Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management

Is shockwave therapy effective in the management of greater trochanteric pain syndrome? A systematic review and meta-analysis

BACKGROUND

Evidence is lacking for the efficacy of shockwave therapy (SWT) in the treatment of greater trochanteric pain syndrome (GTPS).

AIM

To investigate the efficacy of SWT on pain and function in the management of GTPS.

METHODS

A systematic search of electronic databases and grey literature was conducted up to May 2023. Studies utilising SWT on adults for GTPS, providing measures of pain and/or function at baseline and at follow-up were considered for inclusion. Meta-analysis was undertaken using converted pain and functional outcomes. Studies were assessed for quality and risk of bias, and assigned a level of evidence as per the Grading of Recommendations, Assessment, Development and Evaluations criteria.

RESULTS

Twelve articles (n = 1121 subjects) were included, including five randomised controlled trials (RCTs) and seven non-RCTs. No statistical differences were observed for pain over time f(1,5) = 1.349 (p = 0.298) or between SWT and control f(1,5) = 1.782 (p = 0.238). No significant differences in functional outcomes in short- (H = 2.591, p = 0.181) and medium-term follow-up (H = 0.189, p = 0.664) were identified between SWT and control. Moderate magnitude treatment effects for pain (Hedges-G [HG] 0.71) favouring SWT groups over control was identified, decreasing to low for function (HG 0.20). Further pain and functional treatment effects were identified at higher magnitudes across follow-up time-points in SWT groups compared to control.

CONCLUSION

Moderate-quality evidence demonstrated no statistically significant improvements in pain and function post-SWT compared to control. Low-quality evidence established clinical improvements throughout all included studies favouring SWT over control. Consequently, owing to relatively low incidence of side effects, SWT should be considered a viable option for the management of GTPS. Issues with both clinical and statistical heterogeneity of studies and during meta-analysis require consideration, and more robust RCTs are recommended if the efficacy of SWT for the management of GTPS is to be comprehensively determined.

Current and future advances in practice: tendinopathies of the hip

Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review

BACKGROUND

Cortico-Steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain.

OBJECTIVES

To identify factors that influence improvements in pain for patients with GTPS treated with CSI.

DESIGN

Systematic review.

METHODS

A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion if they investigated factors that influenced changes in pain experienced by patients with GTPS who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk Of Bias 2 (ROB2) tools were used to assess bias.

RESULTS

The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores.

CONCLUSIONS

Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance.

Effects of exercise-based interventions on gluteal tendinopathy. Systematic review with meta-analysis

The objective of this review was to evaluate the effect of exercise on pain intensity, function, and quality of life in individuals with gluteal tendinopathy. Searches were carried out in PUBMED, EMBASE, CINAHL, Cochrane Library, and PEDro databases. Randomized or quasi-randomized controlled trials were included. Five studies met the eligibility criteria, comparing exercise-based interventions with minimal interventions and/or corticosteroid injections. Three studies, involving 383 participants, were included in the quantitative analysis. Meta-analyses showed that exercise is superior to minimal intervention for function in short-term [mean difference (MD) = 10.24; 95% confidence interval (95%CI) = 5.98, 14.50) and long-term (MD = 6.54; 95%CI = 1.88, 11.21]). However, no difference was observed for quality of life in the short [standardized mean difference (SMD) = 0.33; 95%CI = -0.29, 0.94] and long-term (SMD = 0.11; 95%CI = -0.16, 0.37). The effect of exercise was no different from that of corticosteroid injections for pain intensity in the short (MD = 1.25; 95%CI = -3.56, 6.05) and long-term (MD = -1.37; 95%CI = -3.72, 0.98]). In conclusion, exercise is superior to minimal interventions for function in the short- and long-term in individuals with gluteal tendinopathy. Exercise and corticosteroid injections had similar effects on pain intensity, however, exercise showed a higher treatment success rate when compared to corticosteroid injections in this population. The GRADE analysis revealed that the certainty of the evidence ranges from low to very low, therefore, large high-quality randomized controlled trials are recommended.PROSPERO registration number: CRD42021242853.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

The reliability and validity of the Norwegian version of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire (VISA-G-Norwegian) for patients with greater trochanteric pain syndrome

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS) is a common chronic musculoskeletal condition that may affect physical function, quality of life and sleep. The Victorian Institute of Sport Assessment-Gluteal questionnaire (VISA-G) has been developed as a Patient-Reported Outcome Measurement (PROM) to address pain, everyday activities, physical activities, and difficulty with weight bearing activities. The aim of the study was to test the reliability, validity and floor and ceiling effects of the Norwegian version of the VISA-G (VISA-G-Norwegian) in a population with GTPS in a specialist health care setting.

