Gluteal Tendinopathy - A Pain in The Butt
Gluteal tendinopathy is a common cause of lateral hip pain. Corticosteroid injections are a common procedure used to treat gluteal tendinopathy along with exercise. A recent study by Rebecca Mellor, et al. in the British Medical Journal compared education and exercise, corticosteroid injections, and a wait and see approach for the treatment of gluteal tendinopathy. The study included 204 participants with a one year follow up.
Gluteal Tendinopathy Treatments
Education & Exercise Group
The education and exercise group consisted of 14 individual sessions over an 8 week period. The exercise protocol was based on the LEAP trial by Rebecca Mellor, et al. The education component consisted of avoiding positions that compress the gluteal tendon against the greater trochanter as well as advice on proper loading on the gluteal tendon. The load management and exercise component was divided into three stages: (1) familiarization, (2) early loading and movement optimization, and (3) graduated loading. The difficulty of the exercises were graded on the Borg Scale. Light difficulty was rated an 11-12, somewhat hard 13-15, and hard to very hard was 14-17. For loading, a maximum of 5/10 was tolerated as long as the pain decreased after stopping and did not remain elevated at night or the next morning.
Week 1 Exercises - Familiarization
[embed]https://youtu.be/G_dJtThzM4I[/embed]
Week 2 Exercises - Early Loading & Movement Optimization
[embed]https://youtu.be/cYZAUV5jqTA[/embed]
Week 3-8 Exercises - Graduated Loading
[embed]https://youtu.be/1N-sh8H1eyQ[/embed]For complete details of the exercise progression used, click here.
Corticosteroid Injection Group
The corticosteroid injection group received one ultrasound guided corticosteroid injection.
Wait & See Group
The wait and see group had one session with a physical therapist. The participant was given general information regarding gluteal tendinopathy and treatment advice. Advice included that rest does not cure tendinopathy and participating in a walking program maybe helpful.
Research Results
The two primary outcomes assessed in this study were global rating of change and hip pain intensity. Between the three treatment groups, the baseline characteristics were similar. At eight weeks, the education and exercise group had a 77.3% success rate on the global rating of change scale compared to 58.5% for the corticosteroid injection group and 29.4% for the wait and see group. At baseline, the average pain rating for both the education and exercise group and the corticosteroid group was 4.8. After eight weeks, the education and exercise group pain rating was 1.5 and the corticosteroid injection group was 2.7. The wait and see group decreased from 4.9 at baseline to 3.8.
"A novel finding that was not hypothesized was the greater benefit of education plus exercise over corticosteroid injection on all primary outcomes at eight weeks." Rebecca Mellor, et al. 2018.
At 52 weeks, the education and exercise group had a 78.6% success rate on the global rating of change scale. This was compared to 58.3% in the corticosteroid injection group and the wait and see group 51.9%. The average pain rating for education and exercise after 52 weeks was 2.1. The corticosteroid injection group was 2.3 while the wait and see group was 3.2
What This Research Adds
Both the education and exercise group and the corticosteroid injection groups were better than the wait and see groups for the primary study outcomes. However, the education and exercise group was better than the corticosteroid injection group at both the 4 week and 8 week periods for global rating improvement and pain intensity. The early success rate of the education and exercise group demonstrates the importance of avoiding positions that cause compression of the gluteal tendons against the greater trochanter. It also aids in the importance of a targeted exercise program to increase the load capacity of the gluteal tendons. An interesting secondary finding of this paper was muscle strength did not differ between groups at eight weeks. Therefore, the strengthening effect of exercise may not be an important factor for recovering from a gluteal tendinopathy. It also highlights why education should be considered a primary treatment component.
In Conclusion
This study demonstrates that education and exercise are effective treatments for both short term and long term gluteal tendinopathy. Corticosteroid injections have frequently been shown to have good short term outcomes, but longer term consequences. However, this study suggests that education and exercise actually have a better short term outcome than corticosteroid injections. In the treatment of other tendinopathies, heavier loads are recommended for isometric and isotonic exercises. Early rehabilitation for Achilles and patellar tendinopathy recommends up to 70% of MVIC for 30-45 seconds. The heavy, slow resistance protocol also uses 15 RM progressing to 6 RM for the treatment of Achilles and patellar tendinopathy. It is a possibility that heavier loading in the treatment of gluteal tendinopathy may result in better outcomes, as has been suggested for other lower extremity tendinopathies.
References
Beyer, R., Kongsgaard, M., Kjær, BH., Heavy slow resistance versus eccentric training as treatment for Achilles tendionpathy. Am J of Sports Med. 2015;43(7):1704-1711.Mascaró, A., Cos, MA., Morral, A., Roig, A., Purdam, C., Cook, J., Load management in tendinopathy: clinical progression for Achilles and patellar tendinopathy. Apunts Med Esport. 2018;53(197):19-27.Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., Vicenzino, Bill. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomized clinical trial. BMJ 2018,360:k1662.Mellor, R., Grimaldi, A., Wajswelner, H., Hodges, P., Abbott, JH., Bennell, K., Vicenzino, Bill. Exercise and load modification versus corticosteroid injection versus 'wait and see' for persistent gluteus medius/minimus tendinopathy (the LEAP trial): a protocol for a randomized clinical trial. BMC Musculoskel Dis. 2016;17:1043-6.