Gluteal tendinopathy typically affects sedentary people but it can also be problematic in individuals participating in running and other athletic activities. It is the most common lower limb tendinopathy though it is nearly three times more common in women than men. Gluteal tendinopathy may affect as many as 25 percent of women more than 50-years-old and has recently been understood as part of a cascade of signs and symptoms associated with greater trochanteric pain syndrome.
One of the most contentious topics in rehabilitation of the hip is the existence of “gluteal amnesia.” First described by Dr. Stuart McGill, gluteal amnesia is the inability to engage the hips during athletic activities or exercise which is believed to have a negative effect on performance and potentially increase the risk of injury.
This condition has also been referred to as “dead butt syndrome,” or expressed as the gluteal muscles being “turned off” or “inhibited.”
This popular theory has been refuted by electromyographic (EMG) studies of the hip muscles that have found no consistent firing pattern in asymptomatic individuals. They found that muscle activation order is largely variable with the only consistent finding being that gluteus maximus is the last to be activated.
All things considered, it is likely incorrect to label hip pain and symptoms as “gluteal amnesia” or “dead butt syndrome.” Clinicians must take time to recognize individual differences in movement patterns and identify root causes of dysfunction to craft the most appropriate treatment plan.
Anatomy of the gluteal muscles
The gluteus medius is a broad, thick muscle that arises from the iliac crest and travels inferiorly to the greater trochanter. The tendon is strong and flat with two insertions on the trochanter at the superoposterior and lateral facets. The greater trochanteric bursa sits between the tendon and the bony trochanter where it serves to decrease friction between the soft tissue and bone. Similar to gluteus medius, gluteus minimus is a fan-shaped muscle that originates on the outer surface of the ilium and inserts at the anterior facet of the greater trochanter. The superior gluteal nerve innervates both muscles.
The gluteus medius primarily functions as a hip abductor and is responsible for maintaining a level pelvis during the single-leg phase of the gait cycle; it acts as an internal or external rotator of the femur, depending on which portion of the muscle is active. The gluteus minimus assists the gluteus medius in these roles.
Hip anatomy is akin to shoulder anatomy and, as such, these muscles have been coined the “rotator cuff of the hip.” Common anatomical features of the shoulder and hip include: each having a powerful internal rotator that attaches to the smaller protuberance of the bone (subscapularis and iliopsoas), two abductors that attach to the greater protuberance of the bone (supraspinatus/infraspinatus and gluteus minimus/gluteus medius), and a tendon crossing the ball of the ball-and-socket joint (long head of biceps brachii and head of rectus femoris).
Just as supraspinatus is the first muscle implicated in rotator cuff tears at the shoulder, gluteus minimus is the first involved in tears at the hip. In both joints, non-traumatic tearing seems to start as fraying and degeneration that progress to larger tears involving multiple muscles.
To compensate for weakness or injury to the lateral gluteals, tensor fascia lata will assist with pelvic stability. Because of its attachment to the iliotibial band, increased activity of tensor fascia late may cause tightness that pulls the IT band taut over the lateral femoral condyle or greater trochanter leading to compression that creates pain and dysfunction.
What are the symptoms of gluteal tendinopathy?
Patients with gluteal tendinopathy typically present with moderate to severe pain in the lateral hip region that is particularly point tender and disabling. Historically, pain in the region of the greater trochanter has been diagnosed as trochanteric bursitis but has recently been described, along with gluteal tendinopathy, as part of greater trochanteric pain syndrome.
Similar to hip arthritis, the clinical presentation of gluteal tendinopathy generally starts as a subtle, nagging pain that gradually worsens over time. Some of the symptoms the patient may report include:
- Tenderness to palpation over the lateral hip, specifically in the region of the greater trochanter
- Pain with side-lying on the involved side
- Pain with standing, walking, etc.
- Pain when sitting for long periods of time or with their legs crossed in any fashion
- Decreased strength on the symptomatic side
Weakness of the lateral hip stabilizers is typically first identified by a Trendelenburg sign. A Trendelenburg gait occurs when pain, biomechanical dysfunction, or weakness cause the pelvis to drop to the contralateral side during the single-leg stance phase of the gait cycle. This gait may or may not have an associated trunk lean toward the stance side which shortens the lever of gluteus medius and improves its function.
