Gluteus medius

& proximal
hamstring
tendinopathy
Dr Alison Grima ldi
BPhty, MPhty(Sports), PhD
www.dra lisongrima ldi.com

Presentation
Gluteal Tendinopathy

Pain over GT
Some radiation
Impact:
Extends most commonly
down lateral thigh Sleep disturbance
Significant functional
Pain with: limitations

Sidelying Reduced activity levels

SLS eg to dress
Walking *upstairs/uphill Fearon et al 2014

Rising from sitting

Running/COD

Terminology & Pathology

Trochanteric bursitis?? ITB Thickening – 29%
- Not 1° pathology
- Only 20% of 877
- Inflammation??
Bursal distention
Gluteus medius &/or minimus
tendinopathy +/- tear
- 1° pathology
Greater Trochanteric Pain Syndrome
- Umbrella term

(Kingzett-Taylor et al., 1999; Bird et al., 2001; Connell et al., 2003; Pfirrmann et al.,
2005; Kong et al., 2007, Silva et al., 2008; Fearon et al., 2010; Long et al., 2013)

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 Prevalence

Older In those with In those with Athletic

population LBP hip OA population
F: M 3-4:1
20-35% 20% Anecdotal
F:23.5% M:8.5%
GMT tears Runners
50-70 age group Collee et al 1991
Segal et al 2007 Tortolani et al 2002
Howell et al 2001 Step training

Prevalence
Tendinopathy PR IR
Adductor 1.22 1.13
Tendinopathy
GTPSyndrome 4.22 3.29
Jumpers Knee 1.60 1.60
Achilles 2.35 2.16
Tendinopathy
Plantar Fasciopathy 2.44 2.34
PR: prevalence rate per 100 person-years; IR: incidence rate per 1000
person-years. Albers et al 2014. Presented at recent ISTS, Oxford

Greater Trochanteric Pain Syndrome was the most

prevalent tendinopathic condition seen by GP’s in the
Netherlands in 2012.

Pathoaetiological
Mechanisms

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 Adaptation to tension
INS

Adaptation to compression

ITB ITB thickening

Troch Bursal distention
bursa
Production of larger
proteoglycans – gel
matrix
SubGM
bursa GT
Hydrophilic
Shift to cartilage like cells
Excessive Reduces tensile
Compression loading capacity
(Almekinders et al 2003, Cook & Purdam 2012)

What causes compression at the GT?

ITB

Neutral Add/Abd 10° Add 40° Add

4N 36N 106N
(Birnbaum et al 2004)

Muscle factors

ITB Tensioners Trochanteric Abductors

Abductor Synergy

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 Muscle factors
Increase tension in the ITB

Activity of ITB Tensioners

amplifies compressive effect
of adduction

Mechanical advantage in
adduction

ITB Tensioners
TFL, UGM, VL

Muscle factors
Better lever arm than
ITB tensioners for pelvic
control

Allow function in
minimal adduction

Trochanteric Abductors
GMed,GMin

Changes assoc with gluteal tendinopathy

Glute Med & Min atrophy Normal
TFL hypertrophy

TFL

GMin
Ant GMed
Mid
Post

Pfirrman et al 2005, Sutter et al 2012

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 Diagnosis

Diagnostic Utility Study

Dr Alison Grimaldi1,2, Dr Rebecca Mellor2, Professor Kim Bennell3,
Professor Paul Hodges2, Professor Bill Vicenzino2

Lateral Hip Pain Trial – LEAP Trial

LEAP is funded by the National Health & Medical
Research Council Program Grant (#2012000930)

Aim: Determine the diagnostic utility of clinical

tests for gluteal tendinopathy, using MRI as
reference standard
• 60 patients with lateral hip pain
Recruit Age: 54±9yrs BMI: 28.2±kg/m2

• Battery of clinical tests (Blind to MRI)

Clin Ax

• Diagnostic MRI (Blind to Clin Ax)

MRI

• Sensitivity, Specificity, PPV, NPV, LR

Stats

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 Clinical Test Battery
Palpation +
FABER FADER/R ADD/R SLS

+ve Test = reproduction of pain at GTrochanter

Clinical Diagnosis of Gluteal Tendinopathy (CDGT)
= +ve Palp & 1 other

PALPATION
SN SP PPV NPV +LR -LR
PALP 83 43 0.83 0.43 1.5 0.4

High sensitivity, Low specificity

Best –LR

-ve Palp Unlikely to have

gluteal tendinopathy
Sensitivity (SN): % of people with +ve MRI who test +ve on the clinical test
Specificity (SP): % of people with –ve MRI who test –ve on the clinical test
+LR: Identifies strength of test in determining who will have +ve MRI
-LR: Identifies strength of test in determining who will have -ve MRI

