GLUTEAL TENDINOPATHY

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TENDINOPATHY/)
Marc Surdyka

 June 25, 2023

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Do you have pain on the outer part of your hip when walking, going up stairs, or lying on your side?

In this blog, I’m going to discuss gluteal tendinopathy (also often referred to as hip bursitis,
trochanteric bursitis, or greater trochanteric pain syndrome), dispel the most common myths
associated with the diagnosis, and teach you everything you need to know about managing the
condition.
:
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function and performance? Check out our Hip Resilience program
(https://store.e3rehab.com/products/hip-resilience)!

Anatomy & Function

If you put your hand on the side of your hip, you should feel a bony prominence known as the
greater trochanter, which is part of your femur, or thigh bone.

The greater trochanter serves as an attachment site for the gluteus medius and gluteus
minimus tendons.

In a non-weight bearing position, these two glute muscles act to abduct the hip. More
importantly though, they stabilize the pelvis when standing on a single leg, such as when
walking, running, and going up stairs.
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 There is also a trochanteric bursa, which is a @uid-Alled sac that serves to cushion and reduce
friction in this area. Over the top of these structures lies the Iliotibial (IT) Band.

What’s In A Name?
Hip bursitis, the diagnosis often provided to people experiencing pain in this region, generally
refers to in@ammation of the trochanteric bursa. However, research spanning across 20 years
(Bird et al 2001 (https://pubmed.ncbi.nlm.nih.gov/11592379/), Connell et al 2003
(https://pubmed.ncbi.nlm.nih.gov/12764651/), Kong et al 2007
(https://pubmed.ncbi.nlm.nih.gov/17149624/), Silva et al 2008
(https://pubmed.ncbi.nlm.nih.gov/18391676/), Blankenbaker et al 2008
(https://pubmed.ncbi.nlm.nih.gov/18566811/), Woodley et al 2008
(https://pubmed.ncbi.nlm.nih.gov/18515960/), Fearon et al 2010
(https://pubmed.ncbi.nlm.nih.gov/19941093/), Long et al 2013
(https://pubmed.ncbi.nlm.nih.gov/24147479/), Lange et al 2022
(https://pubmed.ncbi.nlm.nih.gov/35781127/)) has determined that bursitis is actually unlikely
to be the primary contributing factor to symptoms.

In fact, MRIs often And bursitis in hips that are completely pain-free. For example, a study by
Woodley et al in 2008 (https://pubmed.ncbi.nlm.nih.gov/18515960/) concluded that “…bursitis
was equally prevalent in symptomatic and asymptomatic hips…” It’s common to have bursitis of
both hips despite only having symptoms on one side.

Much of the same research found that the tendons of the gluteus medius and minimus are
more often involved. Therefore, gluteal tendinopathy, which refers to pain and impaired function
associated with the loading of these tendons, has been proposed as the preferred diagnosis.

Having said that, it’s important to point out that tendon changes seen on MRI are also common
in people without symptoms. For example, a study by Ganderton et al in 2017
(https://pubmed.ncbi.nlm.nih.gov/28263673/) reported that “…88% of asymptomatic
participants had pathological gluteal tendon changes on MRI, from mild tendinosis
[degeneration] to full-thickness tear.”
:
 Since these “pathological” Andings are present in individuals with and without symptoms,
imaging is unnecessary in most instances.

In addition to reporting symptoms with sleeping on your side or with activities that load the
gluteal tendons, such as walking and climbing up stairs, a study by Grimaldi et al in 2017
(https://pubmed.ncbi.nlm.nih.gov/27633027/) concluded that “…a patient who reports lateral
hip pain within 30 seconds of single-leg-standing is very likely to have gluteal tendinopathy.”

Alternatively, if you don’t have pain when pressing on your greater trochanter, it’s unlikely that
you have gluteal tendinopathy.

It’s also necessary to rule out other causes of lateral hip pain, such as hip osteoarthritis and low
back-related issues.

