What is Gluteal Tendinopathy (aka Hip Bursitis)?
Are you suffering from pain on the side of your hip? If so, you might have gluteal tendinopathy.
Are you struggling to lie on your side at night because of pain?
Maybe you’ve been experiencing pain when you’re walking, or going up and and down stairs?
Gluteal tendinopathy is common problem that causes pain on the outside (lateral area) of the hip. You may also have heard terms such as ‘hip bursitis’ or ‘greater trochanteric pain syndrome’, which are other labels for this problem.
It’s most common in women who’ve gone through the menopause, but it’s also common in runners or people with hip joint stiffness.
What is gluteal tendinopathy?
Many people are surprised to learn that the actual ball-and-socket hip joint isn’t located on the side. It’s seated deep in the groin- much further towards the midline than most suppose.
The painful, lateral area, consists of an angle in the thigh bone, called the greater trochanter, the gluteal tendons, and a bursa, (which is a gristly sac that enables the tendons to glide around the trochanter).
We’ve got three gluteal muscles:
Gluteus Maximus (which is the biggest muscle, which extends our hip and gives us a round-looking butt cheek).
Gluteus Medius and Gluteus Minimis, which are very important muscles for stabilising the pelvis.
When the medius and minimis muscles are weak, or don’t fire with good control, we tend to drop at the hip.
This means that the gluteal tendons wrapping around the trochanter become excessively loaded and compressed. Much like an achilles tendon, they can become ‘tendinopathic’ (meaning the fibres of the tendon start to degrade).
When the gluteal tendons are ‘annoyed’, the bursa will often become inflamed, adding to the misery.
What causes gluteal tendinopathy?
Whether we’re walking, running, or climbing the stairs, we’re dependent on good strength and coordination of our glutes to hold our pelvis level. If our glutes are weak, or their firing is inhibited, we tend to drop at the hip, and this exessively compresses the tendons at the trochanter.
If you’re a runner and your glutes become fatigued, this can create poor loading of the tendons. The tendons can also become compressed in certain positions such as prolonged sitting with your legs crossed, or if you’re side-lying in bed.
Sometimes the way we’re put together can predispose us to gluteal tendinopathy, for example, if you’re born with particularly wide hips, or a bit of difference in the length of your legs.
If you’re new to a sport such as running, and your pelvic control is poor, you may drop at the hip when your foot hits the ground. A great deal of compressive and tensile force goes through the gluteal tendons at that time, and you might be aware of a sensation on the side of you hip at foot strike. Some runners will report having pain when the position is exaggerated when running on a cambered road.
If you up the mileage, and haven’t worked on the strength and conditioning work, you overload the gluteal tendons, which struggle to keep up with the demands placed upon them.
3. Other contributing conditions.
We’ve mentioned that going through the menopause increases your chances of developing gluteal tendinopathy, and that’s because the hormone oestrogen (which decreases after menopause) is important collagen regeneration.
Similarly, other conditions such as thyroid under activity can also affect tendon health.
And finally, let’s remember the mechanical role that a stiff lumbar spine, or a stiff, arthritic hip has to play in balance around the pelvis.
She is positive, listens, and takes a holistic approach to identify all of the contributing factors to the problem, rather than just narrowly focusing on an isolated site of pain or injury. She put together a team to ensure a clear path through rehab.
What are the symptoms of gluteal tendinopathy?
Typically, you’ll be experiencing pain on the side of hip (aka the lateral hip area), which might extend down your IT band in the direction of your knee.
You might notice it on a long drive, if you’re laying on the affected side at night time, or if you’re going for a run. When it’s particularly bad, it can make walking and even sitting a desk, painful.
How do I know it’s not hip arthritis or another problem?
Occasionally, osteoarthritis (wear and tear) hip arthritis can mimic gluteal tendinopathy, because it can sometimes refer pain into that area.
Sometimes sciatica or pain generated from inflammed facet joints in the low back can masquerade as a glutes problem.
If you don’t have pain the groin or limitation in your hip’s movement (e.g. when tying your shoe laces), it’s unlikely to be hip arthritis. If you’re very happy arching your back or touching your toes, the your back probably isn’t the culprit.
How is Gluteal Tendinopathy diagnosed?
Making a diagnosis of gluteal tendinopathy may seem straightforward, but it isn’t always the case. Most cases are diagnosed by simply taking a good history, and then examining the patient, but it’s important that you get a proper assessment to rule out other conditions which may masquerade or contribute to the problem.
When you come to clinic, I’ll listen carefully to your symptoms and the story of how your problem unfolded, and then I’ll watch you move. I’ll be looking for signs of tenderness over your lateral hip (trochanteric) area, and carry out some examination tests (such as ‘FABER’, ‘Modified Ober’s’ and ‘Slump’ tests).
Will I need any tests or investigations?
Sometimes tests may be needed to clarify the diagnosis of gluteal tendinopathy, especially if you’ve been going through treatment with your physio or osteo, but you just don’t seem to be making progress.
A musculoskeletal ultrasound scan can help clinch the diagnosis, and it may be done at the same time as an injection, if this is our proposed treatment.
MRI scanning of your hip (and sometimes the lumbar spine) may be needed to see if there are additional problems that are contributing to the gluteal overload. For instance, if you have a very stiff or arthritic hip, the abnormal biomechanics can unfairly load the glutes.
Sometimes it’s actually the lumbar spine that is referring pain to the side of the hip e.g. when there is compression of a nerve root by a disc (aka ‘radiculopathy’, often known as ‘sciatica’), and worn facet joints or irritation within the sacroiliac joints can also refer pain in this way.
What is the treatment for gluteal tendinopathy?
Thankfully, most cases of gluteal tendon pain can be readily treated with physical rehab with a physio or osteo who is skilled in treating this kind of problem.
There is a good deal you can do to help yourself.
We know that when your gluteal tendons are put in a position of prolonged compression, they can become very irritated. Try to avoid sitting with your legs crossed, and when you’re standing, don’t hang off your hip. If you can avoid sleeping on your side at night, that helps too.
We also know that stretching your lateral hip area can lead to tendon compression – so avoid those kinds of stretches if you’re in a gym class.
The mainstay of the physio treatment is all about retraining your movement patterns (especially your gait), and loading the hip in a graded way.
There’s been lots of research into the kinds of exercises that are really helpful for rehabbing your glutes – here come the technical terms – isometric abduction work, progressed forms of bridging, functional loading through squatting, and frontal plane abductor loading.
If you’ve mainly been given ‘clam’ exercises (which might even be aggravating things), you may need a change of direction in your rehab.
Dr Spencer Smith is a very nice, caring, and comprehensive doctor.
But what if I’m still not getting better?
Sometimes the diagnosis may need clarifying if you’re still not getting better with physio or osteopathy.
Ultrasound-guided steroid injections
We know from the ‘LEAP’ trial that in the longer term, the right kind of rehab and education is the way to go.
If you’re really struggling with pain, then you might benefit temporarily from an ultrasound-guided steroid injection to reduce pain and inflammation, but this is only a short-term game, and it’s really important that you do the rehab.
Shockwave therapy is a relatively new treatment for gluteal pain – you may have heard of shockwave being used to treat conditions such as plantar fasciitis in the foot.
If you’re struggling to walk because of the pain in the side of your hip, a course of shockwave therapy can help reduce pain, giving you a ‘window of opportunity’ to do the rehab work.