Gluteal Tendinopathy
Tendinopathy: “Tendinopathy is the term given to the combination of pain and loss of function originating from tendon. It is a common clinical presentation and occurs in upper and lower limb tendons. Tendinopathy is typically associated with changes in tendon structure, but not all changes result in symptoms and a loss of function.”
Three phases of tendinopathy:
Reactive tendinopathy: The tendon responding to a rapid increase in loading. (In running this usually occurs in times where you have a sudden increase in mileage, reduction in rest days or a change in running type (speed/ hill training)
Tendon disrepair: This follows on reactive tendinopathy where the tendon are continuously exposed to excessive loading.
Degenerative Tendinopathy:It’s the response of the tendon with chronic overloading, usually in the older population, where the tendons’ structure had multiple changes and are less efficient at dealing with load.
Tendons is the anatomical part which connects muscle to bone. The main function of a tendon is to prevent injury by absorbing external forces by transmitting forces from muscle to bone. Tendon pain/ injury is mostly related to a sudden increase in load. For every person the amount of load differs, as it is specific to each tendons specific capacity. Injury occurs when the load exceeds the tendons capacity. Capacity is the tendons ability to withstand load without causing damage or dysfunction. There is three different types of loads that can cause tendon pathology:
Tensile: most common load that works on the “energy store and release” principle. I t occurs when two forces pull in opposite directions. ex. jumping, changing direction at high speed.
Compressive: Specifically where tendons pass bony protuberances- when the tendons are compressed against the bony prominences during specific movements. For ex. During hip adduction the gluteus medius and gluteus minimus compress agains the greater trochanter.
Combination loads (combination of shear and friction loads): Combination load happens when the tendon is required to follow the “energy store and release “ principle while it is compressing over a bony prominence at the same time. Ex. Pushing off with your ankle in dorsiflexion (achilles tendon compressing on calcaneus) while, at the same time, the tendon is required to spring the body forward (by storing and release energy).
Gluteal tendinopathy: Classified as non-inflammatory pain usually produced by gluteal medius and/ or gluteal minimus tendons presenting as a moderate to severe disabling pain on the lateral side of your hip- especially over the greater trochanter (palpable bone on the side of your leg).
(Gluteal tendinopathy usually affects the inactive population, but are also very common in athletes for ex. Runners. Women more susceptible, women to men ratio is 4:1.)
Gluteal tendinopathy, as mentioned above is an example of compressive load tendinopathy.
Management of Gluteal tendinopathy:
Load management strategies
Tendon load rehab
Load management strategies:
Avoid crossed leg sitting
Avoid sitting with hips flexed 90degrees and knees together.
Avoid standing with all your weight on one leg (hanging on 1 hip)
Adjust your sleeping position (put a pillow between your knees when sleeping on your side- to avoid placing your hip in adduction. Make sure your hips are in neutral or slight abduction.)
Avoid lying on affected side. (Lying on the affected side increase compressive load on the gluteal tendon.
Prevent stretching in a hip adduction position. (Added/ sustained compression on the gluteal tendon will only aggravate the pain.)
Stair climbing: make sure your pelvis (opposite hip) doesn’t drop while you are climbing stairs. If stair climbing is painful- do 1 step at a time with your pain-free leg first. (Focus on not placing feet in one line/ close or crossing midline)
Tendon rehabilitation:
Education regarding tedinopathies and importance of “active” rehab strategies. High tensile loads should slowly be introduced in sport and recreational activities to avoid a rapid increase in activity, to prevent pain aggravation.
Complete rest could be detrimental to the recovery and rehab process. Instead of completely stopping all activities, activity modification should take place. Activities consisting of high tensile and compressive loads should be avoided while specific eccentric and isometric strengthening exercises should be focussed on. Progressive tendon loading should form part of your rehab training to assist with matrix remodelling (promote tendon healing).
Running specific strategies:
Avoid or reduce running during reactive stage.
Reduce stride length and increase cadence.
Don’t run with feet close to midline/ crossing midline. (If your feet is close to midline- widen your base of support)
Run on flat roads, only re-introduce hill running after rehab, when the pain has subsided.
Avoid running around a track or where you have to regularly change direction.
Tendon rehabilitation exercise- phases:
Phase 1: Isometric contraction: (muscle contraction that is held for a specific time period, without changing length) 5x45sec with 2min rest between contractions.
Phase 2: Isotonic loading and strength endurance(once pain is under control). This phase should include functional strengthening and endurance training. Isotonic contraction: muscle changing length (shortens and lengthens) while maintaining the same tension. (2x per week )
Phase 3: Loading “energy storage and releasing” activities: exercises broken up into energy absorption and energy releasing (propulsion) phases. (2-3x per week )
Progressing through phases:
Start with phase 1 and if it is comfortable (not aggravating your pain, add phase 2 as well. Do phase 1 activities 2x per week and phase 2 activities 2-3x per week.
Ideally you would like to be completely pain-free and have an acceptable level of strength and strength endurance during phase 1 and 2 before progressing to phase 3.
Running can be incorporated with phase 2, but prevent aggravating factors such as high mileage, incline running or speed work.
Increase morning stiffness or pain the following day means the load was too much. Adapt according to your own tendons’ capacity.
NB to note: Pain will improve if load is correct. Pain will increase if load is too much. Pain will stay the same if load is too little.
"Every tendon is different. Every person is different. Every starting point is different. Every end point is different. You cannot standardise exercise in tendons"
Prof Jill Cook
References:
Ebert, J. R., Edwards, P. K., Fick, D. P., & Janes, G. C. (2017). A Systematic Review of Rehabilitation Exercises to Progressively Load the Gluteus Medius, Journal of Sport Rehabilitation, 26(5), 418-436. Retrieved May 5, 2020, from https://journals.humankinetics.com/view/journals/jsr/26/5/article-p418.xml
Hamstra-Wright, K. L., & Bliven, K. (2012). Effective Exercises for Targeting the Gluteus Medius, Journal of Sport Rehabilitation, 21(3), 296-300. Retrieved May 5, 2020, from https://journals.humankinetics.com/view/journals/jsr/21/3/article-p296.xml
Screen H, Cook J, Rio Ebonie and Lewis J. Tendon and Tendinopathy Activity completed. Chapter 10 In: Jull et al. Grieve’s Modern Musculoskeletal Physiotherapy. Elsevier, 2015.