GTPS

[AJ Lievre]

This weekend we spent a fair amount of time discussing the evaluation and management of intra-articular hip pathologies both arthritic and non-arthritic. Let’s use this discussion forum to elaborate more on extra-articular management, specifically gluteal tendinopathy. We also discussed exercise dosage based on specific rehabilitation goals.
What are some key features that you believe are needed to identify from the patient’s presentation that would assist you in making decisions on how much to load or unload the tendon?
Based on the resources below, and what you learned this weekend, how might you approach a patient with gluteal tendinopathy differently than you had previously?
If conservative management fails to meet the patient goals, what are options you may present to the patient and who might you refer them to?

Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management

How physiotherapists treat gluteal tendinopathy

Gluteal Muscle Activation During Common Therapeutic Exercises

[Sarah Frunzi]

This past weekend was very helpful for me as I have a patient currently with a likely gluteal tendinopathy. Initially, lumbar referral was on my radar and something we were working on however she didn’t seem to make much progress. I then transitioned to targeting the hip and that didn’t seem to make much of an impact either. I felt like I was chasing her symptoms and couldn’t figure out the root of the cause. I sought out some advice on the presentation and gluteal tendinopathy was mentioned. After attending this weekend’s course and reading the associated articles, it is a fairly clear presentation of gluteal tendinopathy. She is an 84 y/o female with the symptom presentation of glute and lateral thigh pain, glute weakness, and described pain with activities of side-lying sleeping, stairs, SL stance, and sometimes sitting. She has recently started responding well to glute medius targeted exercises. Initially, her symptoms would be aggravated with exercise, and we had to be mindful of dosage and intensity of exercises prescribed, but now she is able to tolerate more exercise with increased resistance within the clinic. Though we are doing more in the clinic, the dosing of the exercise varies based on her ability and the level of difficulty of the exercise. Most exercises are with a moderate resistance (resistance bands, kettle bells, and bodyweight) and work to a level of fatigue. I also explained potential sleeping position modifications to provide decompression with pillows since pain at night/waking up seems to be the one variable unchanged (she sleeps side-lying with significant adduction of affected limb); I am hopeful to see some impact in this by the end of the week. After having this patient and the weekend course, I will be more cognizant of the presentation and be able to identify it much quicker in the future. Also, I will be able to perform more specific exercises for this type of patient presentation. Prior, I feel I wasn’t as specific because I did not fully understand the presentation or recognize that was the potential diagnosis. Moving forward, I think I will be able to address this presentation much more efficiently. Should conservative management fail to mee the patient’s goals, some options may consist of further patient education on expectations and functional abilities, as well as a potential referral to another provider. The two that come to mind are orthopedic surgeon and functional medicine. Most people are familiar with ortho and this could be an opportunity to see what methods are available and potential avenues for the patient. I also like the potential of what functional medicine offers. I have had good experience with functional medicine doctors that also treat with the “whole person” mindset and might dive deeper into more holistic and less invasive methods to see if there are other variables that can be addressed in the patient’s lifestyle. These referrals would also be paired with patient education on what the current research shows regarding potentially invasive procedures so that my patients can make an educated and informed decision regarding their healthcare.

References:
1. Distafeno, L. et al, “Gluteal Muscle Activation During Common Therapeutic Exercises,” JOSPT 2009 July 1; Volume 39, Issue 7: pg 532-540
2. Grimaldi, A. et al, “Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management,” JOSPT 2015 October 31; Volume 45 Issue 11: pg 910-922

[David Brown]

Sarah,

I think this is a very interesting reflection on your experience with this condition, because like you, I have had trouble diagnosing it and recognizing it with some patients as well. I feel like I am very quick to assume it’s related to tightness in the TFL and glute max causing compression of the GT via the IT band when in reality that is just one of many causes that could be contributing to pain in this region. Like you, I have treated patients with lateral hip pain with limited relief in their symptoms that would leave me scratching my head. I am curious, once you picked up on the fact that your patient was presenting with gluteal tendinopathy, how did you go about dosing your patients and from there, how did you plan your progressions? Did you prescribe exercise purely based on goals and functional limitations or did you start your patient on one of the progressions outlined in the literature provided?

