Gold Standard Scaffold for Gluteal Tendinopathy

Part 2: ManagementMarisol Reyes Fuentes

B.Phty, M.Musc Phty, APAMAPA Musculoskeletal Physiotherapist

Certified APPI Pilates InstructorMember Hip Pain Professionals

Most common misbeliefs• It will get better with rest

• Stretching the glutes is good for it

• It doesn’t hurt when I am running, therefore, running is not a problem

Education

Tendon decompression

Gradual tendon load

Education

Empower

Expectations

Misbeliefs

Medbridgehttps://www.medbridgeeducation.com/patient-education-library/condition/91-Gluteus-

Medius-Tendinopathy

Hip Pain Helphttps://hippainhelp.com/gluteal-tendinopathy-trochanteric-bursitis-greater-trochanteric-pain-syndrome-gtps/

Tendon DecompressionWHY?

Tension within the ITB may result in frictional trauma to GMed/min tendons and their bursae, similar to the effect of the acromion process on the rotator cuff

Aiming to reduce compressive loads over a 24h period – key in early pain management

Grimaldi, A. Lateral hip pain: mechanism and management. Sourced from https://dralisongrimaldi.com/lateral-hip-pain-mechanisms-and-management/

Compression

Decompression

Tendon Decompression

• Posture, gate modification• Reduce stairs climbing• Use wedge cushion• Avoid sitting in low chairs• Change sleeping position (back, ¾ prone, side lying with pillows*)• Check car seat• Check previous rehab/gym/pilates program (clams, side leg lifts, glute/hamstring stretch?)

https://www.medbridgeeducation.com/patient-education-library/condition/14367-Gluteus-Medius-Tendinopathy-Dos-and-Donts

Do not stretch• Stretching glutes is NOT indicated in the acute/sub-acute phase• Use massage, self-trigger point releases, dry needling and/or heat instead.

Isometrics• WHY? Pain relief, early stages of tendon load

• GRADUAL RAMP OF ACTIVATION - VISUALISE

• Supine or high sitting

• Use belt around mid-thigh

• 5x10sec 2 sets at 50%MVC (Alison Grimaldi’s protocol)

• 10x10sec at comfortable contraction, feeling PGM contracting, low or no pain (Henry Wajswelner’s protocol)

• 3-4 times a day, use as PANADOL

• Small study: 6 volleyball players with PT

• Compared immediate and 45min effect after isotonic and isometric quadriceps contraction

• HEAVY isometric contractions (5x45sec, 2 min rest 70%1RM) reduced tendon pain immediately and • for at least 45min post-intervention

• The effect of exercise on the motor cortex may be modulated in the presence of pain. Exercises that are painful to complete may change motor control and cause cortical reorganisation, as pain itself is known to alter cortical representation. This may contribute to persistence of tendon pain

https://www.bmj.com/content/361/bmj.k1662

Key aspects of managementEmphasize

relevance of postural

alignment in EVERYDAY activities

Be SPECIFIC in muscle

assessment & rehab

Address muscle dysfunction in a FUNCTIONALLY specific manner

Let patients PROVE you that they are ready

for a progression (i.e.: DL to SL)

Week 1 Familiarisation

Low load activities: static abd supine/std

Pelvic control -functional

loading: Bridges

Functional strength: DL squat

Abductor loading in frontal plane:

Side step

Week 2Early Loading and

Movement Optimisation

Low load activities = W1

Pelvic control -functional

movements: DL and offset bridge

Functional strength: DL and

offset squat

Abd loading in frontal plane =

W1

Week 3-8Graduated Loading

Low load activities = W1

Pelvic control -functional

movement = W2 but harder

Functional strength = W2 but

harder

Abd loading in frontal plane: side

step, band slide (hard)

Wee 3-8 in clinic

Warm up: sliding platform abd in

upright and squat position

High level loading: as warm up but heavy. Scooter

Early strengthening

Key Exercises

Bridges

Mini-squats Standing Abduction

Step up/down (avoid add moment)

OPEN CHAIN OR CLOSE CHAIN?