FABER F/ABD/ER

SN SP PPV NPV +LR -LR

FADER 46 79 0.88 0.31 1.6 0.8

Low sensitivity
Good specificity

Sensitivity (SN): % of people with +ve MRI who test +ve on the clinical test
Specificity (SP): % of people with –ve MRI who test –ve on the clinical test
+LR: Identifies strength of test in determining who will have +ve MRI
-LR: Identifies strength of test in determining who will have -ve MRI

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 FADER 90°F/ADD to EOR/ER to EOR

FADER-R FADER + Isometric IR

SN SP PPV NPV +LR -LR

FADER 33 79 0.83 0.26 1.6 0.8
FADER-R 48 86 0.92 0.33 3.4 0.6

Low sensitivity, Good specificity

All values improved by the

addition of the active
component
Sensitivity (SN): % of people with +ve MRI who test +ve on the clinical test
Specificity (SP): % of people with –ve MRI who test –ve on the clinical test
+LR: Identifies strength of test in determining who will have +ve MRI
-LR: Identifies strength of test in determining who will have -ve MRI

ADD & ADD-R

SN SP PPV NPV +LR -LR
ADD 22 79 0.83 0.23 1.0 1.0
ADD-R 41 93 0.95 0.32 5.9 0.6

All values improved by adding

the active component

Low sensitivity, high specificity

+LR for ADD-R: Moderate effect

Sensitivity: % of people with +ve MRI who test +ve on the clinical test
Specificity: % of people with –ve MRI who test –ve on the clinical test
+LR: Identifies strength of test in determining who will have +ve MRI
-LR: Identifies strength of test in determining who will have -ve MRI

SLS Sustained single leg stance (30s)

SN SP PPV NPV +LR -LR

SLS 42 100 100 0.34 58.6 0.6

Greatest diagnostic utility

Low sensitivity
Excellent specificity

+LR >50 = large and often

conclusive shifts in probability
Sensitivity (SN): % of people with +ve MRI who test +ve on the clinical test
Specificity (SP): % of people with –ve MRI who test –ve on the clinical test
+LR: Identifies strength of test in determining who will have +ve MRI
-LR: Identifies strength of test in determining who will have -ve MRI

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 Diagnostic tests
Lateral hip pain within Very likely to have
30 s of SLS gluteal tendinopathy
SLS, FADER-R, ADD-R Greatest diagnostic
(involve muscle cont) utility
Non-tender over GT on Unlikely to have gluteal
palpation tendinopathy
All tests, except palp,
had poor sensitivity ?? Poor tests

MRI is a poor predictor of

symptomatic tendon/bursal
pathology at the lateral hip

Blankenbaker et al 2008
90% of patients scanned for hip pain
have MR changes at the GT
Only 6% had lateral hip pain
(N=256)

Clinical tests may be more useful than

MRI for detecting a clinically positive
pathology

Hip Abductor functional deficits

SLStance SLS Gait

Excessive hip add – pelvic lateral tilt and/or shift

Trunk lateral flexion/shift

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 Management

Traditional Management
Anti-inflammatory Stretching
treatment

RATIONALE??

Commonly prescribed exercises

Compression issues
Open chain strengthening
appears to bias superficial
musculature

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 Contemporary Management
Decompression Exercise
Minimise amount of Optimise muscle
compression over each function & tendon
24 hour period loading

Decompression
MINIMISE:
Sustained, repetitive, or loaded
HIP ADDUCTION
HIP FLEXION > 90°
HIP FLEXION/ADD

HIP OUT KNEE ACROSS THE BODY

Decompression

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 Decompression: Sleeping

Decompression: Stretching

Exercise:
Graduated tensile loading under minimal compression
1. Isometric Abduction

2. Femoro-pelvic Control
during Functional Loading

3. Low Velocity-High
Load Abduction

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 Isometric Abduction

1. Improve motor control *trochanteric abductor

activation
Low load, low velocity exercises requiring focused attention
more effective in creating neuroplastic change & improvements in
motor control than general exercise (Tsao et al., 2010; Tsao & Hodges, 2007)
2. Reduce Pain
Sustained low intensity (25% MVIC) isometric contractions were
found to raise pressure pain thresholds (i.e. reduce pain
sensitivity)
(Hoeger Bement et al, 2008)

Functional retraining

Double leg Offset Squat Single Leg Single leg Step Up

squat Stance squat

Teach to control adduction during functional tasks such as

single leg stance, stair climbing, gait.
Also provides graduated increase in abductor loading
WB provides stimulus to deeper trochanteric abductors

Low Velocity-High Load Abduction

Weightbearing – positive for balance within synergy

Inner range abd– reduced mechanical advantage of sup abd’s
Allows graduation to high tensile loads with no compression

