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Gluteal tendinopathy is recognized as the primary cause of lateral hip pain, and is typically a degenerative process and can involve the gluteus medius or gluteus minimus (Mulligan et al; Reid; Robinson et al; Torres et al). Over time gluteal tendinosis can progress to a partial-thickness tear or full thickness tear with atrophy of the muscle belly (Kingzett-Taylor et al; Kong et al).
Patients typically report pain over the lateral hip. Both ultrasound and magnetic resonance imaging (MRI) have been shown to be able to identify and differentiate between tendinosis and partial-thickness tear (Docking et al; Westacott et al). Ultrasound has been reported to have a high sensitivity of 79 to 100% with a positive predictive value to 95 to 100%, but requires a skilled practioner (Fearon et al; Westacott et al). MRI has a reported sensitivity of 73% and specificity of 95% for the presence of tears (Cvitanic et al).
MRI Grading of Gluteal Tendinopathy (Hoffman & Pfirrmann, 2012)
Grade 1: tendinopathy associated with bursitis and no changes or minimal changes within the gluteal tendon
Grade 2: tendinopathy: characterized by abnormal signal within the T1-weighted, but normal T2 fluid sensitive imaging
Grade 3: tendinopathy with partial-thickness tears with abnormal T2 weighted imaging
Grade 4: tendinopathy and full-thickness tears with discontinuity of one or both gluteal tendons
Abnormality of gluteal tendon pathology has historically been under diagnosed, with a greater recognition of the injury with advances in imaging
Different treatment regimens have been described for the management of gluteal tendinopathy, including non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, shockwave therapy and injections. Surgical management is typically reserved for recalcitrant cases.
Most reviews have not differentiated treatment options based on the severity of the tendinopathy. (Chandrasekaran et al; Ebert et al; Grimaldi et al). In a systematic review of 1103 patients that provides evidence-based treatment recommendation for the different states of gluteal tendon pathology, the authors recommended a single PRP injection for grade 1 and 2 tendinopathy (Ladurner et al). In grade 3 pathology, with partial tears the authors also recommended a PRP injection before considering surgery. In most cases, non-surgical treatment is successful in 60 to 90% of cases (Walsh et al).
In a recent systematic review(ref), only 16 studies reported outcomes after surgery for gluteal tendon pathology. Surgery typically consists of:
The mean complication rate of surgery is 10% (Ladurner et al).
Gluteal tendinopathy is thought to be degenerative and not due to inflammation. Despite this corticosteroid injections can provide short term relief of pain. After a single corticosteroid injection, patients seem to notice greatest improvement 6-weeks after the injection and then the improvement peaks (Fitzpatrick et al. 2018; Fitzpatrick et al. 2019).
What is the evidence for PRP injections?
Platelet rich plasma, or PRP, injections are growth factor injections that have been shown to help with tendon pain and improve function (ref/link) (learn more here). There is high level evidence (level 1b) supporting the use of PRP for grades 1 and 2 gluteal tendinopathy (Fitzpatrick et al. 2018; Fitzpatrick et al. 2019; Jacobson et al).
When compared to corticosteroid injections, patients that received PRP demonstrated greater improvement in pain and function 12-weeks after the injection. The effect of the steroid injections declined after 24-weeks, while up to 2-years after the PRP injection those patients continued to show ongoing benefit from the PRP injection (Fitzpatrick et al. 2018; Fitzpatrick et al. 2019).
When PRP is combined with a needle tenotomy for gluteal tendon there was a significant improvement in pain and function over a 19-month period (Lee et al). However, another study demonstrated that a single PRP injection plus tendon fenestration was not superior to a single PRP injection alone (Fitzpatrick et al. 2019).
There was no studies examining or showing support for PRP injections in full-thickness tears (Ladurner et al).
What is the evidence for tenotomy (Tenex) or fenestration of the gluteal tendons?
Tenotomy procedures are often performed in conjunction with PRP injections, but needle tenotomy or tendon fenestration can also be performed as a stand-alone treatment.
There is high level evidence (level 1b) showing similar effects of tendon fenestration on pain when compared to PRP (Jacobson et al).
The evidence for tenotomy using Tenex is limited to a case series, but in this group of patient 90% were able to avoid an open surgery (Baker et al, 2020). Despite this being a small study, patients were followed for an average of 22 months after the procedure, and only 10% required an open procedure for continued pain.
Conclusion
Gluteal tendinopathy is a degenerative process. Corticosteroid injections are a common treatment for lateral hip pain with good short-term outcomes, but the does not provide long-term benefit or address the underlying degenerative nature of chronic gluteal tendon pain.
In a systematic review of treatments for gluteal tendinopathy by Ladurner et al. the authors found that non-operative treatment was successful in the majority of patients, and the treatment method of choice should reflect the severity of the tendon pathology. There is good evidence that ultrasound and MRI can be used to grade the severity of the tendon pathology, and for gluteal tendinopathy (grade 1 and 2) and partial tendon tears (grade 3) PRP is the authors choice for first line management (Ladurner et al).
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Contrary to the common misconception that symptoms of lateral hip pain are due to underlying "bursitis," the most common cause of lateral hip pain is gluteal tendinopathy due to tendon degeneration and a possible tear.
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