What is the recommended management for gluteal tendinopathy presenting as lateral hip pain in a middle‑aged woman?

Management of Gluteal Tendinopathy

For a middle-aged woman with gluteal tendinopathy presenting as lateral hip pain, initiate a structured progressive exercise program targeting hip abductors (gluteus medius and minimus) as first-line treatment, combined with education on avoiding compressive hip positions, particularly excessive hip adduction during daily activities. 1, 2

Initial Assessment and Diagnosis

• Confirm diagnosis using the FADIR (flexion-adduction-internal rotation) test, which helps rule out hip-related pain when negative 3
• Obtain AP pelvis and lateral femoral head-neck radiographs to exclude competing diagnoses such as FAI syndrome, acetabular dysplasia, or intra-articular pathology 3
• Consider MRI or ultrasound for definitive confirmation of gluteal tendon pathology and to grade severity (grades 1-4, from reactive tendinopathy to full-thickness tears) 4, 2
• Critical pitfall: Do not diagnose based on imaging alone; combine clinical presentation, symptoms, and imaging findings 3

Core Treatment Protocol: Progressive Exercise Program

Load parameters and progression:

• Start strengthening exercises at 60-80% of 1-repetition maximum, performing 2-3 sets of 8-12 repetitions, 3 times weekly 3
• Target hip abductors (gluteus medius and minimus), focusing on both tensile loading and avoiding excessive compressive positions 1
• Use 3-4 seconds for eccentric phase, 2 seconds for concentric phase 3
• Rest 48-72 hours between sessions targeting the same muscle groups 3
• Progress load by 5-10% when current load can be performed pain-free for 2 consecutive sessions 3

Exercise selection principles:

• Avoid exercises that place the hip in excessive adduction, as this increases compressive loads on the gluteal tendons 1
• Include functional weight-bearing tasks that gradually increase hip abductor demand 3

Activity Modification and Education

• Immediately address sleeping position: Avoid side-lying on the affected hip, which compresses the gluteal tendons 1
• Educate on avoiding prolonged hip adduction during daily activities (crossing legs, standing with hip dropped) 1
• Modify footwear to reduce adverse mechanical loading 5
• Explain that pain reflects tendon irritation and mechanical overload, not progressive tissue damage, to reduce fear-avoidance behaviors 3

Monitoring and Expected Timeline

• Use patient-reported outcome measures: Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) 3
• Reassess at 4-6 week intervals using pain scales, hip abductor strength testing, and functional task performance 3
• Expect gradual improvement over 3-6 months with consistent adherence to exercise and activity modification 2

Adjunctive Treatments for Recalcitrant Cases

If inadequate response after 3 months of structured exercise:

• Extracorporeal shock wave therapy (ESWT) provides significant long-term pain relief and is superior to passive treatments 4, 2
• Platelet-rich plasma (PRP) injections demonstrate sustained improvement for grades 1-2 tendinopathy, with better long-term outcomes than corticosteroids 4, 2
• Corticosteroid injections offer only short-term benefit (weeks to months) with high symptom recurrence rates; reserve for severe pain limiting participation in exercise 1, 4, 2
• Ultrasound-guided injections are superior to landmark-based techniques for precise targeting 4

Critical Pitfalls to Avoid

• Do not prescribe complete rest: This worsens tendon load capacity and delays recovery 1
• Do not rely on corticosteroid injections as primary treatment: They provide only temporary relief and do not address underlying pathomechanics 4, 2
• Do not allow return to high-impact activities (running, jumping) until hip abductor strength reaches ≥90% of contralateral side and patient can perform single-leg tasks pain-free 3
• Do not progress exercise intensity before achieving adequate volume tolerance: This violates tendon adaptation principles 3

Surgical Considerations

• Reserve surgery (bursectomy with or without iliotibial band release, tendon repair) for grades 3-4 tendinopathy (partial or full-thickness tears) that fail 6-12 months of comprehensive conservative management 2
• Surgical outcomes are impaired by fatty degeneration, atrophy, and tendon retraction on MRI 2

Return to Physical Activity Algorithm

• Ensure pain-free walking and basic daily activities before progressing to higher-level tasks 3
• Gradually introduce sport-specific movements only after achieving adequate hip abductor strength and single-leg stability 3
• Continue maintenance strengthening indefinitely to prevent recurrence 1, 2