Gluteal tendinopathy, previously thought of as trochanteric bursitis and now more commonly known as lateral hip pain or greater trochanteric pain syndrome (GTPS).
GTPS has become more prevalent recently and there is a lot of new research being published on the subject by Dr Alison Grimaldi in Australia. Many different factors affect tendinopathy but GTPS is most commonly seen in peri-post-menopausal women (23.5% of post menopausal women will be affected), there are also links with a greater hip/width ratio, acetabular anteversion, fluoroquinolones (certain type of antibiotics), and increased BMI. Women have also been shown to have a lower femoral neck/shaft angle and increased adduction and internal rotation forces on stance phase of gait. It is also prevalent as a secondary complication when another pathology exists, such as osteoarthritis, hip dysplasia, hip impingement, and lower back pain.
Presentation:
GTPS typically presents as chronic, persistent pain in the lateral hip and/or buttock. is exacerbated by palpation of the greater trochanter (GT), lying on the affected side, single leg standing or prolonged standing, hip hinging, transitioning to a standing position (due to the knee rolling inwards causing a compression force over the greater trochanter), sitting with legs or feet crossed, and with climbing stairs, running or other high impact activities. Approximately, 50% of patients experience pain radiating along the lateral aspect of the thigh to the knee. Pain extending into to the groin or down the lateral thigh can mimic that of a lumbar disk herniation and may be reported in some individuals.
Pathomechanics underlying the development of gluteal tendinopathy are similar to those proposed for other tendinopathies: overloading or decreased/ unloading (stress-shielding), tensile load applied longitudinally along the tendon, excessive transverse load applied across the tendon (compression, mostly at or near the bony insertion- the GT), and most often a combination of these factors. It is thought that in gluteal tendinopathy the ilioteibial band and tensor fascia lata contribute significantly to compressive forces on the GT.
Diagnosis:
X-ray- To analyse bony anatomy
MRI- Identifies tendon pathology and the stage of tendinitis, and if there are any tears present. It can also identify associated muscle imbalance or other pathology present.
Clinical tests include:
Single leg stand-increased pain over greater trochanter
Tenderness on palpation of the greater trochanter (GT) (most sensitive test).
FADER/R- Flexion, adduction, external rotation and then you can resist internal rotation from this position (this compresses the tendons over the GT).
Add/R- Adduction of the leg and then resisted abduction from the adducted position.
Treatment:
The mainstay of treatment is conservative management and the majority of patients will improve with Physiotherapy.
Education and advice is key, highlighting the importance of decompression strategies, no crossing legs, sleeping on unaffected side and general reduction of any type of compression of the tendons onto the GT.
Pacing of activity- tendons need the correct amount of load, the key is to ensure patients are not entering a boom and bust cycle.
Exercise and load
isometric activation of gluteus medius (without TFL activity).
Gluteus medius strengthening in mid-inner range
Functional loading and ensuring gluteus medius activates to maintain pelvis alignment and then can maintain that during dynamic loading (such as walking).
Low velocity- high tensile load
Progressing to movement retraining.
Important points: No stretches of ITB or TFL or glutes as this will exacerbate symptoms. Reduce open chain exercises in initial stages as patients will tend to recruit the superficial muscles such as tensor fascia lata to abduct the hip, rather than gluteus medius and minimus.
If conservative management fails:
Shockwave therapy
Injections- PRP/steroid
Surgical z lengthening of tensor fascia lata to reduce the compression on the ITB and greater trochanter.
References:
Grimaldi, A., (2017) ' Gluteal Tendinopathy: new evidence with implications for clinical practice,' In Touch - APA Musculoskeletal Physiotherapy, 4, pp.16-19.