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Happy almost Halloween! In honor of the season, I decided to write about something ~spooky~ - pain in the boo-ty! Pain in the outside or lateral part of the hip is a common site of hip / glute pain, especially in runners. This lateral hip pain is often lumped under the diagnosis of "Greater Trochanteric Pain Syndrome," and the most common cause of this is gluteus medius [glute med] tendinopathy. In fact, glute med tendinopathy is the most common lower limb tendinopathy! It most commonly affects females aged 40-60, and is most often caused by a degenerative process that happens overtime, not from a singular, acute incident.
What is the gluteus medius anyway?
Glute med is the intermediate gluteal muscle, sandwiched between the smaller gluteus minimus, and the larger, superficial gluteus maximus. It has a fan-like shape spanning from the greater trochanter (a large, bony prominence on the outside of the thigh bone) to the ilium (pelvis bone).
And what does it do?
Glute med functions to bring the thigh bone away from the body aka abduct the hip. Glute med also secondarily functions to internally rotate and flex the hip (anterior/front fibers) or extend and externally rotate the hip (posterior/back fibers). Most importantly for us two legged folks, it helps maintain hip stability when standing on one leg, which happens during walking and running. This is especially important because frontal plane instability at the hip - hip drop - affects the trunk, knee, and ankle. See below how right hip drop (left hip dropping below right hip) causes a right trunk lean.
What are tendinopathy symptoms?
People with gluteus medius tendinopathy will often experience pain in the outside of the hip. This pain is usually exacerbated by walking or running, lying on the affected hip, and palpation of the greater trochanter. In addition to identifying clinical markers consistent with glute med tendinopathy, an MRI or ultrasound can further diagnose the injury, and if necessary identify if there is a partial or full tear of the tendon.
How can this be treated?
Physical therapy and prescriptive exercise is often first line treatment for glute med tendinopathy. Mellor et al. 2018 found greater patient satisfaction and less hip pain after 8 weeks of therapeutic exercise intervention than after "wait and see" or a singular corticosteroid injection. Working with a physical therapist is important because glute med tendon injuries can vary greatly from person to person, and an individualized approach is key to improving outcomes. Physical therapy treatment will usually involve a period of decreased intensity of activity to reduce irritation of the tendon, strengthening of the gluteal muscles and deep core muscles, and progressive return to activities that were previously painful. Manual treatments including dry needling can be very effective in addressing muscular trigger points that can increase hip pain and impair the glute's ability to fire efficiently.
Outside of physical therapy, an orthopedic or sports medicine physician may recommend PRP injections, which have good outcomes at two years; corticosteroid injections, which have a short term beneficial effect; or shockwave therapy, which has a high level of evidence. These therapies seem to be effective in grade 1-3 injuries, which range includes bursitis, tendinopathy, and partial thickness tendon tears. Surgical repair of partial and full thickness tears (grades 3 and 4) have only a low level evidence to support this type of intervention (Ladurner et al., 2021).
Don't let some hip pain spook you into dropping out of a race or stopping your favorite activity! If you have pain in your glutes or elsewhere, get scheduled with one of our physical therapists who can help you to get back to doing what you love! No tricks!
Thanks for reading!
Dr. Elizabeth Karr PT, DPT
References:
Ladurner A, Fitzpatrick J, O'Donnell JM. Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthop J Sports Med. 2021;9(7):23259671211016850. Published 2021 Jul 29. doi:10.1177/23259671211016850
Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:K1662.