What is the appropriate treatment for tendinosis and tearing of the gluteus medius and minimus tendons?

Treatment for Gluteus Medius and Minimus Tendinosis and Tears

The most effective treatment for gluteus medius and minimus tendinosis and tears is a comprehensive rehabilitation program including NSAIDs for pain relief, eccentric strengthening exercises, and functional support, while limiting corticosteroid injections to short-term relief only. 1

Initial Management (0-4 weeks)

Pain Management

• NSAIDs: Start with ibuprofen 1.2g daily, which can be increased to 2.4g daily if inadequate relief is achieved 1
  • Can be combined with paracetamol (up to 4g daily) for enhanced pain relief
  • Consider naproxen 500mg twice daily as an alternative for short-term pain relief
  • Add gastroprotective agents for patients with increased GI risk

Injection Therapy

• Corticosteroid injections may provide short-term relief but do not change long-term outcomes 1
• Limit use to 2-3 injections, with 4-6 weeks between injections
• Use proper aseptic technique including surgical gloves, skin preparation, and changing needles between drawing medication and injecting
• Avoid injection if there are signs of infection at the site

Initial Rehabilitation

• Focus on pain control and protected range of motion 1
• Avoid excessive compression and high tensile loads on the gluteal tendons 2
• Avoid activities that cause pain, particularly those involving excessive hip adduction 2
• Protect the hip abductor tendons from excessive tensile and compression stresses 3

Intermediate Phase (4-8 weeks)

Progressive Rehabilitation

• Implement progressive strengthening exercises and eccentric training 1, 3
• Apply progressive load in conjunction with physical and anti-inflammatory measures 3
• Focus on correcting biomechanics that may contribute to gluteal tendinopathy, particularly excessive hip adduction 2
• Continue pain management as needed, but begin to taper medications as symptoms improve

Advanced Phase (8-12 weeks)

Functional Rehabilitation

• Implement occupation-specific training and functional exercises 1
• Progress to more challenging exercises that mimic daily activities
• Gradually increase load on the gluteal tendons to improve their load-bearing capacity 2
• Exercise interventions typically show improvement after 4 months to a year of therapy, requiring close supervision 3

Follow-up and Monitoring

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 1

• Return to full activity is permitted when the patient demonstrates:

  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to the uninjured side
  • Successful completion of occupation-specific functional tests 1

When to Consider Surgical Intervention

• Surgical intervention should only be considered when:

  • Conservative measures fail after 3-6 months of well-managed treatment 1, 3
  • Significant functional limitation persists
  • Loss of abductor muscle power is present 3, 4

• Surgical options include both open and endoscopic approaches with good reported clinical results 3

• More severe tears typically require a more rigid and complex type of fixation 3

• Postoperative rehabilitation follows similar protocols to conservative management 3

Important Considerations and Pitfalls

• Diagnostic Challenges: Gluteal tendinopathy is often misdiagnosed or overlooked as a source of lateral hip pain 2, 5
• Gender Differences: Women are significantly more likely to have tears of the hip abductors than men 4
• Negative Prognostic Factors: Fatty degeneration of the abductor muscles or associated scoliosis has a negative effect on the outcome of gluteus medius repair 4
• Anatomical Considerations: Foci of tendinopathy and partial tears are more common in the deep and anterior portions of the gluteus medius tendon attachment 6
• Avoid Immobilization: Complete immobilization is not recommended; instead, focus on protected movement and progressive loading 1