What are the treatment options for gluteal region pain?

Treatment Options for Gluteal Region Pain

The most effective approach to managing gluteal region pain is a combination of exercise therapy, education, and appropriate analgesics, with corticosteroid injections reserved for cases that don't respond to first-line treatments.

Diagnosis and Assessment

When evaluating gluteal pain, consider these common causes:

• Gluteus medius/minimus tendinopathy
• Trochanteric bursitis
• Obturator internus tendinitis and bursitis
• Gluteal muscle tears or avulsions
• Hip osteoarthritis with referred pain
• Post-surgical pain (particularly after hip arthroplasty)

Key diagnostic elements:

• Localized tenderness in the gluteal region
• Pain with side-lying
• Pain with weight-bearing activities
• Possible weakness in hip abduction

Imaging may include:

• Ultrasound: Can detect trochanteric bursitis, gluteus medius tendinosis, and tears 1
• MRI: Useful for assessing peritrochanteric structures including gluteus muscles, abductor tendons, and trochanteric bursa 1

Treatment Algorithm

First-Line Treatment: Exercise and Education

Exercise therapy has the strongest evidence for gluteal pain management with moderate strength evidence of medium effect on pain (SMD = 0.95) and function (SMD = 0.91) in the short term and small effects in the medium and long term 2.

Exercise recommendations:

• Low-impact aerobic activities (walking, swimming, cycling) 1
• Specific strengthening exercises for gluteal muscles 1
• Home-based exercises to improve hip and thigh muscle strength 1

Key exercises:

• Gluteal squeezes: Squeeze buttocks muscles tightly; hold for 6-7 seconds 1
• Hip and thigh muscle strengthening: Keeping back straight, slowly lift leg until straight; hold for 6-7 seconds 1
• Closed-chain, short-arc knee extensions 1

Second-Line Treatment: Pharmacologic Options

1. NSAIDs:

   • Ibuprofen 400-600mg three times daily as needed for 7-15 days 3
   • Use lowest effective dose for shortest duration to minimize side effects 3
   • Monitor for gastrointestinal side effects

2. Topical Analgesics:

   • Lidocaine 5% patches for localized pain 4
   • Topical NSAIDs for localized pain

3. Corticosteroid Injections:

   • Moderate strength evidence of small effect on pain (SMD = 0.51) in the short term 2
   • Ultrasound-guided injection into affected tendon sheath or bursa 5
   • Typically using triamcinolone with local anesthetic 5

Third-Line Treatment: Advanced Interventions

1. Platelet-Rich Plasma (PRP) Injections:

   • Superior to corticosteroid injections for function in the short term (SMD = 0.46) 2
   • Consider when corticosteroid injections fail

2. Focused Shockwave Therapy (f-ESWT):

   • Demonstrates superiority in long-term pain management compared to corticosteroid injection (SMD = 5.77) 2
   • Consider for chronic cases not responding to other treatments

3. Surgical Management:

   • Reserved for cases with failure of conservative management
   • Particularly indicated when there is loss of abductor muscle power 6
   • Can be performed both open and endoscopically 6

Special Considerations

For Post-Surgical Gluteal Pain (e.g., after hip arthroplasty)

• Evaluate for abductor tendon tears or avulsion, which may occur after THA using an anterolateral approach 1
• Ultrasound can identify tendinopathy, partial tear, and complete tears/avulsion of the gluteus medius tendon 1

For Older Adults with Osteoarthritis

• Combine exercise with weight management for overweight/obese patients 1
• Avoid high-impact activities that involve rapid loading of joints 1
• Consider aquatic exercise in warm water (86°F) which provides analgesia and reduces joint loading 1

Treatment Efficacy and Prognosis

A randomized clinical trial comparing education plus exercise (EDX), corticosteroid injection (CSI), and wait-and-see approach (WS) found 7:

• At 8 weeks: EDX showed better outcomes than both CSI and WS
• At 52 weeks: EDX maintained better global improvement than CSI and WS
• Pain scores at 52 weeks: EDX (2.1), CSI (2.3), WS (3.2)

This evidence strongly supports education plus exercise as the most effective long-term management approach for gluteal tendinopathy.

Common Pitfalls to Avoid

1. Focusing solely on pain management without addressing underlying biomechanical issues
2. Overreliance on corticosteroid injections without implementing exercise therapy
3. Failure to modify activities that exacerbate symptoms (excessive hip adduction)
4. Neglecting psychosocial factors that may contribute to chronic pain
5. Premature progression to surgical intervention before adequate trial of conservative measures

By following this structured approach to gluteal region pain, clinicians can effectively manage symptoms and improve long-term outcomes for patients.