The Glutes have enjoyed much of the limelight in running articles in recent years. Indeed our most popular post remains our discussion of glutes exercises. While the glutes certainly have a role in injury treatment and prevention they can also be a source of symptoms in their own right. This article examines one such problem – Gluteal Tendinopathy (GT).
This piece is based on excellent work by Dr Alison Grimaldi who has a free PhysioEdge Podcast on the topic as well as great published work she has kindly made available on her website. Alison was also very helpful on Twitter and discussed some of the issues surrounding this condition – some of her comments from this discussion have been used to inform this article. The full discussion can be found here and you can follow Alison via @AlisonGrimaldi. Her work has been combined with studies from Angie Fearon and seminal tendinopathy research from Jill Cook and Craig Purdam.
If you're a Physio and you'd like to find out more I recommend Alison's new online course and 1 day practical – Tendinopathies of the Hip and Pelvis (online component can be done as a stand alone course for those unable to attend the practical)
Signs, symptoms and pathology
GT typically presents as pain over the greater trochanter (the bony lump felt at the side of your hip). symptoms may spread into the outside of the thigh and knee. It is commonly misdiagnosed as hip joint pathology,ITBS, sciatica or as being referred from the lumbar spine. GT is a good example of how clinical knowledge has progressed in recent years. Initially it was thought of as inflammation of the trochanteric bursa – a fluid filled sac that sits over the trochanter. However as research developed we realised 2 rather important things. The bursa may not be the issue and there isn't really any inflammation. Later the condition was termed Greater Trochanteric Pain Syndrome (GTPS) but further research has enabled us to be more specific with the diagnosis. Bird et al. (2001) examined MRI findings of patients with GTPS, they found that nearly all patients had evidence of Gluteus Medius Tendinopathy. Swelling of the bursa was present in just 8% of cases and did not occur in the absence of gluteal tendinopathy.
The primary pathology of Gluteal Tendinopathy is most likely an insertional tendinopathy of the Gluteus Medius and/ or Gluteus Minimus tendons and enlargement of the associated bursa.
Picture from Williams and Cohen (2009) freely available online here.
Most recent theory suggests that this tendon is compressed by the Iliotibial Band (ITB) when the hip is adducted (which happens when the leg moves in towards the other leg). This compression can be increased if combined with flexion or external rotation of the hip. Recent work by Cook and Purdam (2012) has highlighted the role compression has in tendinopathy.
Tendon structure is well suited to manage tension – it has 'viscoelastic' properties which allow it to work like a complex spring to deal with load. It can manage some compression too – areas of the tendon that are prone to compression develop a slightly different structure that is similar to cartilage found in joints – however it's fair to say it that generally tolerates tension better than compression. Perhaps the biggest issue for tendons is when both types of load are combined and the tendon is under both compressive and tensile load simultaneously. If this excessive load continues the tendon reacts by swelling to 'stress shield' the tendon. However this increase in tendon size can lead to more compression and usually results in pain. If this overload continues in the long term the tendon structure starts to suffer leading to tendon dysrepair and eventually degeneration. In the case of some tendons, including the gluteal tendons, this can lead to tendon rupture.
Gluteus Medius and Minimus anatomy, reproduced from Gottschalk et al. (1989) freely available online here.
How does this relate to GT?
The key variable appears to be hip adduction. The hip can be adducted by moving the leg across the midline and if the pelvis on the opposite side drops during weight-bearing activity. This means the hip is adducted relative to the pelvis (see pic below reproduced from Bolga 2005). If this hip is flexed as well as adducted this can add to the aggravation. So If you have GT it's likely that your symptoms will include pain with crossing your legs and with climbing stairs or hills, even just with single leg balance if your pelvic control is poor. Each case is different though and in milder cases these may be fairly pain free. For runners it's likely to painful during the impact phase of running when your foot strikes the floor and your body weight moves over the foot. If movement control is poor you may find your hip adducts slightly during this phase. This combines both tensile and compressive load and is likely to cause pain in GT. Running on a camber (such as on the side of the road) can exaggerate this hip adduction and aggravate symptoms further, in some cases even walking on a camber will also be painful. Gluteal Tendinopathy is more common in women than men and is common in post menopausal women. Fearon et al. (2012a) found an association between 'adiposity' and GT in women and found 'lower neck shaft angle' was a risk factor. Leg length discrepancy and spinal scoliosis have also been associated with GT.
