Chronic Hip Pain
Has your physician diagnosed you with hip bursitis, but injections have failed to yield long term results? You may actually have gluteal tendinopathy, which requires a different approach to care and recovery. Greater trochanteric pain syndrome (GTPS) has been defined as lateral hip pain to touch, pain can radiate down the outside of the thigh and into the posterior hip, but rarely to the knee. Previously, it was the cause was attributed solely to trochanteric bursitis. However, the origin of pain can include trochanteric bursa, gluteus medius and minimus tendon tears, tendinitis, or iliotibial band irritation. In this study, MRI imaging showed that trochanteric bursitis was an uncommon finding and was not found in isolation; when found bursal distension coexisted with gluteal pathology. Recent studies have found that gluteal tendinopathy to be the primary cause of lateral hip pain. The greatest incidence of GTPS often occurs between the fourth and sixth decades of life with a female ratio of 4:1.
Recent studies of gluteal tendinopathy demonstrate the deep undersurface fibers of the gluteal tendons preferentially develop pathology. Tendinopathy has been described as a continuum of tissue pathology which can be classified as reactive, degenerative, or reactive-on-degenerative phases. These phases represent the various stages of tendon damage. If addressed in the early stages, this can easily be reversed and your pain can be alleviated through simple changes, perhaps rest and over the counter anti-inflammatories.
If however, your hip pain has been problematic for some time it is likely that you have developed tendinopathy and not just tendinitis. This can be a much more difficult condition to treat, often necessitating interventions such as percutaneous tenotomy (such as the Tenex).
Exercises can be effective, however they need to be highly specific in their application and progressive loading. Isometrics are a good place to begin. Isometrics are muscle contractions without movement. Isometrics have been found to reduce pain, and reducing cortical inhibition of muscles; helping them ‘wake up’ and to function better. Generally, clinical management of tendinopathy should include aspects of load management, patient education, progressive increase in mechanical loading and a gradual return to activity. With or without a tenotomy depending on your response to these exercises.
Strong levels of evidence supports performing prolonged isometric contractions 5 repetitions of 45-60 seconds, 2-3 times per day, progressing between 40%-70% maximal voluntary contraction. 1-2 minute resting periods between contractions. Isometric exercises can be done using an exercise band, sidelying abduction (affected side uppermost and pillow between legs) or standing. All exercises should be done in slight abduction to avoid compression of the undersurface of these deep tendons.
Corrective Interventions include postural changes to reduce hip adduction (sitting, sleeping and transitional positions). Avoid lying on the affected side, avoid crossing legs, avoid piriformis, ITB and adductor stretching. Avoid uneven lower extremity weight bearing and avoid running on uneven surfaces.
For a brief discussion on early rehab for gluteal tendinopathy, specifically following a Tenex percutaneous tenotomy, see DrJed.com, Hip pain, Gluteal Rehab Level 0.
The Ohio State University, Wexner Medical Center, 2020.
Robin A. Sopher, PT, DPT; Ann-Marie Walters, PT, cert MDT