What is the treatment for peritendonitis of the gluteus medius and minimus muscles?

Treatment of Peritendonitis of Gluteus Medius and Minimus

For peritendonitis of the gluteus medius and minimus, initiate treatment with NSAIDs for short-term pain relief, followed by locally administered corticosteroid injections if NSAIDs fail, while avoiding peri-tendon injections at high-risk sites like the Achilles, patellar, and quadriceps tendons. 1

Initial Pharmacologic Management

First-Line: NSAIDs

• NSAIDs (oral or topical) are the first-line pharmacologic treatment for short-term pain relief in tendinitis, though they do not alter long-term outcomes 1, 2
• Topical NSAIDs offer effective pain relief with fewer systemic side effects compared to oral formulations 2
• Consider selective COX-2 inhibitors in patients with higher gastrointestinal risk (RR 0.18 for serious GI events versus non-selective NSAIDs) 2
• Be aware that NSAIDs carry gastrointestinal toxicity risk (RR 5.36) and potential cardiovascular risks 1, 2

Alternative Analgesics

• If NSAIDs are insufficient, contraindicated, or poorly tolerated, use paracetamol or opioids for pain control 1, 2
• Paracetamol has no significantly higher GI toxicity than placebo 1

Local Corticosteroid Injections

When to Use

• Locally administered parenteral corticosteroids are conditionally recommended for active enthesitis despite NSAID treatment 1
• Corticosteroid injections are more effective than oral NSAIDs in the acute phase but do not change long-term pain outcomes 1, 2
• Injections at the greater trochanter are specifically mentioned as acceptable sites, unlike high-risk tendons 1

Critical Safety Considerations

• Absolutely avoid peri-tendon injections of Achilles, patellar, and quadriceps tendons due to rupture risk 1
• The gluteus medius/minimus region is considered safer for injection compared to these high-risk sites 1
• Limit the number of injections as corticosteroids can inhibit healing, reduce tensile strength, and predispose to spontaneous ruptures 2
• Never inject directly into the tendon substance—use peritendinous or intratendinous approaches under ultrasound guidance 3

Advanced Treatment Options

Platelet-Rich Plasma (PRP)

• For chronic gluteal tendinopathy (>4 months), a single PRP injection provides superior outcomes at 12 weeks compared to corticosteroid injection 3
• 82% of PRP patients achieved minimal clinically important difference versus 56.7% with corticosteroids at 12 weeks 3
• Mean modified Harris Hip Score was significantly better with PRP (74.05) versus corticosteroid (67.13) at 12 weeks (p=0.048) 3

Non-Pharmacologic Essentials

Physical Therapy

• Physical therapy is strongly recommended and should be initiated alongside pharmacologic treatment 1
• Active interventions (supervised exercise, eccentric strengthening) are preferred over passive modalities (massage, ultrasound, heat) 1
• Eccentric exercises can reverse degenerative tendon changes 2
• Conservative management should continue for 4 months to 1 year before considering surgical options 4

Activity Modification

• Implement relative rest and activity reduction to prevent additional tendon damage 2
• Apply ice for 10-minute periods for acute pain relief 2

Treatment Algorithm

1. Start with oral or topical NSAIDs for 2-4 weeks for pain control 2
2. If NSAIDs fail or are contraindicated, switch to paracetamol or other analgesics 1, 2
3. For persistent localized pain despite oral medications, perform ultrasound-guided corticosteroid injection (peritendinous or intratendinous) at the greater trochanter 1, 3
4. For chronic tendinopathy (>4 months) with failed conservative treatment, consider PRP injection as superior to repeat corticosteroid injection 3
5. Initiate physical therapy concurrently with any pharmacologic intervention, emphasizing eccentric strengthening exercises 1, 2
6. If conservative management fails after 4-12 months and abductor power deficit develops, refer for surgical evaluation 4

Common Pitfalls to Avoid

• Do not use systemic corticosteroids for peritendonitis—they are strongly recommended against for axial disease and lack evidence for peripheral enthesitis 1
• Do not inject corticosteroids directly into the tendon substance, which increases rupture risk 2
• Do not expect long-term benefit from NSAIDs or corticosteroids alone—these provide only short-term symptom relief 1, 2
• Do not delay physical therapy initiation—it should begin immediately, not after pharmacologic treatment fails 1
• Do not confuse gluteal tendinopathy with trochanteric bursitis, as they may coexist and require different imaging approaches 1