Comparing Gluteus Medius Tendinopathy Injections and Surgery Outcomes
Ross A. Hauser, MD. Danielle R. Steilen-Matias, MMS, PA-C
Comparing Gluteus Medius Tendinopathy Treatments – Injections, Physical Therapy and Surgery
When a patient comes into our office for a first visit they will usually tell us a story that goes something like this:
About two years ago I was diagnosed with gluteus medius tendinopathy in my right hip. I did not know what it was a first, but I knew that my hip hurt when I ran or even walked very fast. I was given the usual prescriptions for anti-inflammatories and extra strength TYLENOL® if the pain got a little too much.
Not responding to the anti-inflammatories I was sent to twice a week physical therapy. When the physical therapy made my pain worse, I did not know what to do. I could not go to work because I was too drowsy from the medications. It got so that I could not even get out of bed. My hip pain was getting much worse and very quickly worse.
I was referred to an orthopedist who specialized in this type of tendinopathy. This is where things got confusing. I got more medications, Lidocaine patches, Capsaicin patches, a prescription for Valium first then Xanax for my hip. I was told these anti-depressant medications would help with my hip pain, I was not be given them for depression although depression is what I was getting because of the hip pain.
Then I had an MRI. To my surprise, the doctor told me that since I had a disc herniation in my lower back, L4-L5, and probably a pinched nerve, this was probably the cause of my worsening acute hip pain. I immediately received an epidural steroid injection. This seemed to work, at least for a day or two, then the hip pain came back. Now I am convinced that I have a bigger problem and my gluteus medius tendinopathy is one just component of what is going on.
The search for an answer when your doctor thinks your Gluteus Medius tendinopathy pain is actually from your hip, lower back, knee, and ankle.
Sometimes a person will reach out to us with a medical history that they call “a wild goose chase.” Their story may go something like this:
I have been searching for an answer for two years. I have had numerous MRIs. At first, my doctors thought that my problem was a low back problem, one of sciatica or SI joint dysfunction, maybe both.
Since one of my MRIs showed degenerative disc disease and a bulging disc I was sent to get cortisone then an epidural injection. These injections did not provide any relief. So my doctors took me in a different direction. A search for the pain element in my knee and my hip. I got cortisone in my painful knee, that did not help. I got cortisone in my hip, that helped. Another MRI and an ultrasound showed gluteus medius tendinopathy. As the cortisone helped in my hip, my doctors now started isolating on my hip. The cortisone has now worn off, I am on painkillers. We don’t seem to have a plan in place that can effectively help me. I can’t walk because I have pain from the low back to my ankle.
When this patient comes into our clinic, we talk with them about the difficulties in isolating one part of the pelvic-hip-spine complex as the main culprit of their problem. This we find especially true in treating a patient with problems of Gluteus Medius tendinopathy.
The connection between hip, back, leg, and knee pain under the Gluteus medius syndrome umbrella
In February 2020, researchers publishing in the Journal of Physical Therapy Science (1) summarized the connection between hip, back, leg, and knee pain under the Gluteus medius syndrome umbrella and how easily a Gluteus medius syndrome or tendinopathy can be missed or thought of as something else:
- “The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition.” In other words, the researchers here wanted to establish a diagnosis of gluteus medius syndrome separate from other diagnoses.
- “Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius.” (Muscle pain from the gluteus medius, one that can be reproduced as a “trigger point,” by gentle palpitation.)
- Finding: Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain.
- Finding: Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome.
- Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.
How does the Gluteus Medius do all this?
When the hip joint region becomes unstable, the muscles, including the Gluteus Medius, try to create stability by tensing, cramping, or going into spasm. When the muscle tenses, you have a “pull” on the tendon. If the tendon is damaged, it will be very painful. That painful tendon starts sending signals to the hip and spine and knee and leg and ankle that it needs help taking some of the load. Suddenly you have pain messages going up and down your leg from the spine to the foot.
- This compensatory mechanism to stabilize the hip joint eventually causes the whole hip region to react. You have now a worsening hip pain that no longer keeps itself confined to the outer hip. Your gluteus medius, piriformis muscle, and iliotibial band/ tensor fascia lata muscles all tighten and spasm because they are compensating for hip joint instability. The contracted gluteus medius can eventually irritate the trochanteric bursa, causing trochanteric bursitis.
