Gluteal Tendinopathy

Written by: Emily Grant; additional contribution by: Dr Jeremy Steinberg – created: 28 June 2020; last modified: 23 April 2022

This article is still missing information.

The facets of a right greater trochanter. The gluteus medius inserts at the superoposterior and lateral facets; gluteus minimus inserts at the anterior facet.
Gluteal Tendinopathy

Greater trochanteric pain syndrome (GTPS) is an umbrella term encompassing different musculoskeletal entities that may contribute to chronic lateral hip pain. Tendinopathy of gluteus medius and/or gluteus minimus is the most common cause of GTPS and is generally simply referred to as gluteal tendinopathy. Other causes of GTPS are coxa saltans (snapping hip) with disorders of tensor fascia lata and/or the iliotibial band, and trochanteric bursitis. However, any inflamed or enlarged bursa seen (sub-gluteal minimus/medius) is invariably secondary to or co-exists with an underlying gluteal tendinopathy. Therefore the terms "trochanteric bursitis" and "trochanteritis" are generally regarded as misnomers.

Anatomy

In the "rotator cuff of the hip" there are six external rotators and three internal rotators.

• The external rotators are piriformis, gemellus superior and inferior, obturator internus, obturator externus, and quadratus femoris. 
• The internal rotators are gluteus minimus, gluteus medius, and tensor fascia lata.

Gluteus medius is a large fan-shaped muscle that has its origin at the outer edge of the iliac crest running from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine (PSIS). It has three equal portions: anterior, middle, and posterior. The anterior and middle portions assist with initiating hip abduction. The posterior portion is active in heel strike to full stance during gait to stabilise the hip. It inserts at the superoposterior and lateral facets of the greater trochanter.

• 

  gluteus medius shown on the right

• 

  gluteus minimus shown on the right

• 

  lateral hip with foot prints of gluteus medius, gluteus minimus, and vastus lateralis

Aetiology and Pathophysiology

Gluteal tendinopathy is caused by exposure to load that the tendon did not have adequate adaption or recovery time in order manage. This could be due to a traumatic event (e.g. direct blow) or a frequent and repeated exposure to a load (e.g. jumping athlete). Three continuous stages of disease have been described: normal to reactive tendinopathy to tendon dysrepair to degenerative tendinopathy. This is explained in more detail in Tendinopathy. It is difficult because pain is not closely connected to progression of pathology.

Epidemiology and Risk Factors

Common condition with prevalence highest in women over 40 years old. One study reporting 23.5% of females and 8.5% of men between 50-79 years being affected in community-based population. A rapid increase in intensity and/or frequency of on gluteal tendons puts individuals at risk. Both athletes and sedentary individuals are affected.

Clinical Features

History

Lateral hip pain over greater trochanter. Onset typically slow but can occur following a traumatic event (fall, forceful sporting action). Pain typically worsened with time and can be associated with a change in physical activity. Pain can radiate around the trochanter and down the lateral thigh. Associated symptom of stiffness of hip on standing or walking following sitting. Sleep can be significantly disturbed as pain is typically worse at night time and pain makes it difficult for sleeping on side. Pain can cause significant disability, particularly with single leg standing activities e.g. dressing, walking and going up stairs or hills.

Examination

The patient is assessed during gait to evaluate for a Trendelenburg pattern.

The most important sign is pain on palpation of the greater trochanter. Absence of pain on palpation would indicate an alternate diagnosis.

Lateral hip pain reproduced on 30s single-leg stance test was a sensitivity and specificity of 100% and 97.3% respectively for gluteal tendinopathy. The high utility of the test is only maintained if lateral displacement of the hip is avoided. The examiner may provide gentle fingertip support to steady the patient.

The FABER test is useful in the differential diagnosis as limited range of movement is associated with hip joint pathology but not gluteal tendinopathy.

The Ober's test has been shown to lack diagnostic utility for gluteal tendinopathy.

The resisted internal rotation test had a sensitivity of 92% and specificity of 85% for the detection of gluteus medius tears.

Investigations

MRI is gold standard as it can visualise changes associated with gluteal tendinopathy, such as tendon thickening and soft tissue oedema, the clearest. MRI is also useful in excluding other causes of lateral hip pain. However, MRI is expensive and not very accessible. Consequently, ultrasound is typically used in clinical practice. The accuracy of ultrasound in identifying gluteal tendinopathy is variable and dependent on operator experience and patient characteristics. It is important to note that it is normal for radiological changes to be present in the asymptomatic population, thus, any findings need to be considered within the clinical context.