METHODS

This psychometric evaluation of the VISA-G-Norwegian questionnaire were conducted with a prospective observational design. The VISA-G was translated into Norwegian following recommended guidelines. A subgroup repeated the VISA-G-Norwegian a week after the initial submission. For the reliability, the Intraclass Correlation Coefficient (ICC2.1), Standard Error of the Measurement (SEM) and the Smallest Detectable Change (SDC95%) were calculated. Internal consistency was measured using a Cronbach´s alpha. Floor and ceiling effects were evaluated, and construct validity was assessed with three a priori hypotheses.

RESULTS

78 participants were included in the study of which 47 stable participants undertook the test-retest reliability arm of the study. The ICC2.1 for the total score was 0.85 (95% CI 0.68, 0.92), SEM was 6.6 points and SDC95% 18.4 points. Cronbach`s alpha was 0.77 (95% CI 0.69, 0.84). No floor or ceiling effects were found in the total score, but ceiling effect was found in three of the eight items. For construct validity, one of the three hypotheses were confirmed. VISA-G-Norwegian correlated to the modified Harris Hip Score (mHHS), Oswestry Disability Questionnaire (ODI) and Numeric Pain Rating Scale (NPRS), 0.64, -0.75 and - 0.63 respectively.

CONCLUSION

The VISA-G-Norwegian has acceptable reliability and validity, despite ceiling effect of individual items. The large SDC95% should be considered when measuring change in similar cohorts with GTPS. For a potential future version, it would be recommended to consider response options for questions with ceiling effect and the comprehensibility of question eight.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov the 28/02/2020 (NCT04289922).

Exploring the role of intratendinous pressure in the pathogenesis of tendon pathology: a narrative review and conceptual framework

Despite the high prevalence of tendon pathology in athletes, the underlying pathogenesis is still poorly understood. Various aetiological theories have been presented and rejected in the past, but the tendon cell response model still holds true. This model describes how the tendon cell is the key regulator of the extracellular matrix and how pathology is induced by a failed adaptation to a disturbance of tissue homeostasis. Such failure has been attributed to various kinds of stressors (eg, mechanical, thermal and ischaemic), but crucial elements seem to be missing to fully understand the pathogenesis. Importantly, a disturbance of tissue pressure homeostasis has not yet been considered a possible factor, despite it being associated with numerous pathologies. Therefore, we conducted an extensive narrative literature review on the possible role of intratendinous pressure in the pathogenesis of tendon pathology. This review explores the current understanding of pressure dynamics and the role of tissue pressure in the pathogenesis of other disorders with structural similarities to tendons. By bridging these insights with known structural changes that occur in tendon pathology, a conceptual model was constituted. This model provides an overview of the possible mechanism of how an increase in intratendinous pressure might be involved in the development and progression of tendon pathology and contribute to tendon pain. In addition, some therapies that could reduce intratendinous pressure and accelerate tendon healing are proposed. Further experimental research is encouraged to investigate our hypotheses and to initiate debate on the relevance of intratendinous pressure in tendon pathology.

Care for the patient with hip pain

ABSTRACT

Hip pain is a common and sometimes disabling condition that affects adults in the primary care setting. The NP must understand the assessment, diagnosis, and treatment options for patients with hip pain. Proper care of these patients often involves conservative medical management and coordination with physical therapy.

Do posted foot orthoses alter hip biomechanics and pain during walking in women with greater trochanteric pain syndrome?

BACKGROUND

Greater trochanteric pain syndrome (GTPS), including gluteal tendinopathy and bursitis, is a common, painful and debilitating condition. It is thought to involve overload of the gluteal tendons, which may be amplified through increased hip adduction moment (HAM) seen during gait in these individuals. Reducing the aberrant HAM may improve pain and function in this population. We aimed to determine if medially-posted foot orthoses immediately reduce HAM and pain in females with GTPS during walking gait.

METHODS

A double-blind, repeated-measures trial with randomised intervention order compared three conditions in 53 women with GTPS. Participants acted as their own control during baseline (everyday-shoe insole), medially-posted (active) orthosis, or flat insert (sham orthosis) walking. Data were collected via three-dimensional gait analysis for HAM, hip, pelvic, and thorax kinematics; as well as ground reaction force; and pain via the numerical rating scale. Subgroup analysis was performed based on a pronated foot-posture defined by the Foot Posture Index.