The naming of a diagnosis matters in how it informs management.

Many people associate bursitis with the need for ice, complete rest, and anti-in@ammatory
medications, and that sometimes creates the idea that management of your symptoms is out
of your control.

Gluteal tendinopathy presents more options for self-management, but may oversimplify the
problem to a speciAc set of tissues.

As long as hip osteoarthritis, low back-related issues, and other similar conditions have been
ruled out, simply calling it lateral hip pain is another alternative. Although it’s non-speciAc in
nature, it encompasses the potential contributing factors of speciAc tissues, such as loading of
the gluteus medius and minimus tendons, as well as other factors like your metabolic health
that I’ll discuss shortly.

Who Gets Gluteal Tendinopathy/Lateral

Hip Pain and Why?
Research by Tortolani et al in 2002 (https://pubmed.ncbi.nlm.nih.gov/14589475/) and Segal et
al in 2007 (https://pubmed.ncbi.nlm.nih.gov/17678660/) informs us that it’s more common in
women.

One subgroup of women affected is runners (https://pubmed.ncbi.nlm.nih.gov/11916889/).

Consider that running consistently loads your gluteal muscles and tendons. If the frequency,
volume, and/or intensity of your runs exceeds your capacity to recover and adapt appropriately,
gluteal tendinopathy may occur. In this simpliAed scenario, it’s thought of as a training load
error in which you did “too much, too soon.”
:
 More commonly however, gluteal tendinopathy affects older, less active perimenopausal
women. Although loading of the gluteal tendons is still a component of the diagnosis, it’s been
well-documented that other lifestyle and metabolic factors
(https://pubmed.ncbi.nlm.nih.gov/20646281/) in@uence the health of tendons, such as
diabetes, hypercholesterolemia (https://pubmed.ncbi.nlm.nih.gov/23315787/), adiposity
(https://pubmed.ncbi.nlm.nih.gov/18608380/), and certain medication usage like statins
(https://pubmed.ncbi.nlm.nih.gov/27490216/) and
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4238198/) antibiotics
(https://pubmed.ncbi.nlm.nih.gov/24762232/).

Gluteal tendinopathy is complex and multifactorial. It’s useful to acknowledge the role of tendon
loading and unloading in its presentation, but the importance of your overall health and well-
being cannot be overlooked.

Thankfully, either way, there are a lot of management options!

Load Management & Activity

ModiCcations (Recommended)
Many of the recommendations come from one of the leading researchers, Alison Grimaldi
(https://pubmed.ncbi.nlm.nih.gov/26381486/), and co-authors
(https://pubmed.ncbi.nlm.nih.gov/25969366/). I’ll list out possible aggravating activities and
self-management options. In most cases, the goal is to temporarily modify or minimize painful
activities to aid with long-term recovery.
:
 If you have pain sleeping on your affected side, there are 3 easy things to try:

1. Sleep on your back with or without a pillow under your knees

2. Sleep on your unaffected side with 2 pillows between your legs

3. Purchase a mattress topper for added comfort

:
 3. Purchase a mattress topper for added comfort

If you have pain while sitting, you can try to determine if symptoms are worse when your legs
are crossed, when you sit in a low or deep seat, or when you sit for a prolonged period of time.

If needed, modify your sitting position, raise the height of your seat, or take periodic standing
breaks.

If you have pain while walking, the most important thing to do is track your steps, Agure out your
maximum tolerable distance on a day-to-day basis, and then gradually increase your steps over
time as symptoms improve. You can also trial walking faster or taking shorter steps as both
require less time spent in single limb stance per step.
:
 If you have pain with stairs, make sure to always use the railing on the opposite side of your
painful hip when available. If even that is too much, go up one step at a time, leading with your
non-painful side.

With regards to stretching, many people believe that it’s required to get better, especially as it
relates to the IT band or piriformis. If performing a seated Agure 4 stretch or standing hip
stretch feels good, you can certainly do it, but neither is absolutely necessary. Gluteal
tendinopathy isn’t the result of the IT band or piriformis being “too tight”.

