Physical Therapy for Gluteal Tendinopathy
Gluteal tendinopathy involves inflammation and degeneration of the gluteal tendon due to overuse and excessive loading of the tendon, causing severe lateral hip pain. The gluteus medius muscle and tendon help move the hip out to the side, rotate the hip outwards, and play a major role in stabilizing the pelvis during walking and running. The key to tendon healing is appropriate, gradual loading to restore tendon strength and resilience to stressors. Physical therapy can decrease gluteal tendinopathy pain, appropriately load and strengthen the gluteal tendon, and improve the individual’s function and mobility through a progressive gluteal strengthening exercise program.
Gluteal Tendon Anatomy
One of three gluteal muscles, the gluteus medius is a fan-shaped muscle located on the side of the hip, originating from the side of the pelvis with the gluteal tendon attaching to the top of the thigh bone (at the greater trochanter of the femur). The gluteus medius helps move the hip out to the side, rotates the hip outwards, and plays a major role in stabilizing the pelvis during walking and running. The gluteus medius muscle is the hardest working muscle when running, absorbing 2.6 to 3.5 times your body weight. The gluteal tendon of the gluteus medius muscle is a tough fibrous structure that transmits force from the muscle to the femur bone.
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What is Gluteal Tendinopathy?
Gluteal tendinopathy involves inflammation and degeneration of the gluteal tendon due to overuse and excessive loading of the tendon, causing severe lateral hip pain. Gluteal tendinopathy can occur in athletes who participate in sports that involves a lot of jumping that places stress on the tendon, such as basketball, volleyball, tennis, and running. It is also more prevalent in women than men, particularly in women over the age of 40 who have experienced menopause. There also appears to be a correlation between low back pain and gluteal tendinopathy as up to 1 in 3 of those with low back pain develop gluteal tendinopathy. Gluteal tendinopathy typically occurs slowly over time due to increased loading and subsequent overloading of the tendon from overuse and insufficient recovery time.
Common causes of gluteal tendinopathy include:
Placing too much force on the gluteal tendons during exercise, often due to repetitive overuse such as when running long-distance
Tendon compression due to a fall
Excess pressure on tendons from weight gain or obesity
Menopause, which affects the body’s ability to repair muscle after exercise
Wide pelvis or hip instability
Inactivity or sedentary lifestyle, leading to underuse of and weakness in the gluteal tendon such that it cannot withstand the demands of everyday activities
There are three stages of gluteal tendinopathy:
Reactive stage: During this initial stage, the tendon begins to change shape and becomes thicker due to chemical and structural changes in the tendon from overuse, causing inflammation in the tendon.
Disrepair stage: At this stage, the tendon thickens in response to overuse, causing tendon fibers to become disorganized, leaving the tendon with a reduced capacity to cope with the force from muscle contractions.
Degenerative stage: Long-term overloading over time leads to the tendon entering the degenerative phase. At this point, further disorganization of the collagen fibers of the tendons occurs, causing possible death of tendon cells. Changes to the tendon at this stage are irreversible and the tendon is significantly less tolerant to load. The individual may experience severe pain.
Symptoms of gluteal tendinopathy include moderate to severe hip pain, particularly behind the outside edge of the hip. Pain can extend down the outside of the leg to the knee and lower leg. Pain can worsen when climbing stairs, lying on the affected side, sitting cross-legged, or standing on one leg.
Physical Therapy for Gluteal Tendinopathy
Physical therapy can decrease gluteal tendinopathy pain, appropriately load and strengthen the gluteal tendon, and improve the individual’s function and mobility. The key to tendon healing is appropriate, gradual loading to restore tendon strength and resilience to stressors. Research has found that a progressive strengthening program targeting the lateral hip muscles is effective in treating gluteal tendinopathy. One study found that strengthening exercises help to promote tendon fiber growth and healing of the tendon. Another study noted that 70% of people with gluteal tendinopathy saw significant improvements within 8 weeks of physical therapy exercise.
Complete rest is not the answer to gluteal tendinopathy. Maintaining some level of activity that is within the load tolerance of the tendon is important for gluteal tendon healing. Physical therapists help patients avoid aggravating activities and movements and work with them to implement gentle loading activities to maintain fitness, such as stationary cycling or aquatic exercise. The therapist also provides education on positions to avoid in order to reduce the compressive load on the tendon: avoid standing or sitting with legs crossed; at night, sleep on your back with a pillow beneath the leg or if side-lying, place a pillow between the knees. Avoid hip adduction stretching that can further aggravate the tendon.
Targeted strengthening exercise therapy is essential and typically involves gradual progressive loading exercises to improve the tendon’s load-bearing capacity and restore tendon strength and resilience to stressors. Th therapist begins with isometric muscle contractions, which involves tensing the gluteal muscles without actually moving the leg. This allows for gentle loading of the tendon without aggravation to decrease pain. A common exercise is a side-leg lift using a cushion, beginning with a short hold and low load (10 second hold with the weight of the leg) and then moving on to longer holds and heavier loads (30 seconds with weight).
The therapist then progresses the strengthening exercises to low-velocity, high-tensile load isotonic exercises. This can start with side-leg lifts (raising the leg up and down to the side) and then progress to squats, bridges, and leg presses. These exercises are done three times per week to allow for tendon recovery and adaptation. The load on the tendon is increased slowly and the patient’s response is monitored in order to maximize structural changes in the gluteal muscle and tendon while avoiding pain exacerbation.
The last step of exercise therapy for gluteal tendinopathy is movement retraining and functional loading. As pain eases and the tendon is able to bear heavier loads, it’s important to progress the patient to engaging in activities that require controlled hip adduction and use of the gluteal tendon under higher loads, at faster speeds, and during complex actions like running, landing, and changes of direction.
Are you experiencing gluteal tendinopathy and severe hip pain? Work with a physical therapist to manage pain and restore function and mobility!
