Best Exercise for Gluteal Tendinopathy
Eccentric strengthening exercises of the hip abductor muscles are the most effective exercise intervention for gluteal tendinopathy, delivered through a supervised, progressive program over 12 weeks. 1
Exercise Selection and Prescription
Primary Exercise Approach
- Supervised exercise programs focusing on eccentric strengthening of hip abductor muscles are more effective than passive interventions (moderate-quality evidence from the American College of Rheumatology). 1
- Both isometric and isotonic exercise programs appear effective, with 55-75% of patients achieving clinically meaningful improvements in pain and function after 12 weeks. 2
- Land-based physical therapy interventions are conditionally recommended over aquatic therapy interventions (moderate-quality evidence). 1
Specific Exercise Tiers by Gluteal Muscle Target
For Gluteus Medius (the primary muscle affected in gluteal tendinopathy):
- Tier 1 exercises generating highest muscle forces: body weight side plank (338-483 N), loaded single-leg squat (278-422 N), and loaded single-leg Romanian deadlift (283-405 N). 3
For Gluteus Minimus:
- Tier 1 exercises: loaded single-leg Romanian deadlift (267-389 N) and body weight side plank (272-382 N). 3
For Gluteus Maximus (when concurrent involvement exists):
- Tier 1 exercises: loaded split squat (495-688 N), loaded single-leg Romanian deadlift (500-655 N), and loaded single-leg hip thrust (505-640 N). 3
Progressive Loading Strategy
- Adding 12-repetition maximum external resistance increases peak gluteal muscle forces by 28-150 N compared to body weight alone, allowing for progressive overload as healing permits. 3
- The program should be progressive over 12 weeks with 8 individual physiotherapy sessions for supervision and progression. 2
- Daily home exercise should be prescribed between supervised sessions. 2
Critical Implementation Details
Activity Modification (Essential First Step)
- Activity modification to decrease repetitive loading of the damaged tendon must precede aggressive strengthening. 1
- Avoid activities that worsen pain while maintaining some activity to prevent muscle atrophy and deconditioning (relative rest, not complete rest). 1
Adjunctive Measures
- Cryotherapy (ice for 10-minute periods through a wet towel) provides acute pain relief and should be used as needed. 1
- Passive interventions such as massage, ultrasound, and heat can supplement but should not substitute active physical therapy. 1
Common Pitfalls to Avoid
What NOT to Do
- Do not rely on passive interventions alone (massage, ultrasound, heat) as primary treatment—these should only supplement active exercise. 1
- Avoid repeated corticosteroid injections, which have deleterious effects on tendon substance and don't alter long-term outcomes despite providing short-term pain relief. 1, 4
- If corticosteroid injection is used, it must be ultrasound-guided and injected into the peritendinous space, never directly into the tendon. 1, 4
- Do not delay surgical evaluation beyond 3-6 months if comprehensive conservative treatment fails, as tendon retraction and fatty degeneration worsen outcomes. 1, 4
Red Flags Requiring Different Management
- In patients younger than 45 years with morning stiffness lasting more than 30 minutes, obtain MRI of sacroiliac joints and refer to rheumatology to rule out axial spondyloarthropathy. 1
- Differentiation between trochanteric bursitis and gluteus medius/minimus tendinosis can be difficult, and the two conditions frequently coexist—ultrasound or MRI may be needed for accurate diagnosis if symptoms persist. 1
Expected Outcomes and Timeline
- Most patients (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment. 5
- Clinically meaningful improvement (≥2 points on pain scales) can be expected in 55-75% of patients by 12 weeks. 2
- Surgical evaluation is warranted only after failure of 3-6 months of well-managed conservative treatment. 1, 4