A lot more pain than you should have – according to your doctor
We see five types of patients in our clinic with Gluteus Medius Tendinopathy. Many of them share a common problem, they have more pain than their doctors thought they should. We see…
- the athletic person,
- the person with a physically demanding job,
- the person who has had long-term degenerative wear and tear,
- the person who had a hip replacement and Gluteus Medius Tendinopathy became a post-surgical complication, and
- a middle-aged person, more likely female, who does no exercise. Women are at greater risk for tendinopathy of the hip than middle-aged men, especially inactive ones.
Please refer to our article When painful hip MRI shows nothing. This is a fascinating article that will show you that you have to believe your hip when it is talking to you (signaling more pain) and not an MRI. There is a phenomenon in medicine called rapidly destructive osteoarthritis. This is an osteoarthritis breakdown that suddenly, without a seemingly good explanation, starts accelerated hip osteoarthritis. In our clinic, we see many patients with a lot of pain and seemingly no answers. This is especially true for the people we see who have more hip pain than his/her MRI is showing and more pain than his/her doctors will believe they are having.
Another thing many of these people have in common is that their diagnosis of Gluteus Medius Tendinopathy was not that easy to come by or confirm.
But my MRI says . . . asymptomatic gluteus medius pathology
One of the challenges in helping patients with any pain is that they have an MRI report and that that MRI report reveals all. Sometimes that MRI report reveals too much. What does that mean? It means you may get treatment or surgery for something that is not the cause of your hip pain.
An October 2020 study comes to us from the American Hip Institute Research Foundation and The American Journal of Sports Medicine. (2) Here is what it says:
“Although there is a meaningful prevalence of asymptomatic gluteus medius tendinosis, the prevalence of asymptomatic gluteus medius tears is low. Treatment of gluteus medius tendinosis should therefore be based not solely on MRI findings but rather on a complete clinical evaluation. In contrast, MRI findings of partial or full-thickness gluteus medius tears may be more likely to have clinical significance.”
MRI may misdirect treatment
Now let’s look at the research led by the La Trobe Sports and Exercise Medicine Research Centre, La Trobe University in Australia. This research was published in the Musculoskeletal Science & Practice (3) in June 2019.
- “It has been suggested that imaging findings play a role in directing treatment for Greater Trochanteric Pain Syndrome. Structural diagnoses associated with Greater Trochanter Pain Syndrome include gluteal tendinosis, and partial- or full-thickness gluteal tendon tears. However, few studies have compared imaging to confirmed tendon pathology observed during surgery. (This study investigated the ability of magnetic resonance and ultrasound imaging to identify the presence of a pathological gluteus medius tendon in comparison to surgical and histological (Physical and patient medical history) findings.
How can MRI misdirect treatment?
- Twenty-six participants undergoing gluteal tendon reconstruction surgery or hip arthroplasty were examined
- Prior to surgery, participants underwent both magnetic resonance (MRI) and ultrasound (US) imaging.
- A radiologist (MRI) and nuclear physicians (US) classified the gluteus medius tendon as normal, tendinosis (no tear), partial-thickness tear, or full-thickness tear.
- Both imaging modalities were poor at identifying and differentiating between tendinosis and partial-thickness tears.
The study concluded: “Both imaging modalities showed a reasonable ability to identify tendon pathology. While limited by sample size, these early findings suggest that both imaging modalities may be limited in identifying specific pathoanatomical diagnoses, such as partial-thickness tears. These limitations may misdirect treatment.”
What are we seeing in this illustration?
In this illustration, we can see why there can be a diagnostic misinterpretation of what is happening in your hip. The Gluteus medius muscle attaches to the femur at the gluteus medius tendon. If the hip is unstable, gluteus medius tendinopathy can develop.
The illustration shows trochanteric bursitis. The bursal sac is inflamed because the gluteus medius muscle is irritating it. This occurs because the gluteus medius muscle has to contract so much to help stabilize the pelvis and hip. Why? One reason can be the underlying hip joint instability from a labral tear or ligament injury.
The traditional and conservative care treatments of Gluteus Medius Tendinopathy
For some people, these treatments will be effective in the first go-round, for others it will make your hip pain worse.
