What is the recommended treatment approach for overload and enthesopathic changes at the tendon attachments to the ischial tuberosities?

Treatment Approach for Enthesopathic Changes at Ischial Tuberosities

The recommended treatment approach for overload and enthesopathic changes at the tendon attachments to the ischial tuberosities should begin with conservative management including relative rest, ice therapy, and eccentric strengthening exercises for 3-6 months before considering more invasive interventions. 1

First-Line Conservative Management

• Relative rest and activity modification are essential first steps to decrease repetitive loading of the damaged tendons and promote healing 1, 2
• Cryotherapy (ice application) provides effective acute pain relief, with the most effective method being repeated applications of melting ice water through a wet towel for 10-minute periods 2
• Analgesics can be used for pain relief, though NSAIDs should not be recommended over other analgesics despite their effectiveness for acute pain 1
• Eccentric strengthening exercises are highly effective for treating tendinopathy and may reverse degenerative changes in the affected tendons 1, 2

Rehabilitative Interventions

• Deep transverse friction massage may help reduce pain in tendinopathies 2
• Technique modification to address underlying biomechanical issues is important to prevent recurrence 1, 2
• Progressive loading programs that include both eccentric and concentric components may be more effective than isolated eccentric loading 3

Advanced Interventions

• Corticosteroid injections can provide significant pain relief in the acute phase, with doses of 5-15 mg for smaller areas and up to 40 mg for larger areas 4
• Caution should be exercised with corticosteroid injections to avoid injecting directly into the tendon substance, which can weaken the tendon and predispose to rupture 5
• Extracorporeal shock wave therapy (ESWT) has shown effectiveness comparable to other interventions for tendinopathies and could be considered if other conservative measures fail 6, 7

Surgical Consideration

• Surgery should be considered only if conservative measures fail after three to six months of consistent treatment 1, 2, 5
• Approximately 80% of patients with tendinopathies fully recover with conservative management within three to six months 1, 2, 5

Common Pitfalls and Considerations

• Misdiagnosing the condition as inflammatory ("tendinitis") rather than degenerative ("tendinosis" or "tendinopathy") can lead to inappropriate treatment focus 1, 2
• Enthesopathies can be inflammatory, degenerative, endocrine, metabolic, or traumatic in nature, with specific radiographic features that may include bone erosion, hyperostosis, fragmentation, and crystal deposition 8
• Premature return to aggravating activities before adequate healing can lead to recurrence 5
• Delayed referral for surgical consultation when conservative measures have failed after 3-6 months can lead to prolonged recovery 5

Treatment Algorithm

1. Begin with relative rest and activity modification to reduce load on the affected tendons 1
2. Apply ice therapy for acute pain relief 2
3. Initiate eccentric strengthening exercises, potentially combined with concentric exercises 1, 3
4. Consider analgesics for pain control 1
5. If no improvement after 6-12 weeks, consider corticosteroid injection or ESWT 4, 6
6. If symptoms persist beyond 3-6 months despite conservative management, consider surgical referral 1, 5