If you have pain with running, it’s essential to modify the frequency, volume, and/or intensity of
your runs to And a tolerable starting point. You can also test out increasing your cadence
(https://pubmed.ncbi.nlm.nih.gov/26243741/), which is the number of steps you take per
minute, by 5-10% with the intention of decreasing the load on the glutes.

There are a lot of options, but you only need to address the activities relevant to you.
:
 What About Exercise?
To date, there are three (https://pubmed.ncbi.nlm.nih.gov/19439758/) randomized
(https://pubmed.ncbi.nlm.nih.gov/29715073/) controlled trials
(https://pubmed.ncbi.nlm.nih.gov/30385462/) assessing the effectiveness of exercise as it
relates to gluteal tendinopathy. Without going into the details of each study, I want to highlight
that some people will get better without having to do speciAc exercises – perhaps due to the
passage of time. We don’t know exactly who those individuals are, but if you’re watching this,
you get to decide what information from this blog that you want to apply to your own life.

My bias is to include at least some exercise for several reasons:

1. To improve function. Although it’s a chicken or egg scenario, individuals with gluteal
tendinopathy demonstrate muscle weakness
(https://pubmed.ncbi.nlm.nih.gov/26418561/), which may affect single limb stance
(https://pubmed.ncbi.nlm.nih.gov/27395451/). If speciAc exercises have the potential to
improve your function so you can walk further or go upstairs with less diiculty, I think
they’re worth a shot.
2. To improve your overall health and well-being. People with severe gluteal tendinopathy
(https://pubmed.ncbi.nlm.nih.gov/29427310/) tend to be less physically active, have a
poorer quality of life, and have greater BMIs. General physical activity may address some
of these factors, as well as the metabolic factors I mentioned earlier. Whether it’s
walking, swimming in a pool, riding a stationary bicycle, or something else, any amount of
physical activity is beneAcial.
3. To improve your conAdence. An exploratory analysis
(https://pubmed.ncbi.nlm.nih.gov/36306175/) of the most recent exercise trial found that
“Education plus exercise improves a patient’s overall perception of improvement through
mechanisms associated with improving pain self-eicacy and patient-reported hip
function and reducing the proportion of time in pain, not through gains in isometric hip
abductor muscle strength.” This paper essentially showed that you don’t necessarily have
to get stronger or move differently to get better, but believing in your ability to manage
your symptoms and accomplish tasks might be an important component of rehab.

I’m going to present 3 categories of exercises and explain my rationale for each. Remember
that you get to decide what exercises you choose to do, if you choose to do exercises at all. I’m
trying to provide options to accommodate different goals and needs.

Exercise Category #1: “Functional”

Movements (Recommended)
:
 Exercise category #1 relates to movements that mimic day-to-day activities, such as getting up
and down from a chair, climbing stairs, and standing on a single leg. I think knowing you can
accomplish these movements is beneAcial for everyday life, regardless if you have gluteal
tendinopathy or not.

The Arst exercise is a bridge. Lie on your back, squeeze your butt muscles, and lift your hips up
toward the ceiling. If you want to progress, you can stagger your legs so that one side is
working harder than the other. You would do that on both sides. If you want to progress even
more, you can perform single leg bridges on each leg. You can set a goal of working up to 3 sets
of 20 repetitions, but it’s Ane to start with as few repetitions as you need.

The second exercise is a sit-to-stand. You’ll scoot to the front of a stable chair, lean forward,
stand up, slowly sit back down, and repeat. If you need to make it easier, you can use your
hands for assistance. If you want to make it harder, hold a weight in your hands. Once again,
you can have a goal of working up to 3 sets of 20 repetitions, but it’s Ane to start with as few
repetitions as you need.

