Gluteus Medius Tendinopathy/Hip Bursitis – What does it feel like if you’ve got it?
This article puts the microscope on another of my top ten running injuries – Gluteus Medius Tendinopathy. This is the first time the blog has ventured up to the hip so far, but we’ve got a good reason to be up this high, because this injury can be a difficult one for runners to shake.
This is a condition that’s experienced by men and women but, I’m sorry to say ladies, women do seem to get it more, and often it’s post-menopausal women. There’s no complicated hormonal reason for this. The current theory is that many post-menopausal women go through a period of weight gain and then have a ‘I want to get fit again/lose weight’ period and simply overload their hip as their motivation to get into shape outstrips their bodies current abilities.
If you have glute. med. tendinopathy you’ll generally feel pain around the greater trochanter of the hip. That’s the bony part on the outside of the hip where the glute. med. tendons insert (see below). Patients that are diagnosed with glute. med. tendinopathy complain of pain in tasks like standing on one leg, standing in a queue when they ‘hang’ on their hip, running (especially as they fatigue), going up stairs or up hills, sitting for long periods of time, especially if their legs are crossed or knees together (very lady-like but not necessarily great for this condition for reasons you’ll find out as we progress through the article).
As a quick side note…we often like to confuse people in medicine by giving the same condition different names. So if you see any of the following, or have been told you have any of the following, it can be used synonymously with glute. med. tendinopathy, they’re the same thing!
Greater Trochanteric Bursitis
Greater Trochanteric pain syndrome
Bursitis is probably still the most commonly used term with GP’s and consultants. We’ve come away from this a little bit as our understanding of the condition has improved. The current evidence shows that it’s unlikely to be an inflammatory process therefore bursitis (inflammation of the bursa) is not seen as the best descriptor and more focus is now on the glute. med. tendons, hence the newer diagnosis of gluteus medius tendinopathy (if this changes as the evidence advances I’ll update you!)
Gluteus Medius Tendinopathy/Hip Bursitis – What causes it?
Like most running injuries that I see, glute. med tendinopathy usually manifests as a result of overloading the structure in question, plus or minus any other threats to your bodily tissues or you as a person. The point where loading turns into overloading is always difficult to quantify because that question is always answered by your individual brain, and we know that everyones brain is different and may also give a different answer in different situations.
However, if we know that perceived overload is a big part of the problem we can look at how the glute. med. tendons get loaded in general to then work out how to unload them. It appears that a combination of excessive (and remember, excessive is a perception of your brain so will be different for everyone) compressive and tensile forces (compression = squashing of the tendons, tensile forces = stretching the tendons). So in an overload problem the structures in question, the gluteus medius tendons, are undergoing a level of loading that the brain is not happy with. The brain is sensing that the tissues may be getting close to their threshold of failure and your brain will therefore protect you via pain.
Positions of hip flexion and abduction, or combinations of these movements, are the chief compressive and tensile positions for the glute. med. tendons, so if you find yourself regularly in these positions it could be one of the reasons that the brain is trying to get you to offload. Here’s a few activities to be aware of:
Running – A classic one, especially if someone runs with what’s termed a cross over gait. This gait patterns is a bit like running on a tight rope where the legs scissor across each other. With this kind of running technique the glute. med. tendons are working hard to provide the lateral stability needed to run, as well as being compressed by the hip adduction of the cross over gait. This problem can also be seen in runners that run the same way around a track putting unbalanced stresses through one hip.
Click HERE to see a nice article by James Dunne at Kinetic Revolution on the cross over gait.
Running hills – To run hills you needs plenty of hip flexion. Hip flexion along with adduction will cause an increase in compressive forces over the glute. med. tendons, so if you’ve started running a lot of hills recently then this could be a contributor.
Sitting – Now, this really depends on how you sit. If you sit in a low chair you will be sitting in more hip flexion = greater compression. If you sit with your knees together, or with your legs crossed, then you will be sitting in a degree of hip adduction and flexion = even more compression. This is why people with glute. med. tendinopathy often complain of pain in these positions.