One other key characteristic with GMT is pain in sidelying. Unfortunately it can be painful on either side making sleep very difficult. The issue is if you lie on your painful side there is likely to be some direct compression of the gluteal tendons. If you lie on your good side the bad leg is upper most and often falls into adduction and flexion. Considering we spend some hours sleeping this can be a significant source of aggravation for the tendon.
While hip adduction is a key factor but I don't want to demonise it too much! Hip adduction is a normal movement, sleeping on your side is fine in a normal situation. The issue is when the tendon has reacted to load and swollen it can be sensitive to even relatively small amounts of compression leading to pain. If we keep aggravating this tendon in compressive positions it's unlikely to settle.
Is it Gluteal Tendinopathy?
Diagnosing GT is not straight forward – the hip is a complex area and there are a host of other potential diagnoses. In addition GT is often seen alongside other hip pathologies and can present with low back pain. Tortaloni et al. (2002) found that 20% of those referred to a spine specialist had GT.
If you have persistent pain in the hip region see a medical professional for assessment, diagnosis and treatment.
It is possible for several conditions to present at once but generally GT wouldn't present with pain down the entire leg as far as the ankle or pins and needles/ numbness. It may present with back pain but the main core of the pain will usually be over the greater trochanter in GT. This is a key part of the diagnosis. Aggravating movements are more likely to be related to hip movements, especially ones involving adduction as detailed above. If your pain is more centred around the lower back or is aggravated more by back movements it is less likely to be GT.
Osteoarthritis of the hip and GT can easily be confused, and may present with pain in similar areas. Typically OA of the hip may be more likely to include groin pain and restricted movement of the hip joint but if diagnosis is unclear an X-ray may be indicated to help rule out OA. It is also possible for these 2 conditions to co-exist. Fearon et al. (2012b) compared Greater Trochanteric Pain Syndrome (GTPS – another term for GT – to avoid confusion we'll stick with the abbreviation of GT) and hip OA, they found a trend for GT patients to be younger (on average 53.8 years old for GT and 62 for OA). That said they found just 2 key factors that were significant in differentiating between OA and GT; the ability to manage socks and shoes and the FABER test (detailed below).
So if you have pain over the greater trochanter but have no difficulty managing socks and shoes with a positive FABER test it's significantly more likely that you have Gluteal Tendinopathy than OA of the hip.
Your Physio or GP will assess the area and do a number of tests. Within these are a few key tests to assist diagnosis. Alison Grimaldi describes 2 tests for GT – 1) combining hip adduction, 90° flexion and external rotation and 2) a modified 'Ober's test' which involves adducting the hip in sidelying. Both are likely to cause compression of the gluteal tendons. These tests can be modified by palpating the tendon in this position or resisting internal rotation of the hip to work glute med. These additions can be used to further confirm diagnosis of GT if the initial test is only mildly painful. The work of Angie Fearon (detailed above) would also suggest adding the FABER test to differentiate between OA and GT;
Staging the tendinopathy
Excellent work by Cook and Purdam (2009) has helped us understand different stages on tendinopathy and how to treat them. Broadly speaking we consider there to be 2 stages seen clinically – reactive (and early dyrepair) and degenerative (and late dysrepair). More here on staging of tendinopathy. I discussed staging of gluteal tendinopathy with Alison Grimaldi and she said it's easier to stage patellar and achilles tendinopathy as they have an inherently more simple structure and that load management is crucial at any stage in GT.