The third exercise is a step up, assuming the sit-to-stands are manageable. You can use actual
stairs or stack up sturdy objects available to you. If you need to make it easier, use your hands
for assistance, decrease the height of the step, or do both. A typical @ight of stairs might have
around 15 steps, so you can set a goal of being able to perform at least 3 sets of 10 repetitions
per leg.
:
 The last exercise is single leg balance. Squeeze the glutes of your standing leg and use your
hands for assistance as needed. Build up to 3 sets of 60 seconds.

Whether you choose to do 1 exercise or all 4, they can be done every other day.

Exercise Category #2: Gluteus Medius

:
 Exercise Category #2: Gluteus Medius
SpeciCc Strengthening (Optional)
Exercise category #2 relates to movements that focus on directly challenging the hip abduction
action of the gluteus medius and minimus muscles. I’ll present 3 options of varying diiculty.

For the Arst option, place a band or belt above your knees and then lie on your back with a pillow
under your knees. Gradually push out into the band or belt for 30 to 45 seconds.

For the second option, stand with your heels hip-width apart or greater, imagine spreading the
:
 For the second option, stand with your heels hip-width apart or greater, imagine spreading the
@oor with your feet, and hold this position for 30-45 seconds.

For the Anal option, lie on your unaffected side with your bottom hip and knee bent. Your top leg
should be resting on 2 pillows. While keeping your knee straight, slightly lift the top leg off the
pillows and hold for 30-45 seconds. You can add a band or weight to make this exercise harder.

For any of the exercises, you can put your hand on the side of your hip to feel your glutes
:
 For any of the exercises, you can put your hand on the side of your hip to feel your glutes
contracting. You can choose to do 1 movement, as often as daily, for 3 sets of 30-45 second
holds.
:
 Exercise Category #3: Advanced
Exercises (Optional)
Exercise category #3 includes advanced exercises, which may be most suitable for the runners
who want to try to ward off future occurrences of gluteal tendinopathy. Incorporating single leg
hip thrusts, split squats, single leg deadlifts, side planks, and banded side steps into your
training routine 2 days per week will improve the conditioning of your hip musculature, as well
as the rest of your lower leg and trunk.

Understanding and Monitoring Pain

How much pain is acceptable during exercise and other forms of physical activity? Just make
sure you can answer “yes” to these 3 questions:

1. Are your symptoms tolerable during exercise?

2. Are your symptoms tolerable immediately after exercise?
3. Are your symptoms tolerable the day after exercise?
:
 If you’re experiencing signiAcant pain during or immediately after exercise, or you have a @are-
up in symptoms the following day that you believe to be related to exercise, then it’s worthwhile
reevaluating your approach.

Pain during exercise doesn’t necessarily mean that you’re damaging structures or worsening
your condition. However, if it’s at a level that’s hindering progress with the exercises, daily
activities, or your short and long-term goals, then it’s appropriate to scale back.

The art of rehab is about Anding that Ane line between doing too much and doing too little. You
rarely need to completely rest and avoid all symptoms, but you also shouldn’t approach rehab
with a “no pain, no gain” mentality.

And although tracking your pain intensity can be useful in certain situations, don’t only tie your
successes or failures to its @uctuations. Consider answering other questions throughout the
rehab process to re@ect on your progress. For example:

Do you have more control over your symptoms?

Are you exercising more regularly?
Has your function improved?
Are you sleeping better or walking more?
Are you doing more of the things you enjoy?

Let me put all of this information together by presenting 2 case examples.

Case Example #1 (Runner)

:
 Let’s say you’re a 35 year-old marathon runner who developed gluteal tendinopathy 3 weeks ago
as you were preparing for an upcoming race. Assuming the onset of symptoms was associated
with a signiAcant increase in training mileage in a short amount of time, the Arst diicult
decision you have to make is whether or not it’s feasible for you to continue with the race.

For example, if the marathon is in 3 weeks, but you currently can’t run more than 3 miles before
starting to limp, you probably have to make the sacriAce of losing this battle so you win the war
of getting healthy and back to your normal training.