RESULTS

A small pain reduction was found between the active orthosis and flat insert (mean difference = -0.444, p = 0.017). No difference was detected for pain between other condition comparisons. Thoracic lateral flexion increased at second-peak HAM between the baseline and active conditions (mean difference = -0.917, p = 0.040). No differences were detected for HAM, remaining kinematic or kinetic variables, or ground reaction force data across the three conditions. No significant differences were detected between any of the three conditions for biomechanical or pain data in the pronated-foot subgroup.

SIGNIFICANCE

A medially-posted foot orthosis did not immediately alter gait biomechanics or provide a clinically meaningful pain reduction in women with GTPS. There is uncertainty regarding the clinical benefit of orthoses in the management of GTPS. Longer-term follow-up or the use of customised orthoses may produce different outcomes and should be explored in future research.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Desmoid fibromatosis presenting as lateral hip pain in an outpatient physical therapy clinic: A case report

CASE DESCRIPTION

A 21-year-old healthy female presented with severe left lateral hip pain beginning suddenly two weeks prior. Physical examination revealed zero degrees of left hip external rotation passive range of motion with a firm end feel and pain severity and irritability out of proportion to an expected musculoskeletal presentation. She was referred to her physician with a recommendation for imaging to determine the source of pain and appropriateness of physical therapy.

OUTCOME

Magnetic resonance imaging revealed a foreign mass in her left gluteus medius muscle which biopsy revealed to be a desmoid fibromatosis.

CONCLUSION

This case demonstrates a thorough differential diagnostic process leading to medical imaging referral in a patient with a non-musculoskeletal source of pain. Physical therapists must be diligent in their differential diagnostic process to ensure appropriateness of their treatments or the need for referral.

The use of physical function capacity measures in the management of lower limb tendinopathy: A scoping review of expert recommendations

BACKGROUND

Physical function capacity measures are recommended as outcome measures for people with lower limb tendinopathy.

OBJECTIVE

(i) Explore measures of physical function capacity recommended by experts in lower limb tendinopathy (ii) the context they were used, (ii) identify recommended criteria for exercise progression and return to sport or activity.

DESIGN

Scoping Review.

METHOD

Three databases were searched using keywords for lower limb tendinopathy and physical function capacity to identify studies that outlined a progressive exercise rehabilitation program. A 15-item tool was used for data extraction.

RESULTS

26 studies were included, only eight recommended a physical function capacity measure. There were 10 physical function capacity measures identified for a range of lower limb tendinopathies including patellar (50%), Achilles (13%), proximal hamstring (13%), gluteal (13%), combined patellar and Achilles (13%). Pain was the most common criterion that was used to determine the progression of rehabilitation (96%), with physical function capacity measures rarely used (12%).

CONCLUSION

Physical function capacity measures are used infrequently across expert recommended exercise rehabilitation programs. There remains a high reliance on pain as the criterion for progression of exercises during rehabilitation. There is a need to develop measures of physical function capacity to better inform and progress rehabilitation.

Mediators and Moderators of Education Plus Exercise on Perceived Improvement in Individuals With Gluteal Tendinopathy: An Exploratory Analysis of a 3-Arm Randomized Trial

OBJECTIVE: To investigate mediators and moderators of effects of an education-plus-exercise program compared to corticosteroid injections or wait and see on perceived improvement in individuals with gluteal tendinopathy. METHODS: Exploratory analysis from a clinical trial (n = 204) comparing education plus exercise, corticosteroid injection, and wait and see on global rating of change at 52 weeks. Potential mediators measured at baseline and 8 weeks were hip active abduction range, abductor muscle torque, pain self-efficacy, pain constancy, and patient-specific function. Potential moderators at baseline were Victorian Institute of Sport Assessment for gluteal tendinopathy, menopausal status, symptom duration, magnetic resonance imaging-determined tendon pathology, and pain catastrophizing. RESULTS: There is evidence from mediation analysis that the beneficial effect of education plus exercise on global rating of change relative to corticosteroid injection or wait and see may be due to changes in patient-specific function (indirect effect relative risk; 95% CI: 1.14 [1.05-1.29], 1.29 [1.12-1.58], respectively), pain constancy (1.12 [1.03-1.27], 1.2 [1.08-1.41]), and pain self-efficacy (1.1 [1.02-1.25], 1.18 [1.04-1.44])-not active hip movement/muscle torque. Moderation analysis did not support our included patient characteristics. CONCLUSION: Education plus exercise is likely to improve global rating of change for persons with gluteal tendinopathy relative to corticosteroid injection and wait and see through improvements in patient-specific function, pain self-efficacy, and reduced pain constancy. We found no evidence of differences in the effect of education plus exercise in patient subgroups based on disability, menopausal status, symptom duration, tendon pathology, or pain catastrophizing. J Orthop Sports Phys Ther 2022;52(12):826-836. Epub: 17 October 2022. doi:10.2519/jospt.2022.11261.