The reactive stage is usually an acute response to excessive load. If you've increased or changed your training and you have pain as a result this is more likely to be reactive, especially if you've had no issues before. Change in training might be longer distance, adding in hills or doing step aerobics all of which can lead to a combination of compressive and tensile load on the tendon cause a reactive response.
If you've had grumbly lateral hip pain for a while which has progressively worsened and you're an older athlete then it's more likely in a degenerate stage. However, given the complexity of gluteal tendinopathy it's hard to make this diagnosis without examination and appropriate imaging.
Reactive/ early dysrepair
Arguably the key treatment strategy in reactive tendinopathy is reducing load on the tendon to a level that stimulates recovery rather than symptom aggravation. Compression of the tendon or activities that require the tendon to behave like a spring (known as the stretch-shortening-cycle) are likely to aggravate a reactive tendon. Activities that combine both these loads are likely to be especially provocative…
…so what should you be careful with – the key factor is adduction of the hip (the movement where the leg moves in towards the midline, such as crossing your legs). If this is combined with flexion of the hip or a lateral tilt of the pelvis it can add to the compressive element. Any movements that increase tension on the ITB or structures that attach to it (such as TFL) are likely to increase compressive load.
The tables below show activities that can be modified to reduce load on the gluteal tendons. We rarely recommend avoiding activities altogether but rather 'pacing them' – this means modifying them or reducing them to a level the tendon can manage. If some movements are especially provocative you may choose to avoid them initially but this should only be a short term measure. Generally your guide is to see how activity affects your symptoms a) in bed at night and b) the following morning. Aim to find a level of activity that doesn't provoke symptoms at these times.
During the reactive stage of a tendinopathy the tendon swells, this can make it more vulnerable to compression and exacerbate the problem. By 'pacing' these activities the tendon is able to recover and gradually the swelling and pain will reduce. How quickly this happens depends on the severity of the tendinopathy, it's causes and how much you are able to reduce aggravation. In mild cases pain may reduce within the first 5-10 days but these problems can linger and tendon healing is generally slower than other tissues. In some cases it may take 3-4 months to settle.
Another consideration in the reactive stage is non steroidal anti-inflammatory drugs (NSAIDs). Although tendinopathy is not an inflammatory pathology NSAIDs are thought to help by reducing tendon swelling. Cook and Purdam (2009) recommend ibuprofen as an option as it's thought to help without having a negative impact on tendon healing.
Always discuss taking new medication with your GP or pharmacist, NSAIDs have a range of side-effects and are contraindicated in a number of conditions.
Isometric exercises are thought to be helpful in the reactive stage, however these need to be done correctly to avoid increasing tension on the ITB. An issue here is the TFL muscle, it can be over active in abduction activities. If when doing these exercises you work TFL rather than Gluteus Medius and Minimus you may well exacerbate the problem. It's also very important not to do these exercises with the hip adducted. There are a host of glutes exercises but some I would avoid for this condition – these include 'the clam' and 'pelvic drop' (detailed here in glute med exercises). It's important to progress to weightbearing but single leg activities (such as single leg balance and single knee dip) should not be started until you have adequate pelvic control. Alison Grimaldi discusses exercises in her PhysioEdge podcast – a good starting point is isometric hip abduction in side-lying (pictured below). This be achieved by lying on your good side with your painful hip supported on pillows so it rests in a neutral or slightly abducted position. Start by trying to lift some of the weight of your leg off the pillow and hold for 10. Progress to lifting the leg 1-2 cm off the pillow and holding. You should feel the muscle working just above and behind the greater trochanter rather than down the side of the leg. This isn't an easy exercise to get right, in fact many of the glutes exercises are easy to get wrong!…
The best advice is to see a Physio who can assess you and provide appropriate exercises and help you perfect the technique. They can then help progress your exercise into functional weightbearing positions and help identify other potential causes of GT.
Assessment and rehab of single leg balance - focus should be on maintaining a level pelvis without adducting the hip. Use support initially if needed. Aim for 10-15 seconds, repeat 5-10 times (stop if painful).