Quality of life may be significantly impacted by gluteal tendinopathy as the symptoms are similar to those of osteoarthritis of the hip joint. Weight-bearing activities such as walking, stair climbing, and sleep may be difficult as well.
It has been suggested that the differentiation between gluteal tendinopathy and hip osteoarthritis lies in an individual’s ability to put on socks and shoes. Hip osteoarthritis limits the motion at the joint which impedes the ability to cross one leg over the other; gluteal tendinopathy may create pain in this position but it does not typically have limitations in motion associated with it.
What are the causes or risk factors of gluteal tendinopathy?
The source of tendon degeneration may be the “wear and tear” created by the tendon’s relationship with the greater trochanter whereby compression creates decreased blood flow in the tissue and thus interrupts the normal recovery/regeneration that occurs after activity. The anatomic relationships between the femur, pelvis, lumbar plexus, and soft tissues may cause this increased compression directly or indirectly.
Degenerative joint disease and other hip pathologies can become risk factors for the development of gluteal tendinopathy secondary to altered movement patterns and gait deviations. Osteoarthritis, femoroacetabular impingement, and avascular necrosis are all associated with pain and range of motion restrictions that may lead to a person off-loading their painful side in a single-leg stance position which results in increased adduction on the contralateral side which could cause gluteal tendinopathy.
The shape of the female pelvis has been posited as a potential risk factor for the development of gluteal tendinopathy. The wider pelvis may require increased hip abductor strength to control hip adduction during squatting, jumping, running, and other functional movements.
Femoral offset is a measure of the distance from the center of rotation of the femoral head to a line bisecting the long axis of the femur. Abductor strength varies depending on this angle as the offset influences the force that needs to be generated by gluteus medius to maintain balance of the pelvis.
Coxa vara, a decrease in the angle between the femoral neck and shaft, may also influence the development of gluteal tendinopathy as this deformity creates an anatomical predisposition toward adduction.
In patients with lateral hip pathology, magnetic resonance imaging (MRI) comparison of gluteus medius and minimus, tensor fascia lata, and iliopsoas, makes apparent that the disproportionate tendon pathology and atrophy of the lateral gluteal muscles do not appear related to compromises in nerve supply. The prevalence of tendon pathology and atrophy in the lateral hip region suggest that atrophy of these muscles is more strongly associated with tendon pathology than denervation.
An additional indirect cause of gluteal tendinopathy may be low back injury that causes nerve irritation at the levels responsible for the gluteal muscles. The hip abductors are innervated by L4, L5, and S1 as well as superior gluteal nerve which means injury to any of these structures can result in weakness. Ninety-five percent of lumbar disc herniations occur at these levels. Additionally, the pain and dysfunction associated with piriformis syndrome may create an antalgic or Trendelenberg gait that increases compression of these tissues on the affected side.
Younger subjects were found to have degeneration of the superoposterior insertion of gluteus minimus while older adults had involvement at both attachment sites suggesting the superoposterior portion is prone to earlier degeneration. Of note, most of the cases of isolated tendon involvement at either the superoposterior or lateral facet were not associated with atrophy which may indicate that attachment of one tendon is sufficient for maintaining muscle bulk.
Based on a robust magnetic resonance imaging study, lateral gluteal tendinopathy progressively worsens along a spectrum of tendinitis to tendinosis to low-grade partial tears to high-grade partial tears. This progressive degeneration of the tendon seems to be associated with age.
Diagnosis of gluteal tendinopathy
As with most musculoskeletal conditions, gluteal tendinopathy is best diagnosed using a combination of subjective report, symptom presentation, and a cluster of clinical tests. Common tests used in the differential diagnosis of gluteal tendinopathy include: FABER, single-leg stance test, resisted external derotation test, passive hip adduction, and palpation.
A positive FABER test can be used to discern between gluteal tendinopathy and hip osteoarthritis. A patient with reduced hip range of motion due to osteoarthritis will have pain and difficulty achieving the position necessary to conduct this test. Also, the test position is similar to that used when donning shoes and socks which may help correlate clinical findings to subjective history given by the patient. Research has shown the FABER test to be excellent at ruling gluteal tendinopathy in and out.
The single-leg stance test, sometimes referred to as the Trendelenburg Test, involves asking the patient to stand on their involved leg for 30 seconds. A positive test is indicated by contralateral pelvic drop indicating insufficiency of the hip abductor musculature or pain. This test is highly sensitive and specific.