"I feel I have been taken seriously" Women's experience of greater trochanteric pain syndrome treatment-A nested qualitative study

BACKGROUND

Women experiencing greater trochanteric pain syndrome (GTPS) report high levels of pain and reduced quality of life. Exploring how they manage GTPS in a daily life context can provide important knowledge about individual coping strategies. Education, extracorporeal shockwave therapy (ESWT) and exercise have good group level evidence for efficacy in clinical trials and are increasingly used in routine care for patients with GTPS. Exploring women's experiences of such treatment may help understand the mechanisms underpinning these positive results and inform treatment strategies. We therefore aimed to explore how women with GTPS experience and manage their daily life, and their experience of the combined treatment of education, ESWT and exercises.

METHODS

This qualitative study was nested within a cohort study based in a hospital outpatient clinic and a physiotherapy clinic in Denmark assessing the combined treatment of education, ESWT and exercises. Data was collected from eleven women using in-person, individual, semi-structured interviews which were audio recorded. Transcripts were coded and analysed using an inductive thematic analysis approach.

FINDINGS

Five themes were identified: (1) Daily life was controlled and structured by pain; (2) The condition was acknowledged and taken seriously by treating professionals; (3) The participants´ experiences of the intervention-information is key; (4) Improved capability and autonomy in pain management and (5) The women´s perspectives on improving and expanding the intervention. Learning how to manage pain was experienced as the most important element of the program to the women to be able to minimize pain and manage daily life.

CONCLUSION

Exploration of how women with greater trochanteric pain syndrome experienced and managed daily hip pain, and how they experienced and adapted to treatment are important novel findings that will inform clinical practice. This new knowledge may be used to inform an individualized patient education, treatment and evaluation strategy for women with the painful and debilitating condition of GTPS.

Caring for adults with hip pain

This article discusses the pathophysiology, assessment techniques, and management of hip pain in adults and the role of nurses in caring for patients with hip pain.

Exercise With Low-Loads and Concurrent Partial Blood Flow Restriction Combined With Patient Education in Females Suffering From Gluteal Tendinopathy: A Feasibility Study

Introduction

To date, there exists no gold standard conservative treatment for lateral hip pain due to tendinopathy of the gluteus medius and/or minimus tendon (GT), a condition often complicated by pain and disability. Higher loads during everyday activities and exercise seems to be contraindicated with GT. The purpose of this study was to evaluate the feasibility of exercise with low-loads concurrent partial blood flow restriction (LL-BFR) and patient education for patients present GT.

Methods

Recruitment took place at three hospitals in the Central Denmark Region. The intervention consisted of daily sessions for 8 weeks with one weekly supervised session. From week three patients exercised with applied partial blood flow restriction by means of a pneumatic cuff around the proximal thigh of the affected leg. Throughout the intervention patients received patient education on their hip condition. Sociodemographic and clinical variables were collected at baseline. The feasibility of LL-BFR was conducted by adherence to the exercise protocol and drop-out rate. Patient reported outcome measures (The Victorian Institute of Sport Assessment-Gluteal Questionnaire, EuroQol - 5 Dimensions-Visual Analogue Scale, Oxford Hip Score, Copenhagen Hip and Groin Outcome Score), maximal voluntary isometric hip abduction-, hip extension, and knee extension strength (Nm/kg) measured using a handheld dynamometer, and functional capacity tests (30 second chair-stand test and a stair-climb test) was conducted as secondary outcomes.

Results

Sixteen women with a median (IQR) age of 51 (46–60) years were included. Median (IQR) Body Mass Index was 26.69 (23.59–30.46) kg/m2. Adherence to the total number of training sessions and the LL-BFR was 96.4 and 94.4%, respectively. Two patients dropped out due to (i) illness before initiation of LL-BFR and (ii) pain in the affected leg related to the LL-BFR-exercise. At follow-up both pain levels and patient-reported outcome measures improved. Isometric hip abduction-, hip extension-, and knee extension strength on both legs and functional performance increased. Conclusion: LL-BFR-exercise seems feasible for treatment of GT. At follow-up, a high adherence and low drop-out rate were observed. Further, patients reported clinically relevant reductions in pain, and showed significant increases in isometric hip and knee strength.