Imaging Findings

Grey scale Ultrasound

• Thickened tendons
• Reduced echogenicity of tendons
• More heterogeneous echogenicity of tendons
• Increased echogenicity of muscles as reduced muscle bulk and increased fat
• Partial tear are indicated by thinning of the tendon and partial thickness area free from echo
• Complete tear indicated by the full thickness of the tender being free from echo and a “bald” facet
• Deep to gluteus tendons insertions there may be cortical irregularities

On Doppler Ultrasound can helpfully but uncommonly see increased vascularity

MRI

• Intensity of signal increased in T1w view within tendons of gluteus minimus and/or gluteus medius
• Hyperintensity in T2 view within tendon of gluteus minimus and/or gluteus medius
• Presence of fluid distension of the greater trochanteric bursa
• On coronal T1w view, fatty streaks or fatty infiltration of gluteus minimus and/or gluteus medius
• Partial tear indicated by hyperintensity  in T2 view within tendon of gluteus minimus and/or gluteus medius
• Partial tear can presents with or without tendon thinning
• Complete tear indicated by disruption of tendon of gluteus minimus and/or gluteus medius
• Osseous avulsion may or may not be present in a complete tear

Other Investigations

Other imaging techniques are currently being developed. These include ultrasound tissue characterisation and elastography.

Diagnosis

No clear diagnostic criteria exists for gluteal tendinopathy. Typically the diagnosis is made clinically. The history most commonly involves lateral hip pain that is exacerbated by activity and lying on the affected side. On examination, one would expect to find tenderness on palpation of the greater trochanter. This is the most common clinical finding in gluteal tendinopathy.

Hip osteoarthritis is  a common differential diagnosis for lateral hip pain. Asking about difficulty in manipulating shoes and socks is a useful way to differentiate the conditions. A paper published in the British Journal of Sports Medicine suggested that diagnostic criteria for gluteal tendinopathy should include the patient reporting to have no difficulty in manipulating socks and shoes. This paper also suggested the diagnostic criteria to include lateral hip pain reproduced on the FABER test as the FABER test should not produce lateral hip pain in hip osteoarthritis.

Differential Diagnosis

Lateral Hip Pain

Treatment

Gluteal tendinopathy for the majority is self limiting. It has been reported that more than 90% of people are responsive to conserverative treatment. Those who are not are considered refractory cases.

Conservative treatment can include physiotherapy, shockwave therapy, NSAIDs, corticosteroid injections (CSI) and PRP injections. There are varying levels of evidence for each of these interventions. Evidence does not support the conservative treatment of deep transverse friction massage, therapeutic ultrasound and acupuncture.

Physiotherapy that is based around eccentric exercises has been shown to be effective in other tendinopathies. Therefore, eccentric exercise has promise in the treatment of gluteal tendinopathy.

Ultrasound can be used for needle guidance of CSI. The injectate is deposited directly on the bone and around the injections or into the tendon itself. However, no significant difference between ultrasound guided and blind injection outcomes have been found. CSI may provide benefit in the short term but with a high recurrence rate and poorer results in the long term.

Given the paucity of treatments for chronic gluteal tendinopathy (>3 months) and transient amelioration effect of CSI, there is interest whether biologic products such as PRP may provide better long-term outcomes for this condition. The use of PRP has been controversial, especially in tendinopathies given its slower onset of action to see its efficacy. Some tendons respond differently to PRP. Technician skills, type of condition being treated and type of PRP used are all variables that can affect its effectiveness.

There is no universally prescribed treatment protocol. However, the LEAP protocol is shown to be promising when compared to no treatment and single corticosteroid injection. The LEAP protocol involves education on load management (e.g. avoiding lying on side of affected leg) and a specific exercise programme. This study and its results can be found in the resources below.

Exercise

Leap Trial

LEAP trial

Surgery

Gluteal tendon reconstruction is experimental with no standardised techniques. If surgery is done it will involve a combination of some of the procedures listed: bursectomy, ITB release, trochanteric reduction osteotomy and gluteal tendon repair.

Follow Up and Prognosis

Over 90% respond to conservative treatment but there are still large number of patients thar fail non-operative treatment with significant levels of dysfunction making important to find novel treatment strategies.

Summary

• Aetiology and pathophysiology for gluteal tendinopathy remains unclear
• Prevalence is highest in women over 40 years
• Both athletes and sedentary individuals are affected
• History of lateral hip pain
• Examination of lateral hip pain reproduced on FABER test and 30s single-leg stance test
• No set diagnostic criteria
• Diagnosis is typically clinical
• Imaging can be done with MRI being gold standard but ultrasound more clinically available
• No universally prescribed treatment protocol but LEAP protocol provides some promise
• Conservative treatment effective in more than 90% of cases

Downloads

Gluteal Tendinopathy - Grimaldi 2015 - 2.94 MB (f)

Good review article from a physiotherapy perspective

LEAP Trial - Mellor 2018 - 455 KB (f)

Important RCT comparing corticosteroid to structured load management

LEAP Protocol - 1.34 MB (f)

Links

How physiotherapists treat gluteal tendinopathy by Dr Alison Grimaldi

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,