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 Home Alternatives

Sidestepping Doorway sideslides

Proximal Hams Tendinopathy

Presentation
Ischial pain
+/- post thigh pain or tightness
+/- paraesthesia post thigh
Often misdiagnosed as sciatica

Pain with:
Sitting, esp on hard surfaces,
Forward lean activities
Stairs, Walking esp uphill
Running – uphill, higher speeds

Patho-aetiology
Compression
Compression is key

deep tendon fibres

against ischium
(Cook & Purdam 2012)

*semimembranosis

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 Patho-aetiology

SM

ST&BF

SM ST BF

Anatomical models © Primal Pictures Ltd

Compression in hip flexion

* with muscle active
* with muscle & tendon at length
Increased use of hip flexion
may be associated with:

Excessive hip mobility

Habit
Ankle or knee restrictions
– unable to use triple flexion
Quads weakness

Effect of trunk inclination

Difficulty achieving
trunk upright
posture if:
Tightness of:
Calves/Ankles
Hip flexors/Jt

Weakness of:
Glute Max
Trunk Extensors

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 Effect of lower gluteal atrophy
Increased hams workload
Reduced padding over ischial tuberosity in sitting
Asymmetric atrophy
Axial MRI
- pelvic obliquity in
sitting
- increased load on IT
IT
affected side
GMax GMax
R

Diagnosis

Standing forward lean

+ve – reproduction of pain over ischium +/- thigh pain
Neck F/E to help differentiate SN
Bilateral Unilateral

HIGH LOAD esp if add step

& speed, or load

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 Heel Drag & Shoe Off
Symptoms of pain/discomfort at ischium
Standing Heel Drag Taking Off The Shoe Test
Bowman et al 2013 Reiman et al 2013

Isometric
hams
contraction

Puranen-Oravo Test
Symptoms of pain/discomfort at ischium
Stretch forward

Puranen & Oravo 1988

Cacchio et al 2012
Reiman et al 2013

Bent Knee Stretch

Maximal hip flexion + slow knee
extension to EOR or P1
Fredericson et al 2005

Modified Bent Knee Stretch

As above except the examiner
rapidly extends the knee
Cacchio et al 2012
Reiman et al 2013
Cacchio et al 2012

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 BKS + Active Loading
Active load superimposed on passive compression
+ Isometric knee flexion + Single leg bridge

Palpation

SM
CO

Copyright
Primal Pictures

Contemporary Management
Decompression Exercise
Minimise amount of Optimise muscle
compression over each function & tendon
24 hour period loading

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 AVOID
Hard chairs Stretching Forward lean
Hip F + Knee Ext or loading hams & bending from hips
on stretch

Decompression
Substitute with:

Exercise
Aims:
Reduce Pain
Address motor control issues
- excessive low load hamstring activation - guarding
- poor gluteus maximus activation
- lumbo-pelvic control
Load musculo-tendinous complex – Hip extensors
- Reverse atrophy
- Improve tensile loading capacity of hamstring tendons
- Improve ability of hamstrings to lengthen under load

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 Exercise:
1. Isometric Hams/Glutes
4 x/day; 10-45 secs; 5-10reps

2. Graduated Loading of
hip extensors
Low load daily
High load 3 x/wk

3. Lengthening under load

1-3x/week
Petersen et al 2011, AJSM 39(11)
for Nordics programme

Bridging

Double leg Offset Single foot Single leg Single leg

hover extensions dips

No posterior pelvic tilt – neutral Lx,

Gently preset lower glute max
Purpose - Lower limb patterning
- Strengthening glute max and hamstrings

Bridging with
higher hamstring bias
Allows more advantageous length tension relationship for
hams

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 Lengthening under load

Functional retraining

Double leg Offset Squat Single Leg Single leg Split lunge Step Up
squat Stance squat
Functional WB progressions
Minimise functional adduction
Initially minimise depth & fwd trunk inclination due to compression
Purpose - Lower limb patterning – improve fem-pelvic control
- Graduated increase in hip extensor loading

Other associated muscle groups

Hip abductor strengthening & Hip flexor strengthening &
endurance endurance

Inadequate pelvic control may To improve knee lift, and

result in increased use of thigh enhance ability of hip flexors to
musculature to stabilise from provide an increase in cadence,
below
as required

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 AVOID

Hamstring loading in hip flexion

AVOID
Hamstring stretching should be avoided
Cook & Purdam 2012, Lempainen et al 2009
Use massage, trigger point release, acupuncture/needling

Take Home Messages

Compression esp under high tensile loads
- High exposure - negative loading environment for
insertional tendons
- Useful for diagnostic testing
- Advise patients to avoid/minimise these loads
- Avoid/minimise these loads during
exercise/activity

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 Thank You
For further information
e: info@physiotec.com
Online Learning/Courses:
www.dralisongrimaldi.com

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