Gluteal tendinopathy, or pain and tenderness over the greater trochanter (lateral hip pain), is prevalent and impacts on quality of life, in a similar way to end stage hip osteoarthritis. Consensus for successful management of tendinopathy focuses on load management. Load management was delivered as an education and exercise package in the recent LEAP trial. The trial looked at education plus exercise versus corticosteroid injection versus wait and see on global outcome and pain from gluteal tendinopathy.
The study found that an education, load management, and exercise programme for gluteal tendinopathy resulted in greater rates of global improvement than corticosteroid injection use and wait and see. Corticosteroid injection use was more successful than the wait and see approach only in the short term.
Alison George, a participant from the LEAP trial recently contacted us to express gratitude after undergoing the education and exercise programme (completing the trial February 2015). She was a typical patient with persistent gluteal tendinopathy (i.e., post-menopausal female, high BMI, weak hip abductors) and MRI findings of gluteus medius and minimus insertional tendinopathy.
“I volunteered on the basis of nothing to lose. I felt old for my age, led a sedentary life, and had walked with a lot of hip pain for many years. Placed in the physiotherapy group, the reality of having to exercise, and regularly, was a shock. The sessions eased me into the exercises, which I continued at home. I was surprised by the reduction in pain achieved in relatively short period of time. I was more surprised that the ongoing reduction in pain became the inspiration to never go back to ‘ground zero.’
I found the support, encouragement, and help to complete the exercises properly to be invaluable. The professional guidance and corrections to my technique in those early weeks meant I never forgot how to do them properly.”
Alison reported that she was very much better and has continued to remain pain free, while becoming more active. She now participates regularly in Pilates and fit boxing sessions.
Alison’s physiotherapist, Rod McLean, was similarly positive about being involved in the education and exercise programme.
“Participating in the LEAP trial as a physiotherapist was a very positive experience. I observed substantial improvement within 2-3 weeks in patients with long standing lateral hip pain. This was reassuring because the programme utilized contemporary evidence of providing a comprehensive education package alongside the exercise, which was quite different to my experience in other exercise trials where treatment responses were small.
“I think that the early positive responses could be ascribed to the education component. It was critical to settling the pain and in performing the exercises with appropriate form. I recently managed a patient with long standing lateral hip pain who had undergone nine months of prescribed exercises, similar to those in the LEAP trial, but without the education component of the education and exercise programme. I simply added the education component and removed some higher-level exercises over the first month, and her pain subsided. We then progressed exercises in the subsequent two months and her pain completely resolved. This reinforced my observations that the education component is critical.
“There is evidence that patients with long-standing lateral hip pain will have weak gluteal muscles, which require exercise to rebuild capacity and enable performance of normal daily activities. A unique feature of this exercise programme is the linkage with education, ensuring correct performance of the exercises.
“I still use the education and exercise programme clinically although in the private sector some patients are unable to attend as frequently, so I tend to see them once weekly for 8 weeks (14 sessions/8 weeks in LEAP trial). Regular visits are necessary to deliver and reinforce the information in the education package, as well as to institute, monitor and progress exercises.”
While the LEAP trial studied a specific education and exercise programme, against widely used steroid injection and control, it remains unknown whether other exercise programmes or variations of the LEAP programme are as effective.
Further research into customising the education and exercise programme to individual patients is required. For example, some patients with small strength deficits may benefit from a focus on education rather than supervised exercise, whereas patients in persistent pain, associated psychological distress and larger strength deficits may require more comprehensive care.
The high rate of global improvement following education and exercise compared to wait and see or corticosteroid injection provides a positive and empowering perspective for both patient and clinician in a condition that is notorious for poor outcomes and quality of life, with few options of proven medical treatments.
Bill Vicenzino is the Chair of Sports Physiotherapy in the University of Queensland School of Health and Rehabilitation Sciences, and Chief Investigator in the National Health and Medical Research Council funded Program grant: ‘Musculoskeletal pain and disability: improving outcomes through conservative measures’ and the Centre of Research Excellence grant: ‘Translation of Research into Improved Outcomes in Musculoskeletal Pain and Health.’ Tweets: @Bill_Vicenzino
Rebecca Mellor is the Senior Research Officer in the University of Queensland School of Health and Rehabilitation Sciences in the National Health and Medical Research Council Program grant: ‘Musculoskeletal pain and disability: improving outcomes through conservative measures’. Lower limb musculoskeletal conditions are the focus of her work.
Alison Grimaldi is an Australian Sports Physiotherapist, the principal of Physiotec Physiotherapy Clinic in Tarragindi (Queensland, Australia) and an Adjunct Research Fellow for the University of Queensland School of Health & Rehabilitation Sciences. Her clinical and research specialty is the management of hip pain. She posts regularly on twitter: @alisongrimaldi
Acknowledgement: Thanks you to Alison George and Rod McLean for their comments.
Patient consent obtained
Competing interests: Please see full declaration of competing interests on the research paper.