Differentiating Buttock Pain - Gluteal Tendinopathy

Original Editors - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Tarina van der Stockt, Lucinda hampton and Ewa Jaraczewska 

Deep Gluteal pain can be a complicated presentation due to the variety of structures that could be involved in the pathology.

Gluteal Tendinopathy as a potential source of deep gluteal pain has been introduced as a concept very recently in the research compared to other structures that can cause gluteal pain such as SIJ and the Lumbar region.

Gluteal Tendinopathy

Also known as Greater Trochanteric Pain Syndrome is a pain that starts in the greater trochanter region and may radiate to the lateral thigh and/or leg. Trochanteric Pain primarily is caused by the gluteal tendons and a secondary cause of this pain is the bursal inflammation that used to be thought as the main source of pain. Other structures that could be involved int he pathology are the posterior hip capsule, Gemelli's and the Obturators.

This condition has significant impacts on sleep quality, physical activity, work participation and the quality of life. One study reported the quality of life of Gluteal Tendinopathy patients is equivalent to the severity of a patient waiting for a total hip replacement for severe osteoarthritis of the hip.

The pain of Gluteal Tendon origin can refer to the sacroiliac region, the buttock, the groin and into the anterior thigh. This overlap of referral pattern doesn't help in differentiating other pathologies.

The Visa G questionnaire was validated by Angie Fearon as an outcome measure for disability resulting from lateral hip pain. The questionnaire looks at activities such as lying on the affected side, stairs negotiation and the overall severity of the hip pain.

This condition should be differentiated from Deep Gluteal Pain as this is mainly originated from a structure working on the hip joint (Lateral or groin pain). Patients often may refer to the whole area as hip pain but the reality is that pain could come from a deeper structure in the buttock that is not directly related to the hip.

Gluteal Tendinopathy is more relevant in females over 40 years old. 73% of the patients are believed to be either menopausal or peri-menopausal indicating a link between hormonal changes and tendinopathy. Certain medications are also shown to influence the tendon structural changes such as quinolone antibiotics, oestrogen inhibitors such as Tamoxifen for patients who had breast cancer.

Other factors that were found to affect the presence and prognosis of Tendinopathy are:

• Smoking
• Diabetes
• Steriods
• Changes in load either underload or overload.

A common sign is a reported difficulty in walking after sitting for a period of time. A Patient can describe it as'' hobbling''.

Compression forces can aggravate the lateral hip pain. An exercise such as Clam can provoke the tendon pain due to the high compressive force. Similarly, sitting with crossed legs and sleeping on the affected side place the gluteal tendon under a high compression force of Tensor Facia lata.

An important finding is that hip abductor strength wasn't associated with the severity of the tendinopathy. Factors such as greater psychological stress, poorer quality of life, a greater waist girth and a higher BMI were relevant in sever cases. However, these factors might also develop as a result of pain

Diagnosis

Patient's history is an important measure in reasoning Gluteal Tendinopathy. Gender, BMI, age and history of loading.

Pain location: lateral hip pain.

Pain severity: usually 4/10 on most days

Palpation: tenderness over the superior aspect of the greater trochanter (the insertional point of glute medius and glute minimus)

FADER or FADER resisted tests ( flexion adduction external rotation position). Pain over the lateral hip region is a positive test and could be diagnostic of gluteal tendinopathy. If the pain was reported in the deep gluteal region it could indicate deep gluteal pain syndrome. When the leg is flexion> 60 degrees, adduction, external rotation, the Piriformis becomes an internal rotator. Also, glute med and glute max swap roles from being an external rotator to being an internal rotator.

To exclude osteoarthritis of the hip, the subjective history of the patient and FADIR ( flexion adduction internal rotation test) are important diagnostic measures. A positive FADIR test might not rule out OA completely but a negative test is recognised to rule out intra-articular hip pathologies such as OA, Femoral Acetabular Impingement or Labral tear.

Total Arc of motion rules out inter-articular pathologies.

OA hip will tend to have a loss of hip flexion range of motion

Hip External Rotator; Gemelli's, Obturators and Quadratus femori have been included in Lateral hip pain pathology.

They have an anatomical position of lying at 90 degrees to the long axis of the hip. Functions:

• Compress the hip joint and to provide stability at the joint.
• Reinforce the posterior capsule of the hip

Overactivity of the deep hip external rotators limits hip internal rotation range of motion.

Tenderness over the posterior deep aspect of the greater trochanter with restricted internal rotation could more likely be that the short hip external rotators are causing the patient's presentation.

Managing the condition

Healthy lifestyle changes such as quitting smoking and promoting weight loss .

Load management: gently increase the load on the tendon and managing the weekend-warrior exercise or load and no-load scenario.

Avoid stretches especially in the early phases of the tensor fascia lata or piriformis to avoid compression of the TFL onto the insertional area of the glute med. S

Advise the patient to sleep with a firm pillow between their knees.

They should not sit with their legs crossed and they should avoid hanging on that hip if they standing.

So, for example, if you have a baby on one hip, you want to avoid that type of compressive and tensile loading onto those tendons.

Posture and functional loading mechanics. Dynamic valgus (hip adduction and internal rotation) during loading activities as it increases compression and tensile loading on the damaged tendon.

Selection of Exercises

Progressive exercises that increase the load starting with isometric exercises. Ebonie Rio has shown that isometrics can be very hypoalgesic and can be used in season. So that might be a way to start to try and help the patients self-manage their pain and presentation.

Progressing from isometric to bridging exercises.

The clam is not recommended, instead, a modified clam exercise which effectively allows for the top shin to be lifted off the bottom shin to get a pure abduction motion without bringing in the external rotation component, which will increase the compressive load on the insertional painful tendon.

Other exercises such as monster walks and Sumo walks can be used in this stage. Slow, controlled abduction, external rotation with a loop around both hips.

Some studies have been done on split squats with the weight in the contralateral hand has shown to be very effective in isolating and strengthening the glute med tendon and muscle.

Loading should be monitored. Pain can be used to monitor the load on the tendon. A four out of ten pain during the exercise and no worse over 24 hours.

Abductor slides using slidos, to get more of an abduction component.

Non-discogenic Sciatica Pain

the deep gluteal space, a highly nociceptive area, that is superiorly bounded by the greater sciatic notch, inferiorly by the ischial tuberosity, laterally by the linear aspersa and the greater trochanter and medially by the sacrotuberous ligament.

The sciatic nerve can get entrapped in this area.

The hamstring origin tendinopathy, ischiofemoral impingement.