Gluteal Tendinopathy

Degenerative overload tendinopathy of the gluteus medius and gluteus minimus tendons at their insertion on the greater trochanter, with partial or full thickness tears in a large share of long standing cases. It behaves like a rotator cuff disorder of the hip.

• It is the commonest structural cause of lateral hip pain. Pathology is collagen disorganisation and increased ground substance, with little true inflammation, so the label "bursitis" is often wrong. A bursa may be irritated secondarily.
• Prevalence is about 10 to 25% in adults over 50 years, and women are affected 3 to 4 times more often than men. Peak age is 40 to 60 years.
• Compressive load is the key mechanism: the iliotibial band presses the tendon against the trochanter when the hip is adducted. Triggers are lying on the affected side, standing with the weight on one leg, crossing the legs, sitting in low chairs, and running or stair climbing with a narrow step width.
• Risk factors: female sex, wide pelvis, obesity, hip and lumbar osteoarthritis, leg length discrepancy, gluteal weakness, diabetes, previous steroid injection, fluoroquinolone exposure, and menopause.
• Most patients improve over 6 to 12 months with loading exercise. About 20 to 30% have symptoms beyond a year.

• Lateral hip pain, aching or sharp, sometimes spreading down the lateral thigh toward the knee but rarely beyond it. Night pain when lying on the affected side is the commonest complaint, followed by pain on stairs, rising from a chair, walking and prolonged standing.
• Examination: focal tenderness over the greater trochanter, particularly the superoposterior facet. Pain on single leg stance held for 30 seconds is the most sensitive sign. Other signs: pain on resisted hip abduction, pain with resisted external derotation from a position of flexion and external rotation, a positive FABER test, and a Trendelenburg gait or sign when the tendon is torn.
• Hip internal rotation range is usually full and pain free, which separates it from hip joint disease.
• Differential diagnosis: hip osteoarthritis, femoroacetabular impingement, labral tear, lumbar radiculopathy (L4 or L5), referred pain from facet joints, sacroiliac dysfunction, piriformis syndrome, iliotibial band syndrome, femoral neck stress fracture, avascular necrosis, meralgia paraesthetica, inflammatory arthritis, septic bursitis, and metastasis.
• Red flags: fever, marked warmth, inability to bear weight, rest pain with weight loss, known cancer, and neurological deficit.
• Complications: tendon tear with persistent weakness and limp, chronic pain, sleep disturbance, and reduced mobility.

• Clinical. The cluster of lateral trochanteric tenderness, pain on single leg stance and pain on resisted abduction has a high diagnostic value.
• X-ray of the pelvis and hip for persistent pain, to show osteoarthritis, calcific deposits, fracture or tumour.
• Ultrasound shows tendon thickening, hypoechoic change, calcification, tears and bursal fluid, and guides injection. MRI is the best test for tendon tears, occult fracture, tumour and infection, and for refractory pain or before surgery.
• Check CRP, ESR and urate when inflammatory arthritis, gout or infection is possible. Examine the lumbar spine and the neurological status of the leg.

• Education and load management (first and most important step):
  • Avoid lying on the painful side. Sleep on the other side with a pillow between the knees, or on the back.
  • Avoid crossing the legs, standing with the hip hitched to one side, sinking into low soft chairs, and wide step sitting postures that adduct the hip. Use a cushion to raise seat height.
  • Reduce activities that provoke pain to a level of 4 out of 10 or less that settles within 24 hours. Complete rest is not advised.
  • Weight loss when overweight.
  • Avoid stretching the iliotibial band across the trochanter, which increases compressive load.
• Analgesia: paracetamol 1 g orally 6 hourly. Topical diclofenac 1% gel 2 to 4 g up to 4 times daily. Oral NSAIDs (ibuprofen 400 mg 8 hourly with food, or naproxen 500 mg 12 hourly) for 1 to 2 weeks if no contraindication, with gastroprotection in at risk patients.
• Exercise therapy, 3 times weekly for 12 weeks or longer:
  • Phase 1: isometric hip abduction holds in a neutral position (45 seconds, 4 to 5 repetitions), pelvic control and gluteal activation (bridging).
  • Phase 2: progressive abductor loading (side lying leg raise within a pain tolerable range, standing resisted abduction with a band, step ups, single leg squats to a limited depth), 3 sets of 10 to 15.
  • Phase 3: dynamic control, single leg balance and loaded gait drills, then graded return to running or sport.
  • Load based programmes with education give better long term outcomes than corticosteroid injection.
• Corticosteroid injection, for pain that prevents rehabilitation after 4 to 6 weeks: triamcinolone acetonide 40 mg or methylprednisolone acetate 40 mg with lidocaine 1% 4 to 5 mL, placed around the tendon insertion (not into the tendon) under ultrasound guidance. Relief usually lasts 2 to 12 weeks. Benefit is short lived and long term results are worse than exercise. Limit to 1 to 2 injections per year. Risks: tendon weakening or rupture, skin atrophy, depigmentation, infection, and a rise in glucose for 3 to 5 days in diabetes.
• Other options in persistent disease: platelet rich plasma (3 to 5 mL single or 2 injections, emerging evidence with possible advantage over steroid at 6 to 12 months), and extracorporeal shock wave therapy (3 to 5 weekly sessions).
• Surgery after 6 to 12 months of failed treatment, or for a symptomatic full thickness tear with weakness and a Trendelenburg sign: endoscopic or open tendon repair, with suture anchors, and bursectomy with iliotibial band release when needed. Success is about 80 to 90% for pain, with 4 to 6 months of protected rehabilitation.
• Special groups:
  • Pregnancy: positioning advice, physiotherapy, paracetamol. Avoid NSAIDs after 20 weeks and avoid injection unless essential.
  • Elderly: favour exercise and topical agents, assess for hip osteoarthritis and fracture, and avoid repeated injections.
  • Diabetes: monitor glucose after injection.
  • Anticoagulation: use a fine needle under ultrasound guidance and apply pressure for 5 to 10 minutes.
  • Fluoroquinolone users: review the drug if tendon pain occurs.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 6 weeks and 3 months. Refer to orthopaedics, sports medicine or rheumatology for no improvement by 3 to 6 months, a suspected tear, or diagnostic doubt.