Standing on one leg or “hanging” on the hip – “hanging” on the hip is where you stand “lazy” and let one hip kick out to the side. This position causes a pelvic drop and puts the hip in a relatively adducted position whilst at the same time loading the glute. med. muscle to provide lateral support, so again a position of high tensile and compressive forces.
Laying on painful hip – Patients often report struggling to sleep as they roll onto their affected side. Intuitively, this places greater compression over the glute. med. tendons and can exacerbate the issue. It can also be painful when laying on the non-affected side. This is because if you are laying on the non affected side, your knees tend to be together which means the affected top hip actually falls into adduction which we know is a classic compressive position.
Tests to diagnose gluteus medius tendinopathy/Hip bursitis
A recent study by Grimaldi et al (2016) highlighted the best tests you can use in clinic to help diagnose glute. med. tendinopathy. They argue that a battery of tests is best for diagnostic purposes as no one test in isolation is sufficient for diagnosis. If glute. med. tendinopathy is suspected, these tests, in combination, can help confirm diagnosis.
Palpation – Pain when you touch in or around the greater trochanter (bony part on the outside of the hip) should arouse suspicion of the condition.
ADD-R– This is where, in sidelying with the affected hip uppermost, you adduct the hip to place the glute. med. tendons under compression and then ask the patient to resist abduction from this position, adding tensile loads as well as compressive. Pain reproduced here is a positive sign.
FADER-R – Similar to the above, in supine, the patient is placed into flexion, adduction and external rotation and then asked to resist manual pressure from this position. Again the rational is to place maximal compressive and tensile loads through the glute. med. tendons to look for a pain response.
Single leg stance 30secs – Fairly self explanatory. Ask the patient to stand on one leg for 30secs and see if they get their pain.
Treating gluteus medius tendinopathy/hip bursitis
If you have got to a stage where you feel confident in a diagnosis of glute. med. tendinopathy the next step is obviously to treat it. The key, I feel, is to always look to address the cause of the problem rather than the symptoms. The symptom is pain and/or swelling. Unfortunately, that’s what most people focus on, but the key to recovery is: why has the brain chosen to protect you via pain? Deal with that and the pain goes away.
So if we take a common example of a person with glute. med tendinopathy. At the end of the examination I will use my clinical reasoning to hypothesise what I believe the causes are. Here’s a typical problem list:
Excessive loading of the glute. med tendons. There has been a lot of compressive and tensile stresses put through the tendons. The brain is sensing this and feels that you may be getting close to the tendons capacity. It is therefore protecting you via pain every time you adopt positions/exercises that further load the tendons. The brains goal is to prevent you loading the tendons to protect them.
The patient is not sleeping well due to a combination of the pain and stress levels. Sleep is where we rest and recover, both mentally and physically, from the days stresses. If this is not adequate we go into the next day with a lowered capacity and therefore it becomes easier to overload things. If this happens consistently injuries and illness can occur. I spend a lot of time helping people with sleep as it is so important for health, recovery and wellbeing. Sometimes the best “treatment” I can give someone is a restful nights sleep.
The patient is going through a very stressful time at work with a very demanding boss. This background stress may not be the main cause of the pain but the hormones and chemicals it is producing is not conducive to healing, recovery and desensitisation. Quite the opposite. Prolonged stress will effect the immune system negatively as the brain perceives an emergency fight or flight scenario. It’s literally saying that we may be in grave danger so i’ll shunt energy away from energy sapping tasks such as digestion, reproduction and healing. High levels of stress also have the effect of turning up the pain dial.
The patient has had the pain for so long they have given up hope of ever being pain free. They are worried and depressed that they will never be the free of pain and they will never be able to run again. As you can imagine these thought patterns have a huge effect on mood and in turn pain. These thought patterns tell the brain all is not well in my world. The brain, being your best friend will move to protect you either by increasing stress (protective response to perceived threat) or pain (protective response to perceived threat).