Otherwise, step 1 is easy – reduce the mileage and intensity of your weekly runs to a tolerable
level.

Step 2 is also easy, but requires more patience – gradually increase the mileage and intensity of
your weekly runs while minimizing occurrences of @are-ups.

That’s the gist of it. If you intervene early enough and you’re disciplined with your approach, you
can reduce the likelihood of gluteal tendinopathy becoming a long-term issue.

As I mentioned earlier, you can try a 5-10% increase in your cadence, but this shouldn’t
overshadow proper programming.

Aside from changes in training, ask yourself if anything has changed as it relates to your sleep,
nutrition, or stress levels. If so, try to address any possible contributing factors.

Finally, you can incorporate other forms of exercise. For instance, if you’re unable to run as
much as you normally like, you can replace 1 or 2 of your normal runs with a different aerobic
activity like cycling to maintain your cardiorespiratory Atness.
:
 As you begin to resume normal activity, consider adding in resistance training 1-2 days per week
for 3 sets of 8-12 reps per exercise.

Case Example #2 (Older, Less Active

Individual)
Now let’s say you’re a less active, 59 year-old who feels like you’ve been suffering with hip pain
for 2 years. You don’t remember when your symptoms started, but your health has declined and
you don’t get to do many of the things you enjoy anymore.

Step 1 is going to look much different. What can you do to And some relief with daily activities?
Perhaps you haven’t tried some of the tips I mentioned earlier like sleeping with 2 pillows
between your knees or purchasing a mattress topper to reduce the discomfort of lying on that
side.

Step 2 is harder to overcome than the previous example because it requires accepting that there
is no quick Ax. You’ll have to take it day-by-day while being in it for the long haul and
acknowledging that there are inevitably going to be ups and downs along the way.

So what do you do?

Whatever you can to improve your overall health and well-being.

Find a reasonable amount of physical activity that you can do on a regular basis. It doesn’t have
to be perfect.

As an example, maybe you start walking or riding a recumbent bike for 10 minutes, 3 times per
week. Over the course of 12 months, you might turn that into 30 minutes every single day. Keep
track of your successes with a journal.

If you’re feeling up to it, you can start the exercise with a band around your thighs while lying on
your back each morning.

At some point, you can throw in the bridges, sit-to-stands, step-ups, and single leg balance.

To make all of this more achievable, And support from a friend, family member, healthcare
provider, or a combination of all three.
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 Summary
In summary, gluteal tendinopathy has been proposed as the preferred term for pain presenting
on the side of the hip because research spanning across 20 years has determined that bursitis
is unlikely to be the primary contributing factor to symptoms.

It is characterized by pain with activities that load the gluteus medius and minimus, such as
standing on a single leg, walking, running, and going up stairs, as well as sleeping on the
affected side.

The diagnosis is most common in older, less active women, but it can also occur in runners.

Although some individuals will get better with time, a primary focus of management should
include modifying any aggravating activities.

SpeciAc exercises can be performed to improve the conditioning and function of the glute
muscles.

Since gluteal tendinopathy may be associated with other health-related issues such as diabetes
and hypercholesterolemia, any lifestyle interventions to improve overall health (like regular
physical activity) should be considered.

Regardless of what you decide to do, it’s important to tailor the plan to your individual goals and
needs. There is no quick Ax for gluteal tendinopathy, so it’s helpful to set realistic expectations
and plan for the process to take a minimum of 3 months.

Looking for rehab or performance programs? Check out our store here
(https://store.e3rehab.com/collections/programs)!

Want to learn more? Check out some of our other similar blogs:

Hip Osteoarthritis (https://e3rehab.com/blog/hip-osteoarthritis/), Proximal Hamstring

Tendinopathy (https://e3rehab.com/blog/proximal-hamstring-tendinopathy-rehab/), Gluteus
Medius Training (https://e3rehab.com/blog/gluteusmedius/)

Thanks for reading. Check out the video and please leave any questions or comments below.
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