The resisted external derotation test is performed with the patient supine with the hip and knee flexed to 90 degrees and the hip externally rotated (this position is typically found by finding maximal external rotation and then backing off a bit). The patient is then asked to return the affected leg to neutral rotation; the test is positive if pain is reproduced. This test has demonstrated high sensitivity and specificity for detecting gluteal tendinopathy with values of 88 and 97.3 percent respectively.
Passive hip adduction is performed with the patient side-lying with the affected side toward the ceiling. The bottom leg is bent comfortably while the top leg is supported by the examiner and the hips are stacked so that the anterior superior iliac spine is perpendicular to the table. The examiner passively moves the leg through full range adduction with overpressure. In full adduction, the insertions of the gluteal tendons are under both tensile and compressive load which will elicit pain if gluteal tendinopathy is present.
Palpation of the lateral hip region is also used in the differential diagnosis of gluteal tendinopathy. Pain at the gluteus medius or gluteus minimus tendons is considered confirmation of gluteal tendinopathy and in fact, is so widely recognized as an important sign that absence of tenderness with palpation suggests an alternative diagnosis should be sought.
Imaging may be necessary to rule out the need for surgical intervention. Radiography is typically performed first among imaging modalities however it’s limited ability to detect soft tissue lesions makes it somewhat undesirable for this condition.
For soft tissue evaluation, Ultrasound may be preferable due to lower cost and ease of availability. Ultrasound may be less sensitive than magnetic resonance imaging and its utility may be limited by operator experience. Though more costly and less available, magnetic resonance imaging is the gold standard imaging modality in the diagnosis of gluteal tendinopathy as it allows clinicians to visualize direct (swelling, changes to tendon morphology, abnormalities in intrasubstance signal, and discontinuity of tendon fibers) and indirect (fatty atrophy) signs of tendinopathy.
Remember that different types of hip pain can have similar symptoms, and they can be mistaken for another like sciatica or IT band syndrome. As with any injury or illness, readers should consult with a physician or qualified medical professional to determine the best personal course of treatment.
Gluteal tendinopathy, greater trochanteric pain syndrome, trochanteric bursitis: how similar are they?
Greater trochanteric pain syndrome, formerly trochanteric bursitis, groups together a few related causes of pain at the hip. It may also be diagnosed as:
- Gluteal tendinopathy
- Gluteus medius or minimus tendinitis
- Trochanteric bursitis
Greater trochanteric pain syndrome usually develops over time as a result of degenerative changes to the tendons and bursa resulting from repeated compression of the tendons as they wrap around the outer surface of the femur to their distal attachment on the greater trochanter. Patients experiencing greater trochanteric pain syndrome typically report lateral thigh and hip pain that is made worse with prolonged sitting, exercise, stair climbing, or lying on the painful side.
Greater trochanteric pain syndrome seems to be associated with: being female, iliotibial band tenderness, knee pain or osteoarthritis, and low back pain. Compensatory movements caused by these other conditions may disrupt the kinetic chain and lead to faulty functional movements causing greater trochanteric pain syndrome as well.
Exercise for gluteal tendinopathy
Current concepts in the treatment of tendinopathies suggest early adoption of isometric exercise to modulate pain. Though it hasn’t been studied in gluteal tendinopathies, research on patellar tendinopathy recommends loading the knee extensors isometrically at 70 percent maximum muscle contraction four times for 45 to 60 seconds, several times each day, to increase pain pressure threshold.
Another recent study demonstrated similar results with five 45-second isometric contractions of the quadriceps at 70 percent maximum contraction. This dosage provided near-complete pain relief immediately and up to 45 minutes post-exercise.
Early implementation of a progressive strengthening program helps reduce pain and improve load-bearing capacity of the tendon. Recent research has debunked the classic idea that eccentric training is the preferred method for rehabilitating tendinopathies. Rehabilitation programs that focus solely on eccentric training are not only insufficient but may further aggravate pain and symptoms.
This “old school” thinking should be replaced by heavy, slow resistance training performed in mid-range abduction. Keeping the patient out of adduction prevents compression of the gluteal tendons at the greater trochanter and avoids placing surrounding musculature at a mechanical disadvantage.
When possible, exercise programs should incorporate isolated hip abductor strengthening in weight-bearing positions. Loading of the hip abductors in exercise such as standing abduction on a Pilates reformer, slide board, or slippery (tile) floor allows for weight-bearing stimulus coupled with an ability to adjust resistance while minimizing tendon compression by allowing the exerciser to work in mid-range abduction.
