAM)
Physiotherapist
References:
Brukner, P. and Khan, K. (2007). Clinical Sports Medicine (3rd ed.) McGraw-Hill, Sydney.
Cook, J L and C R Purdam. “Is Tendon Pathology A Continuum? A Pathology Model To Explain The Clinical Presentation Of Load-Induced Tendinopathy”. British Journal of Sports Medicine 43.6 (2008): 409-416. Web. 12 Oct. 2016.
David Pope,. “PE #009 Lateral Hip Pain With Dr Alison Grimaldi”. N.p., 2016. Web. 4 Oct. 2016.
Goom, Tom. “Tendinopathy – The Importance Of Staging And Role Of Compression”.RunningPhysio. N.p., 2013. Web. 12 Oct. 2016.
Goom, Tom. “Gluteal Tendinopathy”. RunningPhysio. N.p., 2013. Web. 12 Oct. 2016.
“Lateral Hip Pain: Mechanisms And Management | Dr Alison Grimaldi”.Dralisongrimaldi.com. N.p., 2016. Web. 11 Oct. 2016.