Running may need to be avoided or at least reduced during a reactive tendinopathy. This is the last thing you want as a runner but may be a necessity in early management of GT. The issue with tendinopathy is that if you continue to overload the tendon it can progress from a reactive tendon, to dysrepair and degeneration during which stages the tendon structure starts to change. Reactive changes are reversible but degeneration of the tendon generally isn't. That doesn't mean it can't be managed it's just better to prevent it happening in the first place!
In mild cases you may continue to run but try to ensure running remains pain free and there is no reaction for at least 24 hours after. Your Physio should guide you on continuing to run and/ or returning to running after rehab. In achilles tendinopathy Silbernagel (2007) demonstrated that continuing to run didn't have a negative impact on recovery as long as runners didn't allow pain to increase above 5 out of 10 (where 0 is no pain and 10 is the worst possible pain) and symptoms had settled by the next morning. The study included only achilles tendinopathy, and only people who had symptoms for at least 2 months so I would urge caution in applying it to GT. Any return to running should be gradual and avoid hill work and speed work initially.
Priscah Jeptoo's running style shows right hip adduction on foot strike
Late dysrepair/ Degeneration
Many of the principles of treatment remain the same during the dysrepair/ degeneration phase – load still needs to be modified by reducing hip adduction and ITB tension and pacing of aggravating activities remains useful. However NSAIDs are no longer likely to be effective and exercises can be progressed and may include heavy loading or eccentric work (but only if adequate control is achieved). These exercises should be provided and demonstrated by a Physio to ensure the deep gluteal muscles are working rather than superficial muscles such as TFL.
The mainstay of managing gluteal tendinopathy regardless of stage is reducing load on the tendon and improving control of hip and pelvic movement. Other treatments may be added to this as long as they assist this process.
Other treatment options
Don't stretch your glutes or ITB. This is vital as it will increase tendon compression. There is some debate on the benefit of stretching and whether is can achieve tissue length changes. The safest choice for GT is not to stretch. If your ITB or TFL feel tight or have 'trigger points' gentle self massage may be helpful. You can try using the foam roller but only if you do so without adducting your hip and it doesn't aggravate your symptoms. There is no direct evidence I'm aware of showing that using a foam roller will help GT but it does have the potential to aggravate it. Direct tendon compression from the roller will aggravate and the action of the roller can cause a 'bowstring effect' increasing muscle tension. It might be best avoided or used very sparingly.
I have used a kinesio taping technique for this condition that seems to help in the clinical setting however I'm not aware of a single piece of research that's examined the use of taping in GT so recommending it is in no way evidence based! The technique is described below. The aim is to provide some extra lateral pelvic stability, whether a tape can really achieve this is certainly debatable but it does seem to achieve one thing very well…it stops people crossing their legs! The tightness of the tape on the outside of the the thigh makes adduction difficult and if nothing else works as a little reminder to stop people spending prolonged periods in an adducted position. It's not research based and I would opt for activity modification first and foremost but taping is something I'd file under might be worth a try. If it's uncomfortable or aggravates your symptoms then remove it.
Closing thoughts: Gluteal Tendinopathy is a complex condition but one that can be treated with management of tendon loading and rehab of movement control. Alison Grimaldi's research has raised important questions about how we work the gluteal muscles. While EMG studies have been helpful in this area they may only identify how to work superficial muscles and not how to normalise muscle function in a condition like GT.
If you have Gluteal Tendinopathy I recommend seeing a Physio or health care professional for detailed assessment and advice, especially on exercise selection. As ever on RunningPhysio, if in doubt get checked out!
Grimaldi (2011) – a detailed discussion of lateral stability of the hip and pelvis
Reiman et al. (2012) – systematic review of EMG studies of Gluteus Medius and Maximus – discussed on RunningPhysio here. It should be noted that many of these exercises would not be appropriate for Gluteal Tendinopathy either due to excess hip adduction or tendency to recruit more superficial muscles.