What is the treatment for gluteus tendonopathy?

Treatment of Gluteus Tendonopathy

Begin with eccentric strengthening exercises combined with load management and NSAIDs for short-term pain relief, as this approach addresses the degenerative nature of the condition while avoiding treatments that may impair tendon healing. 1, 2, 3

Understanding the Condition

Gluteus tendonopathy is a degenerative condition, not an inflammatory one, affecting the gluteus medius and minimus tendons at the greater trochanter. 1, 4 This distinction is critical because it fundamentally changes treatment strategy:

• The condition affects 10-25% of people in developed countries, with females more commonly afflicted than males, particularly in the fifth and sixth decades of life. 4, 5
• Excessive hip adduction combined with compressive and tensile loads on the tendons drives the pathology. 3
• The term "tendinitis" is a misnomer—these are chronic degenerative conditions that should be labeled "tendinosis" or "tendinopathy." 1

First-Line Conservative Treatment (0-3 Months)

Load Management

• Relative rest that prevents ongoing damage while allowing activities that don't worsen pain. 1, 2
• Avoid complete immobilization to prevent muscular atrophy and deconditioning. 2
• Educate patients to avoid excessive hip adduction positions, particularly side-lying on the affected hip. 3
• Consider walking aids (crutches, walking sticks) and orthotic devices to reduce compressive loads. 4

Exercise Therapy (Primary Treatment)

• Eccentric strengthening exercises are the cornerstone of treatment, proven beneficial in multiple tendinopathies. 2, 6
• Supervised exercise programs (active physical therapy) are superior to passive modalities like massage, ultrasound, or heat. 1, 2
• Progressive loading protocols should be implemented under close supervision for 4-12 months. 7
• The goal is to manage tensile and compressive stresses while applying progressive load. 7

Pain Management

• NSAIDs (such as ibuprofen) provide effective short-term pain relief but have no effect on long-term outcomes. 2, 6
• Topical NSAIDs reduce pain without the gastrointestinal hemorrhage risk of systemic NSAIDs. 2
• Cryotherapy through a wet towel for 10-minute periods provides short-term pain relief. 2

Second-Line Treatments for Persistent Symptoms (3-6 Months)

Corticosteroid Injections

• Most effective for short-term pain relief among injection therapies. 4
• However, corticosteroids do not improve long-term outcomes and may have deleterious effects on tendon healing. 2, 6
• Use with caution and only when pain significantly limits participation in exercise therapy. 1
• Image-guided injections (ultrasound or fluoroscopy) improve accuracy. 4

Shockwave Therapy

• Equally effective as corticosteroid injections and appears safe and noninvasive for chronic tendinopathies. 2, 4
• Can be expensive but avoids potential negative effects on tendon healing. 2
• Current data support its use, though larger trials are needed. 6

Emerging Therapies

• Platelet-rich plasma (PRP) injections show promise but require further study. 4
• Sclerotherapy and nitric oxide patches have supportive data but need larger multicenter trials. 6
• Growth factors and stem cell treatments are preliminary and require further investigation. 6

Common Pitfalls to Avoid

• Do not use peri-tendon injections around the gluteal tendons—these should be avoided similar to Achilles, patellar, and quadriceps tendons. 1
• Avoid relying solely on corticosteroid injections as they provide only temporary relief and may impair healing. 2, 6
• Do not use passive physical therapy modalities alone (ultrasound, iontophoresis, low-level laser)—evidence is inconsistent. 6
• Recognize that multiple symptomatic tendons should prompt evaluation for rheumatic disease. 2

Surgical Consideration

• Reserve surgery for patients who have failed 3-6 months of conservative therapy. 1, 2
• Surgery is indicated when conservative management fails AND there is associated abductor power deficit. 7
• Surgical outcomes remain inconsistent with significant morbidity. 6

Treatment Algorithm Summary

1. Months 0-3: Eccentric exercises + load management + NSAIDs for pain + patient education on avoiding hip adduction
2. Months 3-6: If inadequate response, add shockwave therapy OR corticosteroid injection (preferably image-guided)
3. After 6 months: Consider surgery only if conservative measures fail AND functional deficit present

Most patients (approximately 80%) fully recover within 3-6 months with conservative treatment. 1