Thank you.
SPEAKER_01:One of the worst aspects of gluteal tendinopathy is the night pain. So when you lie on your side, you're obviously compressing the tendon on the side that you're lying on. So it gets sandwiched between your great trochanter and the bed. But even when you lie on your good side and your thigh adducts across your body, that adduction component creates this kind of hidden compression as well between the great trochanter and the iliotibial band. So you can't sleep on the bad side. You can't sleep on the good side. And that causes people a lot of sleep distress and that can be one of the worst aspects of it.
SPEAKER_02:Gluteal tendinopathy can be quite common around the clinic and today we had Henry Wiles will now come through to talk to us about assessment, common diagnosis and misdiagnosis as well as a bit of a treatment guide on how to help patients with this condition. We also discussed some things around lifestyle modification and how cortisone can be quite powerful for pain but not super helpful for the condition itself. Now Henry's gone a lot deeper in a physio network masterclass. We're going to include that in the show notes. You can have a free trial for seven days if you haven't signed Please enjoy this episode. My name is Michael Risk, and this is Physio Explained. Welcome, Henry, and thank you for joining us.
SPEAKER_01:Thank you so much for having me, Michael. I'm really excited to be able to talk about the topic of gluteal tendinopathy.
SPEAKER_02:Yeah, you've recently done a Physio Network Masterclass on gluteal tendinopathy, so we're going to spend some time talking about that today. Henry, what's your name? Let's start with the prevalence because we're talking off air about how it's common and commonly misdiagnosed as well. So could you tell us more?
SPEAKER_01:Yeah. Well, gluteal tenopathy is the lateral buttock pain. Buttock pain is a really common symptom that a lot of people have and it's often misattributed to sciatica. That's referred to from the back or piriformis syndrome or sacroiliac problems, that sort of thing. But if it's lateral buttock pain out above that area of the grave rotanda and it's really well localized, and it fits within a pattern of signs and symptoms that we talk about in the masterclass, then it's highly likely to be gluteal tendinopathy or greater trochanter pain syndrome, which is the same thing.
SPEAKER_02:Are we talking glute med tendinopathy or glute max?
SPEAKER_01:Primarily, it's gluteus medius tendinopathy. Now, the gluteus medius tendon is my favorite part of the body. It's a massive tendon. tendon, the largest tendon. It's as big as the palm of your hand. People don't realize how big and powerful the structure is. The gluteus medius is a really big, thick, strong muscle, or it should be, and often it's not. It's often very atrophied and weakened, particularly women more than men suffer this problem. And the weakness and dysfunction of the glutes is one of the triggering factors. So commonly, gluteus medius, I would say 90% of lateral hip pain, gluteal tendinopathy is the medius. The rest is shared between minimus, which is much less common. And then you've got other conditions that aren't really gluteal tendinopathy, which is like proximal hamstring tendinopathy, TFL problems, and that sort of thing. But now we're starting to move away from the actual diagnosis of gluteal tendinopathy.
SPEAKER_02:I'm just rewinding. When I was a young clinician, I was I was like, how did I know if it was tendinopathy or if it was bursitis or am I misdiagnosing something from the back? Do you still grapple with that?
SPEAKER_01:Well, it's something we deal with all the time because bursitis is the secondary pathology. Usually, tendinopathy happens first. Bursitis is the old school diagnosis and we talk about the change in the model of of managing lateral hip pain and beginning with the correct diagnosis. And it was actually about the change in imaging and a better clinical reasoning process when the realization came that it's tendinopathy primarily and not bursitis. The bursitis is secondary. We think that fluid probably seeps from the tendinopathic area into the bursa. There are many bursa on the lateral side of the hip. They're inconsistent. They're called adventitious bursa. They can swell up, they can rupture, and they can regrow. But the primary problem actually is gluteal dysfunction that leads to the tendinopathy and then bursitis as a secondary issue. With that, the old management was cortisone injection into the bursa and everyone thought, well, that's it, we'll fix the problem. But we all know that's not the reality. And the gluteal function remained and the tendinopathy remained. So the cortisone injection is a powerful painkiller, but it usually doesn't last. Some people can be lucky it lasts months or even longer, but most people, their pain recurs fairly quickly.
