What are the next steps in treating hip abductor tendinopathy after physical therapy and medications like meloxicam (generic name: meloxicam) have failed?

Treatment of Hip Abductor Tendinopathy After Failed Initial Management

For patients with hip abductor tendinopathy who have failed physical therapy and NSAIDs, extracorporeal shock wave therapy is the recommended next step, followed by corticosteroid injections under ultrasound guidance, with surgery as a final option for those who fail 3-6 months of conservative treatment. 1, 2

Diagnostic Imaging

Before proceeding with advanced treatments, proper imaging is essential to confirm diagnosis and rule out other conditions:

• Obtain plain radiographs first to rule out bony abnormalities such as loose bodies or osteoarthritis 2
• Ultrasound is recommended to:
  • Detect tendon thickening, decreased echogenicity, and evaluate gluteal tendons 2
  • Differentiate between trochanteric bursitis and gluteus medius/minimus tendinosis (which often coexist) 2
• MRI is indicated when diagnosis remains unclear or for preoperative evaluation:
  • 3.0-Tesla MRI is superior to 1.5-Tesla for detecting specific tendon pathology like partial/full-thickness tears 3
  • Provides comprehensive assessment of peritrochanteric structures including gluteus minimus/medius muscles and tendons 2

Treatment Algorithm After Failed Initial Management

1. Extracorporeal Shock Wave Therapy

• Provides safe, noninvasive, effective pain relief for chronic tendinopathies 1
• Should be considered before more invasive interventions 1

2. Corticosteroid Injections

• Ultrasound-guided corticosteroid injection into the affected area can provide both diagnostic information and therapeutic benefit 2
• May be more effective than oral NSAIDs for acute phase pain relief, though they don't alter long-term outcomes 1
• Use with caution as injections directly into the tendon substance may have deleterious effects 1
• Peritendinous injections are preferred over intratendinous injections 1

3. Orthotics and Bracing

• May help reduce tension on the affected tendon during the healing process 1
• Can be used as an adjunct to other treatments 1

4. Advanced Physical Therapy

• Focus on eccentric strengthening exercises which have proven beneficial in tendinopathies 1
• Continue relative rest while allowing activities that don't worsen pain 1

5. Surgical Management

• Indicated only after failure of 3-6 months of comprehensive conservative treatment 1, 2
• Surgical repair of torn abductor tendons is a viable option when MRI and clinical findings are consistent with tendon disruption and weakness 4
• Provides substantial and durable improvement in strength and clinical performance in most cases 4
• Options include:
  • Direct repair for repairable tears 5
  • Augmentation with grafts for chronic tears with limited muscle atrophy 5
  • Gluteus maximus tendon transfer as a salvage procedure for chronic hip abductor insufficiency with advanced muscle degeneration 6, 5

Common Pitfalls and Caveats

• Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the conditions frequently coexist 2
• Corticosteroid injections should be ultrasound-guided to ensure proper placement 2
• In patients with hip prostheses, adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 2
• The three most common poor surgical outcomes were in patients with the largest tears, suggesting earlier intervention may be beneficial 4
• Despite modest results in some cases, surgical intervention remains the preferred salvage treatment option when conservative measures fail 6