Many of you reading this article will get the first of your anti-inflammatory medication prescriptions or over-the-counter recommendations at the onset of your conservative care treatment. You may have also received a referral to physical therapy.
For some people, these treatments will be effective in the first go-round. These people are not the ones we see in our office. We see the others for whom these treatments accelerated a damaging osteoarthritis breakdown of your hip.
Anti-inflammatory medications, painkillers, rest, cortisone injections, physical therapy, are parts of the conservative care treatment options patients are routinely offered in traditional care doctor’s offices. If you are reading this article are probably well into your treatment options and have found that many do not work.
We have written extensively on these treatment options: Please see our articles:
- Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients
- When NSAIDs make the pain worse.
- Painkillers make the pain worse.
- Corticosteroids/cortisone or steroid injection. This is also a treatment we do not recommend. See below for the research.
The failure of these treatments is not just our opinion. We cite numerous medical references from studies performed at leading hospitals and medical universities around the world to back up the lack of long-term success.
I am seeking treatment because I can’t get back to training or work
Often a runner or active person with outer hip pain comes into our office. He/she is here because:
- They had outer hip pain and continued to run, work, or do their activities.
- They took anti-inflammatories so they could continue to run, work, or do their activities.
- They took on the mindset that they will just run or work through the pain or their activities.
- They started having knee pain, low back pain, ankle pain.
- His/her running/physical activity went from a positive, happy experience into a miserable tale of survival.
We get many emails into our office looking for answers. Someone looking for help may write something like this:
I am a runner, but not now. This hip pain has been going on for almost three years. I no longer run and try to keep in condition with bike riding. I have been in physical therapy and rehab numerous times. They don’t help. I was told to do no training and do as much resting as I could. I completely shut down for 6 weeks, that did not help. I have had numerous cortisone injections, probably more than I should have got. That did not help. I am not looking for one last chance to avoid a surgery I do not want.
My doctor thought my hip pain was from osteoarthritis. So he sent me to a surgeon. I did not have hip osteoarthritis enough to recommend hip replacement, so that was ruled out. I did have wear and tear damage and was told I had gluteal tendinopathy. Since there was no other significant enough damage to the other parts of my hip to recommend any surgeries I was given painkillers and anti-inflammatories and basically sent on my way until the damage became bad enough to get surgery. I was able to get some physical therapy but I found that more painful than helpful. I no longer walk when I can, I ride, take elevators, even scooters in the supermarket. While this has helped my pain, it is not helping me.
How a weak hip creates degenerative disc disease, degenerative knee disease, and degenerative pelvic disease.
Let’s look at a January 2018 study. (2) This study is an illustration of the damaging effects of one joint being wobbly on the entire movement of the whole body. Obviously, we will be looking at the hip as the culprit joint.
Women team handball players are among the fittest athletes. Their sport depends great stress on the player’s joints. The researchers from Auburn University, School of Kinesiology, Sports Medicine and Movement Laboratory examined how lumbopelvic-hip complex stability, via knee valgus, affects throwing kinematics (movement) during a team handball jump shot.
Read again how hip instability is being measured: the complex hip-spine-pelvic interaction and instability is being measured by knee angle. The greater the knee angle the greater the instability coming from the hip/spine.
Points to consider
- The women with greater instability in the hip/spine/pelvic region through the ball with less force (they were weaker)
- The women with greater instability in the hip/spine/pelvic region were at increased risk of injury in the upper (arm and shoulder) and lower extremities (knee, ankle, feet) when landing from a jump shot because of the energy losses throughout the kinetic chain and lack of utilization of the entire chain.
- What does all that mean? Their entire body was at risk of fall, loss of balance, impact injury.
You do not need to be a high-level female team handball player to understand the problems in the hip caused and interact with instability in the lower spine and pelvis and these interactions put the knee, the ankle at risk for instability and loss of balance.
Gluteus Medius tendinopathy is now making your lower back, knee and ankle hurt worse
At this point, we hope you realize that isolating and determining a treatment plan for the Gluteus Medius tendon should include the whole hip. The Gluteus Medius tendinopathy you are suffering from is part of or a cause of a rapidly deteriorating hip situation. As we like to say, if you have four flat tires, fixing one is not fixing the whole problem.