SPEAKER_02:So it sounds similar to... I'm thinking of shoulder pathologies and the movement of the language and the diagnosis more to an umbrella term. Have you noticed a similar pattern?
SPEAKER_01:That's exactly right. There's been that movement of ideas around causative, what's the causative factor and trying to address that. the root cause, which is that gluteal amnesia, which is what a lot of people use that term. And it's the muscle atrophy. Muscle doesn't actually disappear. It's still there, but it converts to this fatty atrophy and the muscle becomes dysfunctional. So once your gluteus medius isn't working properly for you, it can alter your gait and you get this instability in the gait that can be a trigger for more pain. But once the tendinopathy sets in, really everything aggravates it and particularly compression. Compression happens in sitting, just in normal sitting. And we all know that sitting is the enemy for a lot of human conditions, but sitting puts compression first. So tell
SPEAKER_02:me more about what you're noticing as a contributing factor. You mentioned dysfunction, amnesia, and I'm seeing a lot of people speak about, well, we obviously don't forget how to use our glutes, but when you say that, are you like they're not a strop?
SPEAKER_01:I think people do actually forget how to activate their glutes. It's not necessarily a conscious thing, but I think a lot of physios will resonate with this idea that people just have forgotten how to activate and use their gluteal muscles. And you ask somebody like tighten your glutes and they can't do it, or they have an imbalance of one side to the other, or their glutes aren't working at the time that they need to use their glutes. So one of the triggering factors over the last three years with a lot of things was just The impact of COVID and people spending more time inactive or sitting at home, working from home, perhaps in suboptimal sitting positions. So if you sit too low with your hips flexed past 90 degrees, there's already a compression on the gluteal tendon. And we demonstrate that in the masterclass. We show that in that section part of the presentation. Adduction puts pressure on the tendon. So crossing the legs is a causative factor as well. And one of the worst aspects of gluteal tendinopathy is the night pain. So when you lie on your side, you're obviously compressing the tendon on the side that you're lying on. So it gets sandwiched between your greater trochanter and the bed. But even when you lie on your good side and your thigh adducts across your body, that adduction component creates this kind of hidden compression as well between the greater trochanter and the iliotibial band. So you can't sleep on the bad side. You can't sleep on the good side and that causes people a lot of sleep disturbance and that can be one of the worst aspects of it so that's another trigger the third one which is typical of all tendinopathies is some kind of spike in load and we were talking about this earlier off there about COVID did two things. It initially made some people very inactive. Some people swung the other way and went out on a massive fitness kick and a walking program, and that created a spike in load. Or they've come back to an exercise program after being inactive for so long. That's another spike in load. The other one that's typical is, as it's been ironically less of, is overseas travel. When people suddenly go on a big trip somewhere and they start doing a lot more walking, a lot more charging up and down hills and steps and stairs and that sort of thing, that's another trigger. So they can acutely injure the gluteal tendon then as an overuse, an acute overuse episode and then it cycles into, as we all know, a pain and disuse cycle and then that can really perpetuate the problem and it can really last a very long time.
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SPEAKER_02:Yeah, often when people go on holidays, they spike their load. I've definitely noticed that pattern. You mentioned earlier, I was interested in this, you were saying that there's atrophy and fatty infiltration. Are you seeing that on imaging when there's less activity?
SPEAKER_01:Yeah. Absolutely. So that's a common scenario, not just in the gluteal muscles, but we see that muscle, it's sort of an urban myth that your muscle turns to fat if you don't use it, but it's actually true. So you get this fatty infiltration with the atrophy. And then at the same time, a disconnect between the brain and the muscles that we're all familiar with in the concept of the chronic low back pain or other VMO atrophy in the knee, the same sort of thing happens with the gluteal muscles when you have great counter pain syndrome or lateral hip pain. And a lot of the rehabilitation is about initially waking the muscle up. So I use that sort of terminology, your muscle's kind of asleep, it's still there, but you can wake it up and here's how to do it. And you've got to be careful not to over exert the muscle when it's in its weakened atrophied state because that can make problems worse. So you have to have a pretty careful staged approach. We show that very clearly in the masterclass about how to begin with the reactivation of the muscle, start loading it in the correct positions that don't put compression onto the gluteal tendon. We actually avoid a lot of single leg work in the beginning. A lot of work is done on two legs, avoiding that temptation of just charging towards the weakened leg too quickly, staying away from single leg work for a while and just getting that gluteal muscles. Again, that's a big part of the rehabilitation.