[David Brown]

In the few patients that I have worked with that have gluteal tendinopathy the common theme is moderate to severe and disabling pain that can impede the patient from being able to engage in recreational activities or worse, their ADLs. In terms of how I gauge how much to load/unload a patient, I typically base it off the patient’s severity/irritability of symptoms. If a patient begins to experience pain 2 miles into a run versus not being able to even walk because of pain will directly inform me of how aggressive to begin the patient. In addition, I typically will have the patient perform a LQ functional exam and assess for any faulty movement patterns such as excessive adduction moments created at the hip with SL loading. Grimaldi and Fearon demonstrated that there are multiple sound clinical tests to reliably and confidently diagnose gluteal tendinopathy that I plan to use in the future when I suspect this pathology. SLS is something I have always used with these patients but more the purpose of balance and not pain provocation and I never put very much emphasis on how the test feels to the patient compared how their balance was and how much pelvic drop was present. Moving forward, I plan to incorporate many of the tests outlined in this commentary to better improve my own confidence that my diagnosis is correct.
Following the course series last weekend as well as the research provided for this discussion, I have discovered that I have more or less overlooked potential postural contributions that the patient has engaged in at home and put all of my postural related focus on my functional exam. Grimaldi and Fearon did a fantastic job of outlining many postural faults that the patient could be inadvertently engaging in in their daily life that can explain a vast majority of their symptoms. This is something I plan to incorporate in future patients with this condition. Dr. Grimaldi also highlighted these points and went on to stress the importance of educating the patient on avoiding sustained positions with the legs adducted to avoid the strain that is ultimately induced at GT and over the tendons of the glute med/min.
I also enjoyed the loading progressions outlined in Dr. Grimaldi’s article as many of these exercises that were included I have prescribed to my patients for the same purpose. I would say one thing I have overlooked is the progression of these exercises by starting with a more basic form of a squat before going to a SL squat or a step up. I often will start a patient with both a bilateral squat and a step up which are on opposite sides of the spectrum in terms of intensity. Moreover, I have also made the mistake of putting a decent amount of focus on mobility exercises for the glute max and TFL with the purpose of trying to relieve the pressure and compression being imposed on the GT via the IT band, something that both the LEAP and GLoBE protocols in Dr. Grimaldi’s article advised against.
I also enjoyed Beneck et al’s research that was cited over the weekend’s course series pertaining to minimizing TFL activation when performing glute strengthening exercises. After learning more about the importance of minimizing the amount of stretching to perform for the TFL and glutes, it makes sense that with patients trying to recover from this pathology to perform glute strengthening exercises that midgate the amount of TFL activation and thus further compression over the GT. These exercises are something that I plan to incorporate more readily into my patient’s POCs going forward, especially in the early states of rehab when the patient is in pain.
Lastly, if conservatie management fails and the patient has not responded or improved over the course of 6-8 weeks, I have no problem explaining the advantages and disadvantages of steroid injections to calm down the bursa and any other inflammation that could be driving the patient’s pain. Following the injection, this could open a temporary window where we can continue to strengthen the patient with lesser degrees of associated pain in the hopes that when the injection wears off, the patient is in a better place strength wise and hopefully the pain won’t return to the same level.

Grimaldi, A. et al, “Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management,” JOSPT 2015 October 31; Volume 45 Issue 11: pg 910-922

Grimaldi, A., (2021, September 20). How physiotherapists treat gluteal tendinopathy. Dr Alison Grimaldi. Retrieved December 15, 2021, from https://dralisongrimaldi.com/blog/how-physiotherapists-treat-gluteal-tendinopathy/
Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy, 43(2), 54-64.

[Sarah Frunzi]

David,

I enjoyed reading your post and can relate to several of the topics you addressed. I too have made the mistake of incorporating stretching and mobility work to that region that was only adding to the compression issue of the tendon. This is an area I have improved on since then and will change my practice pattern moving forward! I also can related to your statement of broadening the utility of certain tests and looking at them in different ways, such as SLS, to gain more comprehensive information and data in the patient presentation. I also have broadened my knowledge on postural assessments as well, and incorporated this into my patients treatment plan after this past weekend and Dr. Grimaldi’s article. I found this to be an area that could make a significant impact on symptoms if educated properly since these are positions the patient could be sustaining frequently throughout the day. Thank you for your thoughts and commentary!

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