What treatment approach is recommended for a full-time exercise instructor with mild insertional left gluteus medius and minimus tendinosis and mild left common hamstring tendinosis, considering limited resources at a federally qualified health center (FQHC)?

Treatment Plan for Gluteus Medius/Minimus and Hamstring Tendinosis in an Exercise Instructor

This patient requires a structured conservative management program centered on eccentric strengthening exercises and load modification, with orthopedic sports medicine referral only if symptoms persist beyond 3-6 months of appropriate therapy. 1

Immediate Management Plan

Activity Modification (Critical First Step)

• Reduce all repetitive hip loading activities that reproduce pain, particularly exercises involving hip adduction, single-leg stance work, and high-impact movements 2
• Avoid complete rest or immobilization as this accelerates muscle atrophy and deconditioning 3, 4
• For the gluteal tendinopathy: eliminate side-lying positions during sleep and minimize hip adduction across midline 2
• For the hamstring tendinosis: reduce activities involving repetitive hip flexion with knee extension 5

Pain Management

• Prescribe topical NSAIDs as first-line for localized pain relief with fewer systemic side effects than oral formulations 1, 3
• Oral NSAIDs (or acetaminophen up to 4g/day) for short-term pain relief, understanding these provide symptomatic relief only without altering long-term outcomes 1, 3
• Apply ice through a wet towel for 10-minute periods after activities that provoke symptoms 1, 3

Rehabilitation Protocol (Foundation of Treatment)

Eccentric strengthening exercises are the cornerstone of treatment and can reverse degenerative tendon changes 1, 3

For Gluteal Tendinopathy:

• Progressive hip abductor strengthening avoiding excessive hip adduction positions 2
• Load modification education focusing on joint positioning to minimize compressive and tensile loads 2
• Expect 4-12 months of supervised therapy for optimal results 6

For Hamstring Tendinosis:

• Eccentric hamstring strengthening with gradual progressive loading 5
• Activity modification to reduce repetitive strain 5

General Principles:

• Implement deep transverse friction massage to reduce pain 3
• Progress loading gradually to avoid symptom exacerbation 4
• Modify exercise instruction techniques to minimize repetitive tendon stresses 1, 3

Addressing FQHC Resource Limitations

Home-Based Exercise Program

Since physical therapy access is limited, provide:

• Detailed written home exercise protocols with progressive loading schedules that the patient can self-administer 7
• Video demonstrations or illustrated handouts for proper eccentric exercise technique 7
• Weekly or biweekly check-ins via telehealth to monitor progression and adjust loading 7

Alternative Interventions (If Available)

• Platelet-rich plasma injections may provide benefit for chronic tendinosis 5
• Extracorporeal shock wave therapy is safe and effective but expensive 1, 3, 5, 2
• Avoid corticosteroid injections or use with extreme caution - while they may provide acute pain relief superior to oral NSAIDs, they do not alter long-term outcomes, may inhibit healing, reduce tendon tensile strength, and predispose to rupture 1, 4, 7

Orthopedic Referral Specifications

Type of Referral Needed:

Refer to Orthopedic Sports Medicine or Hip Preservation Surgery specialist (not general orthopedics) 8

Timing and Indications for Referral:

• Only if pain and functional limitations persist despite 3-6 months of well-managed conservative treatment 1, 4
• Do not delay beyond 6 months as chronic tears may develop muscle atrophy and fatty degeneration that worsen surgical outcomes 4
• Earlier referral warranted if significant abductor power deficit develops 6

Surgical Options (If Conservative Management Fails):

• For gluteal tendinopathy: endoscopic or open repair with excision of abnormal tissue and tenotomy 1, 8, 6
• For hamstring tendinosis: endoscopic debridement or open repair if progression to partial avulsion 5, 8

Expected Prognosis

Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 1, 3

Critical Pitfalls to Avoid

• Never inject corticosteroids into the tendon substance itself - only peritendinous injection may be considered, and even this should be used cautiously 1, 4
• Do not start with aggressive exercises; progression must be gradual to prevent symptom worsening 4
• Do not completely immobilize or recommend complete rest from all activity 3, 4
• The presence of joint effusions is uncommon with tendinopathy and should raise suspicion for intra-articular pathology requiring different management 1

Documentation Note Template

Diagnosis: Mild insertional left gluteus medius and minimus tendinosis; mild left common hamstring tendinosis

Assessment: Full-time exercise instructor with bilateral lower extremity overuse tendinopathies affecting occupational function. Given mild severity and patient's high functional demands, conservative management is appropriate initial approach.

Plan:

1. Activity modification with load reduction while avoiding complete rest
2. Topical NSAIDs for pain management
3. Home-based eccentric strengthening program with written protocols (due to FQHC PT access limitations)
4. Ice therapy 10 minutes post-activity
5. Biweekly telehealth follow-ups to monitor progress and adjust loading
6. Orthopedic Sports Medicine referral if no improvement after 3-6 months of conservative therapy
7. Patient education on avoiding corticosteroid injections and importance of gradual progression
8. Return to full exercise instruction duties anticipated in 3-6 months with appropriate rehabilitation