If a Pilates reformer or slippery floor is not available or is unsafe for a patient, simple side-stepping with emphasis on trail leg abduction can be employed.
Contrary to popular thinking, targeted abductor strengthening is not strongly correlated with functional tasks such as a single leg squat, nor did improved abductor strength affect knee valgus in patients with patellofemoral pain. This suggests that rehabilitation of gluteal tendinopathy should include hip abductor strengthening accompanied by movement retraining specific to the individual. It may be important to emphasize neuromuscular control of hip adduction in squatting, single-leg stance, stair climbing, running, or other sport-specific movements.
Gluteus medius and minimus are critical to normal gait and as such, the link between atrophy and fall-related hip fractures can not be underscored. Therapeutic exercise after tendon tears must also focus on preventing or delaying atrophy and reducing the risk of falls.
Other treatments for gluteal tendinopathy
At times, gluteal tendinopathy can be so debilitating that rehabilitation exercises are intolerable without other pain-relieving modalities. Corticosteroid injections have been shown to decrease pain intensity at eight weeks and improve the rate of global improvement. Though these injections have proven successful as a short-term solution for pain, their effects do not seem to persist.
Extracorporeal Shock Wave Therapy has been studied in lower limb tendinopathies as well. A 2015 systematic review found moderate evidence that extracorporeal shock wave therapy may be more effective than conservative treatment (rest, therapeutic exercise, stretching, and injections) in both short and long-term management of greater trochanteric pain syndrome. Additionally, there was moderate evidence that extracorporeal shock wave therapy was more effective than a home exercise program at four months.
Of note, extracorporeal shock wave therapy was less effective than corticosteroid injections at one month but more effective at four and 15 months; the success rate with extracorporeal shock wave therapy at 15 months was 74 percent while only 35 percent of those receiving corticosteroid injections have recovered successfully.
Some cases of gluteal tendinopathy may require surgical intervention. Patients who suffer from persistent pain who have failed conservative physical therapy, and have clinical and imaging findings consistent with a tendon tear may consider surgery. Large tendon tears where retraction is visualized on imaging typically undergo open repairs while smaller, less involved tears can be addressed endoscopically.
Self-care with gluteal tendinopathy
The first step in the management of insertional tendinopathies is minimizing positions or activities that involve repetitive or sustained compression, particularly when compression is coupled with high tensile loads. Patients with gluteal tendinopathy should be educated on load management strategies to address their pain and symptoms. Patients with gluteal tendinopathy should be advised to avoid:
- Sitting cross-legged
- Sitting with knees together
- Standing with weight shifted to one side
- Lying on affected side
- Stretching in hip adduction as is typical for glutes or iliotibial band
Finding comfortable sleep positions may be a challenge for those with gluteal tendinopathy. If patients prefer to sleep on their unaffected side, they can place a pillow between their knees to limit the adduction allowed at their affected hip. Sleeping in supine with the hips in slight abduction is most preferable while side-lying with the top hip flexed and adducted should be avoided whenever possible.
What should massage therapists consider when treating a client or patient with gluteal tendinopathy?
Gluteal tendinopathy is not typically associated with active inflammatory processes, but there could be periods of inflammation during the development of the condition. Deep friction applied to the tendon is effective at decreasing pain and improving strength and mobility.
Also, myofascial techniques, deep tissue massage that emphasize lengthening, and similar techniques can all reduce the tensile forces through the tendon. Massage therapists should respect the anatomical structures involved in gluteal tendinopathy by ensuring patient positioning is either supine with slight abduction or side-lying with a pillow or bolster between the knees to avoid allowing the affected hip to fall into adduction.
Foam rolling or the use of other tools that increase compression in the region of the greater trochanter should be avoided.
Gluteal tendinopathy, one element of greater trochanteric pain syndrome, cannot be overlooked when investigating causes of pain in the lateral hip region. The anatomical relationships between the gluteal tendons and the trochanteric bursa should be front and center when designing and implementing rehabilitation and management programs for gluteal tendinopathy to ensure patients are working toward decreasing compressive forces while improving abductor strength.
Dr. Penny Goldberg can be reached at Penny.Goldberg@requestphysicaltherapy.com of ReQuest Physical Therapy.