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

Recommended Treatment for Gluteal Tendinopathy

For a middle-aged woman with gluteal tendinopathy presenting as lateral hip pain, initiate a structured 12-week progressive hip-abductor strengthening program at 60–80% of one-repetition maximum, performing 2–3 sets of 8–12 repetitions three times weekly, with 48–72 hours recovery between sessions, while avoiding corticosteroid injections except for short-term symptom control in refractory cases. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by:

• Excluding intra-articular pathology – Perform a FADIR test; a negative result supports gluteal tendinopathy rather than hip joint disease 1
• Obtaining plain radiographs – Order anteroposterior pelvis and lateral femoral head-neck views to rule out femoro-acetabular impingement, acetabular dysplasia, or other structural abnormalities 1
• Integrating clinical findings – Do not rely on imaging alone; correlate radiological findings with symptom pattern, pain location (lateral hip), and provocative tests that combine compressive and tensile loading 1, 2

Core Exercise Protocol

The foundation of treatment is progressive loading that respects tendon adaptation principles:

Loading Parameters

• Intensity – Start at 60–80% of one-repetition maximum 1
• Volume – Perform 2–3 sets of 8–12 repetitions 1
• Frequency – Three sessions per week with 48–72 hours rest between sessions targeting the same muscle groups 1
• Tempo – Execute a 3–4 second eccentric (lowering) phase followed by a 2-second concentric (lifting) phase 1

Progression Strategy

• Increase load by 5–10% only when the current load can be completed pain-free for two consecutive sessions 1
• Never advance intensity until the patient tolerates the prescribed volume without pain – This volume-first principle is critical for tendon adaptation 1
• Incorporate functional weight-bearing tasks – Progress from side-lying hip abduction to single-leg stance, step-ups, and eventually sport-specific movements 1

Activity Modification

While exercise is the primary intervention, concurrent load management is essential:

• Avoid positions that compress the gluteal tendons – Minimize prolonged hip adduction, such as crossing legs, standing with weight shifted to one side, or lying on the affected side 2
• Do not prescribe complete rest – Prolonged inactivity reduces tendon load capacity and delays recovery 1
• Maintain physical activity within pain tolerance – Physical activity is critical for health and should be continued with modifications 3

Monitoring and Reassessment

Track progress systematically to guide treatment adjustments:

• Use validated outcome measures – Administer the Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) at baseline and follow-up 3, 1
• Reassess every 4–6 weeks – Evaluate pain levels, hip-abductor strength, and functional task performance to determine if progression is appropriate 1
• Provide pain education – Explain that pain reflects tendon irritation and mechanical overload rather than progressive degeneration, which reduces fear-avoidance behaviors 1

Return-to-Activity Criteria

Before permitting return to high-impact activities or sport:

• Ensure pain-free basic function – The patient must walk and perform daily activities without pain 1
• Achieve strength threshold – Hip-abductor strength must reach ≥90% of the contralateral side, and single-leg tasks must be pain-free 1
• Introduce sport-specific movements gradually – Once strength and stability criteria are met, incrementally add sport-specific tasks 3, 1
• Prescribe indefinite maintenance strengthening – Continue hip-abductor exercises long-term to minimize recurrence risk 1

Role of Injections

The evidence regarding injections reveals important nuances:

Corticosteroid Injections

• Provide only short-term relief – Corticosteroid injections do not address underlying mechanical factors and should be limited 1
• May be considered for symptom control – In patients with severe pain that prevents participation in exercise, a single ultrasound-guided corticosteroid injection can provide temporary relief to enable rehabilitation 2, 4

Platelet-Rich Plasma (PRP)

• Superior to corticosteroid at 12 weeks – In chronic gluteal tendinopathy (>4 months duration), a single PRP injection demonstrated significantly better outcomes than corticosteroid injection at 12 weeks, with 82% of patients achieving minimal clinically important difference versus 56.7% with corticosteroid 4
• Consider for refractory cases – PRP may be offered to patients who have failed conservative management including physiotherapy and previous corticosteroid injections 4

Critical Pitfalls to Avoid

• Do not rely on corticosteroid injections as primary treatment – They provide only temporary symptom relief without addressing the underlying tendon pathology 1
• Do not progress exercise intensity before adequate volume tolerance – Advancing load prematurely compromises tendon adaptation and risks symptom exacerbation 1
• Do not misdiagnose as trochanteric bursitis – Gluteal tendinopathy is the primary pathology in most cases of lateral hip pain, not bursitis 2, 5
• Do not permit return to high-impact activities before meeting strength criteria – Premature return increases recurrence risk 1

Expected Timeline

• Initial improvement – Patients typically show measurable improvement in pain and function by 4–6 weeks 1
• Significant functional gains – Expect substantial improvement by 12 weeks if the program is followed consistently 1, 4
• Long-term management – Continue maintenance strengthening indefinitely, as this is a chronic condition with high recurrence rates if mechanical factors are not addressed 1, 2