Gluteus Medius Tendinopathy | Hip tendinitis injections
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Gluteus Medius Tendinopathy
You went to your health care provider or doctor with chronic hip pain that is becoming more and more of a challenge to your daily routine. You tell your health care provider that the pain concentrates on the outer side of your hip and this nagging injury that has bothered you for some time, is getting worse and worse.
Based on this evidence, the health care provider will likely suspect that you have “hip tendinitis.” An inflammation of a hip tendon.
Adding to this evidence is if you are:
- Athletic or sports active
- A middle age person who does no exercise, and a woman. Women are at greater risk for tendinopathy of the hip than middle age men, especially inactive ones.
The focus will then turn to the Gluteus Medius Tendon of the hip as this is the most common and likely tendon injury causing your hip tendinitis and outer hip pain.
- Some doctors may also suspect Greater trochanteric pain syndrome in some patients. Please see our article where we cite research that injuries to the muscles and tendons around the hip are the actual cause of Greater trochanteric pain syndrome, not bursitis. We also discuss this below.
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.
Very likely you will get the first of your anti-inflammatory medication prescriptions or over-the-counter recommendations. You may get a referral to physical therapy. For some people, these treatments will be effective in the first go round, for others it will accelerate 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 it is likely that you are 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 pain worse.
- Painkillers make 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 are no just our opinion. We cite numerous medical references from studies performed at leading hospitals and medical universities around the world to back up these treatments lack of long-term success.
Getting to the evidence: Does Gluteus Medius tendinopathy treatments makes your hip, lower back, knee and ankle hurt and hurt worse?
Often a runner or active person with outer hip pain comes into our office. He/she is here because:
- The had outer hip pain and continued to run or do their activities.
- They took anti-inflammatories so they could continue to run or do their activities.
- They took on the mindset that they will “just run 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.
How did you get here? Because everyone wanted to treat your tendon and not your hip problem
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.
When the hip joint region becomes unstable, the muscles, including the Gluteus Medius, tries to create stability by tensing, cramping or going into spasm. When the muscle tenses, you have “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 spine to 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 a trochanteric bursitis.
Gluteus Medius tendinopathy is now making your lower back, knee and ankle hurt
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: (1)
- 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 maybe 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. The 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 sportsmedicine, (2) lead 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,(3) (a journal dedicated to Orthopedic and trauma surgery.)
What this study points out is who are the three candidate types surgery will help and how long the surgical recovery will take:
Who should consider surgery?
- People with symptomatic 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 the another surgery is needed to fix the first or previous surgeries.
Who surgery should not be recommended for:
- People whos 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.
Expected results: Success rates of 80-90% can be expected in cases with no or only minor muscle atrophy.
Surgery or regenerative medicine options?
Typically a success rate of 80-90% can be expected in cases with no or only minor muscle atrophy in non-surgical treatment as well. In this section we are going to explore regeneartive medicine injections. Let’s be clear, this is not cortisone, nor should this be considered a single shot therapy of anything. Regenerative medicine injections are part of a comprehensive problem of treatments that we offer in our clinics.
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. The video describes the technique, the research below describes the results.
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.
This video was created nine years ago. The basic concepts of healing remain the same. We have been treating sports related injuries with regenerative medicine injections for 26+ years.
In this video you will see the application of Platelet Rich Plasma injections and the use of Prolotherapy injections. Prolotherapy is the injection of dextrose, or a simple sugar, to irritate damaged hip ligaments. Hip ligaments provide stability, damaged hip ligaments provide INSTABILITY.
The dextrose in the Prolotherapy solution, when injected around the injury, causes a mild inflammatory response, mimicking what the body does naturally in response to soft-tissue injuries. The immune system is drawn to the area of injury and immune cells and platelets release growth factors to build new healthy tissue. The ligaments and tendons become thicker and stronger from this inflammatory response. Again, this is explained in the video above, and further below.
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. (4)
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.(5)
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.(6)
- 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 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 methods.
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, (7) what the team was looking for was how did Prolotherapy injections change the immune system’s response to a difficult to teal 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 coordinates the beginning and ending of these three cycles of 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, (8) 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 our clinics, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
Do you have a question about tendon damage and repair? Get help and information from Caring Medical
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