Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Abstract

Background: Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain. Purpose: To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy. Study Design: Systematic review; Level of evidence, 4. Methods: We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed. Results: A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation). Conclusion: There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

Gluteal Tendinopathy

“…Gluteal tendon degeneration has classically been described on a grade scale initially proposed by Bhabra et al, which uses histopathologic findings to determine the extent of damage incurred 38 . Later studies correlated these histopathologic changes to magnetic resonance imaging (MRI) findings to further describe how each grade appears on advanced imaging [39][40][41][42][43] . In grade 1 disease, the normal collagen fiber pattern increases in waviness, and the proportion of type 3 collagen rises; there are minimal or no associated changes on MRI compared with normal tendon.…”

“…Surgical intervention for gluteal tendinopathy/GTPS is generally reserved for cases refractory to the aforementioned nonoperative measures-particularly within the setting of high-grade partialthickness (grade 3) or full-thickness (grade 4) tendon tears 42 . Several casecontrol and cohort studies have described both open [86][87][88] and endoscopic [89][90][91][92] repair of partialthickness or full-thickness tendon tears.…”

Nearly half of patients with chronic tendinopathy may have a neuropathic pain component, with significant differences seen between different tendon sites: a prospective cohort of more than 300 patients

“…10 For patients who fail to improve with rehabilitation alone, many treatment options are available to treat different tendinopathies, with many of the same treatments being offered to tendon pathologies of different anatomical locations. [11][12][13] These different treatments may conceptually address nociceptive pain and/or functional impairments, although any molecular or structural effects of these interventions may remain unclear. 14 Depending on the tendon location, these treatments may include tension night splints (TNS), [15][16][17] guided injections-including high-volume image-guided injections (HVIGI) [18][19][20] or autologous blood injections (ABI), [21][22][23][24] extracorporeal shock wave therapy (ESWT) [25][26][27][28][29] or surgery in recalcitrant cases.…”

“…For patients who fail to improve with rehabilitation alone, many treatment options are available to treat different tendinopathies, with many of the same treatments being offered to tendon pathologies of different anatomical locations 11–13. These different treatments may conceptually address nociceptive pain and/or functional impairments, although any molecular or structural effects of these interventions may remain unclear 14.…”

The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

“…Greater trochanteric pain syndrome (GTPS) encompasses multiple diagnoses including external snapping hip, trochanteric bursitis and gluteus medius (GMed) and gluteus minimis (GMin) tendinopathy or tearing [ 1 , 2 ]. GTPS mainly affects women in their fourth to sixth decade of life, presenting with pain and tenderness in the lateral hip, which worsens with walking, stair climbing and/ or lying on the affected side [ 3 , 4 ]. While the symptoms associated with GTPS were previously thought to be a result of trochanteric bursitis, gluteal tendinopathy with or without bursitis has been identified as the primary source of pain and dysfunction [ 5–8 ].…”