In “past, present, future”, we ask clinical or academic experts to reflect on selected Sports & Exercise Medicine topics. Today Alison Grimaldi on Gluteal Tendinopathy.
Tell us more about yourself
My passion for managing hip and pelvic pain has spanned a career of over 30 years. From my undergraduate degree at University of Queensland, through a Masters in Sports Physiotherapy and a PhD focusing on the hip abductor muscle synergy, I have been able to combine clinical practice and research into this fascinating area. As well as being the Principal of Physiotec in Brisbane, Australia, I am also a senior research fellow and teach on the Masters programs at the University of Queensland. I have conducted over 100 practical workshops worldwide and was a key member of the LEAP randomized clinical trial research team that examined interventions for gluteal tendinopthy. For health and exercise professionals, I have developed an educational website, including my Hip Academy at www.dralisongrimaldi.com.
What was hip and happening 10 years ago?
In the clinical arena, gluteal tendinopathy was more commonly diagnosed as trochanteric bursitis. This was underpinned by a strong belief that lateral hip pain was related primarily to an inflammatory condition of the trochanteric bursa. There was also quite an entrenched belief that the aetiological mechanism for trochanteric pain was a ‘tightness of the iliotibial band’, despite the lack of evidence of such a mechanism. These two assumptions were the basis for the ubiquitous treatments of the time – ‘stretching of the iliotibial band’ and anti-inflammatory treatments such as ice, electrotherapy and corticosteroid injection. If these failed, then surgical interventions to remove the offending bursa and/or lengthen the iliotibial band were undertaken.
The scientific literature was however beginning to question this diagnosis and it’s presumed aetiology. Surgical, imaging and histological studies demonstrated that the primary local pathology associated with trochanteric pain was in fact tendinopathy of the gluteal tendons. A clear inflammatory mechanism could not be established, and it appeared that compressive loads had an important role to play in the development of insertional tendinopathies. We knew this condition was highly prevalent particularly in post-menopausal women and that it was as painful and debilitating as advanced hip osteoarthritis. However, research had not elucidated impairments associated with the condition, and evidence regarding best interventions was lacking. The only non-surgical clinical trial included a rehabilitative program that included hip adduction stretches and sagittal plane strengthening, with meaningful improvements not observable for 15 months. It is no wonder that the prevailing first-line intervention continued to be corticosteroid injection, which was known to return a rapid reduction in pain for many people with trochanteric pain, at least in the short term.
What are we doing now?
The body of literature around impairments associated with gluteal tendinopathy has been building over the last 10 years, providing a foundation for more evidence-based contemporary interventions. We now know that those with gluteal tendinopathy have hip abductor muscle weakness and move in ways that place higher than normal loads across the gluteal tendons. This provides a basis for a shift away from abductor stretching towards abductor strengthening and movement training. Stretching for insertional tendinopathies is usually avoided or minimized in rehabilitation now due to the provocative nature of compressive loads. Non-operative treatments centre around active interventions such as exercise and load management strategies, empowering patients to control aggravating factors. Such a management approach has been tested in a rigorous randomized clinical trial environment (the LEAP trial), demonstrating that a contemporary education and exercise approach is more efficacious than corticosteroid injection, in both the short and longer term. Physiotherapists have adopted this contemporary approach quite widely and continue to develop skills in its application. Despite this, corticosteroid injection remains a prolific treatment for gluteal tendinopathy in community medical practice.
In addition to our enhanced understanding of biological factors underlying trochanteric pain, scientists and health professionals are now also much more aware of the potential role of psychosocial, hormonal and other systemic or general health factors.
Where do you think we will be 10 years from now?
The challenge for the next 10 years will be to better match interventions with individuals. This will optimize outcomes and lessen the burden on health systems that will be under greater strain with ageing populations and possibly future pandemics. Some people with gluteal tendinopathy are likely to do well with education alone, others may need only a few sessions of supervised exercise to develop a targeted self-directed exercise program. Those with more severe and/or persistent presentations may need a more prolonged and comprehensive program, including specific psychological approaches and medical interventions that target hormonal, metabolic and other systemic factors.
Earlier diagnosis and selecting the most appropriate intervention at first presentation are likely to reduce morbidity. Although corticosteroid injection provides early, short term relief, such treatments may increase morbidity in the longer term by reducing tissue health and establishing a cycle where patients seek quick-fix treatments without attending to underlying factors. I anticipate that over the next 10 years, the current and emerging evidence base will enable the development of clear clinical guidelines for effective, stratified treatments that are translated widely into clinical practice.