CKC exercises provide proprioceptive imput similar to the demands of WB functions (walking/climbing stairs)

Studio Rehab

Reformer

Footwork on bar

Scooter

Standing Abduction (Splits)

Feet on straps (keep it wide and less than 90deg HF) – subacute

Trap Table

Supine legs in straps (DL, SL)

Bridges with arm pull on box (low level),

crook lying, sustained bridges, arm pulses

Assisted squats with glute rack +/- belt around knees or

ankles

Wunda Chair

Standing leg press front, side +/-

standing on unstable surface

Step up

Step down (lunges) -advanced

Gait Retraining

Cue neutral spine

Cue neutral/wide stance and gait

Avoid waddling

Avoid adduction moment

Prefer neutral or wide foot position, hip ER and avoid

deep hip flexion to reduce tendon compression

Kinetic Chain

Abdominals

TT: Standing arms DL, split stance or SL +/- heel

raises.Seated abdominal curls

RF/TT: Seated Abdominal curls

Quadriceps

RF: Footwork, seated quads

TT: Seated Quads with ankle weights

TT: high kneeling assisted eccentric quads

Hamstrings

RF/ TT LIS

TT: Prone Hs curl with ankle weights

Calves

RF: Footwork

Calf raises

High LevelPilates Based

Progressions on load (springs), repetitions (endurance)

Add small equipment (IronEdgeband, chi ball, weights)

Functional

Combined movement i.e.: hip abd + trunk rotation

SL standing from a chair

Sports Specific

Landing/jumping/kicking/surfing

Running

Golf/Tennis (trunk rotation)

PRACTICAL (10min)Practice patient education SPIEL

PRACTICAL (10min)EARLY REHAB

Team up and teach each other 1 progression and 1 regression of the following exercises:Bridge

Mini-squatStanding Abduction

Step up/Down

(Include isometrics and use small equipment)

PRACTICAL 2 (30min)STUDIO WORKSHOP

Team up are rotate through the stations to teach and practice exercises(Include isometrics and small equipment)

• Allison, Bennell, Grimaldi, Vicenzino, Wrigley, & Hodges. (2016). Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait & Posture, 49, 108-113

• Connell, D., Bass, A., Sykes, C., Young, C., & Edwards, J. (2003). Sonographic evaluation of gluteus medius and minimus tendinopathy. European Radiology, 13(6), 1339-1347.

• Cowan, R.M., Semciw, A.I.,, T., Cook, J., Rixon, M.K., Gupta, G., Plass, L.M. and Ganderton, C.L. (2020), Muscle Size and Quality of the Gluteal Muscles aPizzarind Tensor Fasciae Latae in Women with Greater Trochanteric Pain Syndrome. Clin Anat. doi:10.1002/ca.23510

• Dr Alison Grimaldi with Practical Physiotherapy Tips on Treating Lateral Hip Pain https://soundcloud.com/bmjpodcasts/dr-alison-grimaldi-with-practical-physiotherapy-tips-on-treating-lateral-hip-pain?in=bmjpodcasts/sets/bjsm-1#t=0:00

• Falvey, E., Franklyn-Miller, A., & McCrory, P. (2009). The greater trochanter triangle; a pathoanatomic approach to the diagnosis of chronic, proximal, lateral, lower pain in athletes. British Journal of Sports Medicine, 43(2), 146.

• Fearon, Neeman, Smith, Scarvell, & Cook. (2017). Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study. Gait & Posture, 52, 237-243.

References

• Impellizzeri FM, Jones DM, Griffin D, et al. Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018. British Journal of Sports Medicine Published Online First: 17 February 2020. doi: 10.1136/bjsports-2019-101456

• Grimaldi, A. (2017). Conservative management of lateral hip pain: The future holds promise. British Journal of Sports Medicine, 51(2), 72-73.

• Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2017). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine, 51(6), 519.

• Hoeger Bement, M., Dicapo, J., Rasiarmos, R., & Hunter, S. (2008). Dose response of isometric contractions on pain perception in healthy adults. Medicine and Science in Sports and Exercise, 40(11), 1880-9.