SPEAKER_02:So take me through, I guess, a simple common few exercises you would do at each of those stages, Henry.
SPEAKER_01:When it's tendinopathy, we now know from a lot of research that isometrics are effective for strengthening the tendon but also managing the pain. So we start with a pretty simple isometric with a belt around the thighs. We've got to find the right position. Finding the right position for the exercise is crucial. so that we don't actually induce more pain and incorrect types of load on it. We might have to regress the exercise all the way back down to lying supine with a belt around the thighs. Now, it's not a rubber band. It's actually an inextensible, either a leather belt works really well, or a luggage strap or a seatbelt or something like that. So it's different to what a lot of people do. They get a TheraBand around the thighs and they start doing resisted abduction, but that's not an isometric. And we actually need the isometric in the early stages to control the pain. So then that goes to three main exercises in the beginning are the belt isometrics, some form of bridge exercise. And again, we've got to be careful how we thrive and execute that bridge because that can trigger cramp in the hamstring. Remember, many of these people are already very weakened and debilitated. They're a bit older. This is really common in the 50 to 70 age group in those decades. Women, the perimenopausal time of life when women losing estrogen, and we know that estrogen is protective of their tendons. Sometimes men get this problem on the background of disuse atrophy or on the background of hip replacement surgery because postrolateral hip replacement, the gluteal tendon is damaged and it can lead to problems after that. So there are bridge and then there is some form of squat. Now, there's a thousand different ways to do a squat, but we've got to find a way that the person can execute a squat actually using their gluteal muscles rather than their quadriceps muscles. So we use a supported back squat and there's a few examples of that in the videos in the masterclass. So there's the three main exercise pillars.
SPEAKER_02:I love it. That's really clear and I'm just like building a mental framework as you went through that. To wrap up, Henry, I wanted to finish on, you mentioned working around the pain and when you might regress. In your experience, are you comfortable with a little bit of pain or do you prefer it to stay away and build up? How do you approach that?
SPEAKER_01:A lot of that is education with a patient about what's acceptable and what's not acceptable. We basically make a contract that I'm only going to allow or we're going to accept a line of, say, two out of 10. For example, when people are doing the exercises, we want them to feel comfortable. the area working, but mild discomfort only one or two out of 10. If they're walking, we don't want them to stop walking altogether, but they should only walk to a pain threshold limit of say three out of 10, but that's variable between time. And I just want to finish up on this point of education. It's really crucial. The ergonomic changes or the lifestyle changes, which are a big part of the management of gluteal tenopathy. So sitting higher, sitting with the hips above the knees, sleeping with a pillow between the knees and so forth. standing on two legs rather than distributing the weight rather than standing only on one leg. So they're just examples of the educational part of the management of gluteal tenopy that this has been tried and tested through a study called the LEAP trial, which was a randomized controlled trial that I was involved with a big team at the University of Melbourne and University of Queensland. So it was found that education part is really 50% of the outcome. It's so important to educate people about what is acceptable for them to do and not acceptable and how to change their lifestyle in particular, their postures at home and at work to manage the problem in the long term.
SPEAKER_02:That's really crucial because they could do everything right in the clinic with you and miss the other 98% of their day. So I'm glad you finished with that. Thank you so much for your time today, Henry.
SPEAKER_01:Oh, thanks. I enjoyed that. It was amazing. Thanks so much, Michael.
SPEAKER_02:And just a reminder, if you want to go deeper on this subject with Henry, we have a link to the show notes on the Physio Network Masterclass. Please check that out.