Gluteal tendinopathy: How do the treatment options compare?
Tuesday, May 07, 2019
What is it?
Gluteal tendinopathy is the most common cause of lateral hip pain. Until recently, the source of pain was thought to be an inflamed trochanteric bursa, but recent studies suggest a more likely cause is irritation of the gluteus medius/minimus muscle tendon.
Symptoms include pain at the outer hip that may radiate down the lateral leg. Pain is felt when lying on the affected side, when crossing legs, and when walking up or down stairs. The condition is far more prevalent in women (especially in the 40-60 age range) due to the wider pelvis and therefore greater angle at the hip joint resulting in higher compressive forces.
Treatment of this condition is usually conservative, using exercise rehabilitation to strengthen the hip abductor muscles as well as patient education to manage load through the area. If unsuccessful, a corticosteroid injection may be administered.
The BMJ recently published an article looking into the treatment of gluteal tendinopathy. You can see the full article here.
The research looked into the outcomes of three approaches to gluteal tendinopathy treatment: education and exercise; corticosteroid injection; and "wait and see."
The trial consisted of 204 individuals, each diagnosed with gluteal tendinopathy via MRI scan. Those with additional pathologies were ruled out. Participants were randomized into three groups, each to receive one of the treatment methods.
Those in the education and exercise group received 14 one-to-one sessions with a physiotherapist over eight weeks of treatment. Sessions included education on tendon care and load management. They also received a home exercise program consisting of four to six daily exercises aimed at strengthening the hip abductor muscles and to control dynamic adduction.
The corticosteroid group each received one injection under ultrasound guidance. The wait and see group attended one session with a physiotherapist, who explained the condition and offered advice and reassurance that the condition should resolve with time.
Outcome measures focused on a global rating of change score from very much better to very much worse and a pain intensity scale covering the previous week from 0, no pain, to 10. Measures were taken at baseline, 4, 8, 12, 26 and 52 weeks.
The results of the study are nicely summarized in the infographic below.
We can see that at both eight and 52 weeks post intervention, the education and exercise group demonstrated a significant improvement in the global rating of change compared to the injection and wait and see groups. The pain intensity levels were clearly lower in the education and exercise group at eight weeks, although this difference was no so clear at 52 weeks.
What are the clinical implications?
Whilst the education and exercise group demonstrated better results at eight weeks in both global rating of change and pain intensity scales, the difference in pain intensity after 52 weeks was not statistically significant between this group and those receiving the steroid injection.
Clinically, considerations should include confirmation of the diagnosis and additional pathologies. The participants in this study all had confirmed cases via MRI scan.
This is not always possible to obtain, and often clinical impression is the only form of “diagnosis.” In addition, those put forward for the study were ruled out if they were found to be suffering with additional pathologies, such as lower back pain or hip OA.
It is very unusual to find a client with an MRI diagnosis and no other pathologies in a clinic setting. All of this must be taken into account and of course alternative treatment techniques and rehabilitation plans may also be required, i.e., gluteal tendinopathy may not be the only focus of your plan!
In addition to this, there is no reason why both a corticosteroid injection and an education and exercise plan cannot be used in conjunction with one another. Whilst a short period of rest from any exercise may be required post injection, both treatment regimens can be used to get the best result for the patient.
Clinically, it is not one or the other, although research may have us believe that. Personally, I would like to see future studies looking into the use of both steroid injections and physical therapy, against both treatment options individually, and a control group.
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