Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management

Abstract

Tendinopathy of the gluteus medius and gluteus minimus tendons is now recognized as a primary local source of lateral hip pain. The condition mostly occurs in mid-life both in athletes and in subjects who do not regularly exercise. Females are afflicted more than males. This condition interferes with sleep (side lying) and common weight-bearing tasks, which makes it a debilitating musculoskeletal condition with a significant impact. Mechanical loading drives the biological processes within a tendon and determines its structural form and load-bearing capacity. The combination of excessive compression and high tensile loads within tendons are thought to be most damaging. The available evidence suggests that joint position (particularly excessive hip adduction), together with muscle and bone elements, are key factors in gluteal tendinopathy. These factors provide a basis for a clinical reasoning process in the assessment and management of a patient presenting with localized lateral hip pain from gluteal tendinopathy. Currently, there is a lack of consensus as to which clinical examination tests provide best diagnostic utility. On the basis of the few diagnostic utility studies and the current understanding of the pathomechanics of gluteal tendinopathy, we propose that a battery of clinical tests utilizing a combination of provocative compressive and tensile loads is currently best practice in its assessment. Management of this condition commonly involves corticosteroid injection, exercise or shock wave therapy, with surgery reserved for recalcitrant cases. There is a dearth of evidence for any treatments, so the approach we recommend involves managing the load on the tendons through exercise and education on the underlying pathomechanics.

Conservative management of tendinopathies around hip

“…The management of tendinopathies is changing with the progression of the research and the growing evidences on this argument 39 . Currently, the treatment should include early functional treatments, rather than rest and immobilization 21 .…”

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

“…64 The most aggravating factors include active abduction of the hip, prolonged sitting, climbing stairs, and side-lying positions. 64,65 A recent systematic review and meta-analysis by Reiman et al deemed 4 clinical tests to be both valid and reliable for the diagnosis of gluteal tendinopathy: Trendelenburg sign, resisted hip abduction, resisted hip internal rotation, and the resisted hip external derotation tests (Video 2). 66 The most clinically reliable test was the external derotation test, with a specificity of 97.3%, sensitivity of 88%, positive likelihood of 32.6, and negative likelihood of 0.12.…”

A Systematic Review of Rehabilitation Exercises to Progressively Load the Gluteus Medius

“…However, it may still prove painful and/or detrimental in the earlier stages after gluteal tendon reconstruction surgery due to the relative hip flexion, adduction and internal rotation created by the body posture required, all positions which may increase compression over the greater trochanter (and subsequent repair site). 47,48 When combining all WB exercises evaluated in this review, single limb stance activities as expected increased muscular demand when compared with bilateral stance, though was further increased when WB on an unstable surface. 49 Furthermore, the addition of contralateral limb movement (hip flexion/extension or circumduction) increased demand again.…”