The science of overcompensation and why your knee, ankle, hip, and knee hurt.
Above we briefly explained the compensatory mechanism your hip is trying to provide you in your walking and running. It is compensating for your tendon problems. Now let’s look at what that compensation is doing to the rest of you.
University researchers in Australia write in the Journal of Electromyography and Kinesiology: (3)
- Musculoskeletal injuries in runners are common and may be attributed to the inability to control pelvic equilibrium in the coronal plane. (In simpler terms pelvic instability or a wobbly gait is causing running problems).
- This lack of pelvic control in the frontal plane can stem from dysfunction of the gluteus medius. (The gluteus medius muscle stabilizes the pelvis when one leg leaves the ground during the running stride. When the gluteus medius tendon is injured, you lose stability when one leg leaves the ground).
Some points the researchers made: This instability in the hip is causing:
Treatments for Gluteus Medius Tendinopathy
Above we described the problems of conservative care in the treatment. Let’s touch on surgery. Surgery may be the right option for some people. It is usually not the first treatment people pick. There is a reason there is conservative non-surgical care. Medical research tells us that “elective,” surgery is just that. You elect to have it, it is usually not considered an essential treatment to fix your problems but it is offered for those people who believe surgery is the only way.
Here is research from September 2018, The Physician and Sports Medicine, (4) led by the Michigan State University College of Human Medicine. It discusses what happens when conservative care does not work and why surgery may be an option.
- “(Damage) of the gluteus medius can result in significant hip pain, loss of motion, and decreased function. Affected patients characteristically have symptoms including lateral hip pain and a Trendelenburg gait (this is an exaggerated walking problem where the hip/pelvis drops because of the lack of support from gluteus medius muscle/tendon complex), which may be (unresponsive) to conservative management such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and injections. In these cases, both open and arthroscopic repair techniques have been described, with recent literature demonstrating excellent patient-reported outcomes.”
Here is an October 2018 study from German doctors in the journal Operative Orthopädie und Traumatologie,(5) (a journal dedicated to Orthopedic and trauma surgery.)
What this study points out is who are the three types of candidates who surgery will help and how long the surgical recovery will take:
Who should consider surgery?
- People with an asymptomatic tear of gluteus medius and/or gluteus minimus tendon with persisting pain after nonsurgical treatment.
- Primarily Reconstruction: mass rupture with gluteal insufficiency (full or massive tear caused by injury or accident – a trauma.)
- People for whom previous gluteus medius tendon surgeries have failed and another surgery is needed to fix the first or previous surgeries.
Who surgery should not be recommended for:
- People whose muscle/tendons are damaged beyond surgical repair
- People whose gluteal muscles have significantly atrophied or have fatty degeneration
- People with local infections
After the surgery:
- Physical therapy with partial weight-bearing for 6 weeks
- No hip rotation 6 weeks after surgery.
- From week 7 after surgery, free range of motion, active-assisted abduction, and increase in weight-bearing.
- No peak load (running or other activities) for 4 months.
- Thromboembolic prophylaxis (blood clot prevention) until full weight-bearing is reached.
Surgery is controversial: September 2020
In the medical publication Hip International: The Journal of Clinical and Experimental Research on Hip Pathology and Therapy,(6) researchers at The University of Auckland wrote in a September 2020 paper of the difficulties in offering treatments, especially surgical treatment.
“Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilizing the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic (surgery causing) injury during arthroplasty (hip replacement) and chronic degenerative tendinopathy. . .While surgery has been attempted over the last two decades, the outcomes are variable and the lack of high-quality studies has limited the uptake of surgical repair.”
Platelet Rich Plasma injections and Prolotherapy injections for Gluteus Medius Tendinopathy
In basic terms, Platelet Rich Plasma injections are the application of concentrated blood platelets, which contain and release growth factors to stimulate recovery in non-healing injuries. Prolotherapy is an injection technique utilizing simple sugar or dextrose.
We do not use PRP treatments in isolation. As we have discussed in this article, gluteus medius tendinopathy is a problem that single injections, for the most part, have not been shown to be effective in the long-term as attested to in the research above.
Research on PRP injections as a non-surgical option:
This is from a study from doctors at the Hospital of Special Surgery in New York published in the Orthopaedic Journal of Sports Medicine. (6)
First a discussion on surgery from this research: (This research is from a surgical hospital.)