So if I have reasoned that all these things are contributing to the pain state. I will need to address them all. Remember, this is just one example, in reality it could be a completely different set of problems causing the pain state. It could be a plain and simple loading problem with no other psycho-social problems influencing it.
So lets take our hypothetical patient above and run through how I’d treat this particular pain state.
Excessive loading of the glute. med. tendons. Too much tensile and compressive stresses perceived by the brain. This is a big one and likely to be involved in most cases, if not all cases, of glute. med. tendinopathy. The first thing I do is get an idea of how much compression and tensile stresses they are putting through their tendons. I want to know everything about a normal week for them. I want to know what they are doing in their training programmes, and very importantly, what they do for the rest of their day. Your brain and body do not know the difference between an exercise in the gym, 3 flights of stairs or sitting for 2 hours, it just knows load. Let’s go through the common ones here:
Running – If running is a problem then I would start with running re-education. I will look to change any cross over gait by increasing step width when running and increase cadence to decrease hip flexion. If these changes are enough to get them pain free they can continue running. If not then I may suggest a short break from running and use some alternatives like an Alter-G treadmill or pool running.
If you’re interested in more running technique info then check out the below FREE running technique webinar for more than an hour of free information on running technique.
Sitting – If sitting was painful I’d look at how they do it. We do not want any crossing of legs, no sitting with knees together and no low chairs. Aim for a higher perched seat with no hip adduction.
Laying on hip – If this is painful, and it often is, then either get an eggshell mattress overlay or sleep laying on the other side. If it’s also painful on the other side then place enough pillows between the knees to bring them out of hip adduction.
I would also add NO ITB or glute. stretches. It sometimes seems intuitive to want to stretch something that is painful but in this condition positions of flexion and adduction increase compressive stress on the tendons so if we want to decrease this in the short term to allow some recovery then this is not a good idea.
The other 3 items on my problem list are all about education. I would spend time with this patient explaining the condition and re-assure them that, although they have had pain for a long period of time, there is still plenty of hope. As long as we do the right things, consistently over a period of time, and address all the factors that play a part in the pain state then there would be no reason they could not move forwards. The aim here is to re-assure the patient and give them hope for the future removing any depression or fear around the pain e.g. decreasing the threat levels in the brain.
The next stage would be to educate them on stress and pain. Sometimes just getting people to understand how important their mental health and social situation is to pain is enough to get them to make some changes in their life. It is well within our scope of practice to offer advice on stress relieving techniques such as mindfulness, yoga and meditation but it doesn’t have to be that mystical or clinical the advice could be as simple as advising spending time with their favourite people in a safe environment or having a warm bath or finding some time for that hobby they love. If I felt that I did not have the expertise to deal with a more complex case then that’s where referring out to a psychotherapist or back to their GP for mental health input may be helpful.
The final part of the treatment picture is exercise. As always with tendon problems I make sure the patient is aware that pain levels between 0-4/10 and that settle within 24hrs are acceptable. Our exercise choices should aim to build confidence and strength in the muscles and tendons in question whilst avoiding excessive compressive and tensile forces. So be careful of exercises with too much flexion and adduction.
Here’s a couple of options:
Exercise 1 – Hip thrusts with theraband. In this video the instructor supersets with hip abductions. You can also do these but make sure you do not adduct the hip e.g. only go back to neutral.
Exercise 2 – Crab walks with theraband
Good luck implementing the above advice. If you want to discuss anything further or join the conversation just place your message in the comments below and i’ll get back to you.
Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., Vicenzino, B. (2016) Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine. 0. 1-7.
Grimaldi, A., Mellor, R., Hodges, P., Bennell, K., Wajswelner, Vicenzino, B. (2015) Gluteal tendinopathy: A review of mechanisms, assessment and management. Sports Medicine. 45 (8). 1107-1119.
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