- Surgery is considered for difficult and unresponsive lateral hip pain due to gluteus medius tears.
- While there are several studies supporting the effectiveness of certain surgeries, some studies indicate prolonged recoveries.
- One study reported that 19% of 72 patients who underwent surgical repair of gluteal tendon tears experienced significant complications, including deep vein thrombosis, pulmonary embolus, tendon retear, wound hematoma, pressure sores, wound infection, and even fracture of the greater trochanter. (7)
Results achieved with PRP injections
- A total of 21 patients (17 females, 4 males) with an average age of 48 were followed for an average of nearly 20 months after treatment.
- “Statistically and clinically significant improvements were observed across all outcome measures with over 1-year follow-up on all participants.”
- “Our results suggest that PRP is a safe and relatively effective nonsurgical treatment option for recalcitrant lateral hip pain secondary to gluteus medius tendinopathy from tendinosis and/or partial tears of the gluteus medius tendon.”
PRP vs Cortisone
In January 2018, university researchers in Australia went into their study with the idea that they can validate the idea that there would be NO difference between the effects of cortisone injection or PRP injection for gluteal tendinopathy. Both treatments would be given one chance to work, one injection. Here is a summary of their findings published in the American Journal of Sports Medicine. (8)
- The average age of the study participant was 60 years old, 90% were female. The patients complained of gluteal tendinopathy pain and function problems for an average of 14 months.
- The single shots were administered and monitored.
- At two weeks, there was no difference between the two groups, measured improvements were about equal.
- At six weeks, there was no difference between the two groups, measured improvements were about equal.
At 12 weeks a change occurred:
- Improvement in the PRP group was significantly better at 12 weeks compared with the corticosteroid group.
CONCLUSION: Patients with chronic gluteal tendinopathy for more than 4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.
Again, let us point out in this research that this was a single cortisone injection vs. a single PRP injection. The video above is reflective of our treatments.
PRP and Prolotherapy for Gluteus Medius Tendinopathy – How we do it.
As mentioned, the above research compares one injection of cortisone to one injection of PRP. One injection of PRP is not our treatment method.
Why treat with Prolotherapy when we inject PRP? Because Prolotherapy makes the PRP work better, the PRP makes the Prolotherapy work better.
Prolotherapy helps repair tendons:
A multi-national team of researchers including those from Rutgers University, Virginia College of Osteopathic Medicine, and the University Regensburg Medical Centre in Germany tested the effects of Prolotherapy on tenocytes repair (tendon cells). Published in the journal Clinical Orthopaedics and Related Research, (9) what the team was looking for was how did Prolotherapy injections change the immune system’s response to a difficult-to-heal tendon injury.
These are the highlights:
- Prolotherapy injections changed the cellular metabolic activity to a healing, regenerative environment in the tendon cells.
- Prolotherapy activated RNA expression. The healing phase of soft tissue injury starts spontaneously after the tendon injury. Healing occurs in three phases: inflammation, proliferation, and maturation. RNA expression is the communication changes in genes (remember the gene expression from above) that coordinate the beginning and end of these three cycles of the healing and injury repair process.
- Activated Protein secretion – the process of rebuilding. For a fascinating look at this subject please see our article on Extracellular matrix in osteoarthritis and joint healing.
- Cell migration. The ability of healing cells to get to the site of an injury, and the denial of damaging inflammatory factors from reaching the same site.
In our own published research, we reported in the Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, (10) we reported that the consensus is growing regarding the effectiveness of dextrose Prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.
Platelet Rich Plasma Therapy and Prolotherapy
Platelet Rich Plasma therapy (PRP) can be added to the traditional Prolotherapy solution to expedite the process, in specific cases.
- PRP treatment re-introduces your own concentrated blood platelets into areas of chronic tendinopathy
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)
In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.
- This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
- This patient has a suspected labral tear and ligament injury.
- The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
- The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
- From the front of the hip (1:05), we can treat the pubofemoral ligament and the iliofemoral ligaments
- From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles too, including the Obturator, the Piriformis attachments onto the Greater Trochanter
- Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
Do you have a question about tendon damage and repair? Get help and information from Caring Medical
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This articles was updated September 14, 2021