The Iliotibial Band: A Complex Structure with Versatile Functions

The development of a pronounced iliotibial band (ITB) is an anatomically distinct evolution of humans. The mechanical behaviour of this “new” structure is still poorly understood and hotly debated in current literature. Iliotibial band syndrome (ITBS) is one of the leading causes of lateral knee pain injuries in runners. We currently lack a comprehensive understanding of the healthy behaviour of the ITB, and this is necessary prior to further investigating the aetiology of pathologies like ITBS. Therefore, the purpose of this narrative review was to collate the anatomical, biomechanical and clinical literature to understand how the mechanical function of the ITB is influenced by anatomical variation, posture and muscle activation. The complexity of understanding the mechanical function of the ITB is due, in part, to the presence of its two in-series muscles: gluteus maximus (GMAX) and tensor fascia latae (TFL). At present, we lack a fundamental understanding of how GMAX and TFL transmit force through the ITB and what mechanical role the ITB plays for movements like walking or running. While there is a range of proposed ITBS treatment strategies, robust evidence for effective treatments is still lacking. Interventions that directly target the running biomechanics suspected to increase either ITB strain or compression of lateral knee structures may have promise, but clinical randomised controlled trials are still required.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

Rehabilitation After Gluteus Medius and Minimus Treatment

We reviewed the current literature regarding rehabilitation after gluteus medius and minimus tears as part of a conservative management or postoperative protocol. The greater trochanteric pain syndrome includes a constellation of pathologies that generate pain in the greater trochanteric region and may be accompanied by varying degrees of hip abductor disfunction. It may be related to tendinitis of the gluteus medius and minimus, greater trochanteric bursitis, or even formal tears of the hip abductor tendons. The initial management strategy of the hip abductor tears is conservative, including different anti-inflammatory therapies such as physical therapy and cortisone and platelet-rich plasma injections. The clearest indication for surgical management is failure of conservative management and loss of abductor muscle power. Surgical management has been performed both open and endoscopic with good reported clinical results. More severe tears typically require a more rigid and complex type of fixation. Exorcise intervention seem to improve symptoms after 4 months to a year of therapy therefore a very close supervision of the rehabilitation protocol is mandatory. Gluteus medius and minimus tears are frequent and may be not diagnosed timely. Treatment of these of lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. Conservative management is based on protecting the hip abductor tendons from excessive tensile and compression stresses while applying progressive load in conjunction with physical and medical anti-inflammatory measures. Surgical treatment is indicated when conservative management fails or an abductor power deficit is associated with pain. Similar physical therapy protocols to those used in conservative management are used postoperatively.

Level of Evidence

Level V, expert opinion.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

Distal semimembranosus tendinopathy: A narrative review

Distal semimembranosus tendinopathy is a relatively uncommon diagnosis that can be responsible for medial knee pain. The semimembranosus tendon inserts on the posteromedial knee and is surrounded by the semimembranosus bursa, with both the bursa and tendon potential sources of pain. Similar to other tendinopathies, semimembranosus tendinopathy often occurs with overuse of the musculotendinous unit and is commonly seen in runners. Diagnosis can be made clinically and may be substantiated with use of ultrasound or magnetic resonance imaging. Scant literature exists evaluating the efficacy of treatments for this condition. Consequently, best practice for treatment is inferred from other similar tendinopathies, clinical expertise, and smaller studies on semimembranosus tendinopathy. Extrapolating from other tendinopathies, rehabilitation should be the cornerstone of initial treatment, with focus on kinetic chain and gait abnormalities, hamstring strength and neuromuscular control, and progressive tendon loading. Recalcitrant cases with a coexisting bursopathy can be treated with an ultrasound-guided bursal corticosteroid injection. Future studies may help delineate the optimal treatment regimen for this relatively uncommon diagnosis.

Reliability of a Novel Scoring System for MRI Assessment of Severity in Gluteal Tendinopathy: The Melbourne Hip MRI Score

Background

Gluteal tendinopathy is commonly reported in the literature, but there is a need for a validated magnetic resonance imaging (MRI)-based scoring system to grade the severity of the tendinopathy.

Purpose

To use intra- and interobserver reliability to validate a new scoring system, the Melbourne Hip MRI (MHIP) score, for assessing the severity of gluteal tendinopathy.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

The MHIP score assesses gluteal tendinopathy according to each 1 of 5 categories: (1) extent of tendon pathology (maximum 5 points); (2) muscle atrophy (maximum 4 points); (3) trochanteric bursitis (maximum 4 points); (4) cortical irregularity (maximum 3 points); and (5) bone marrow edema (maximum 1 point), with an overall range of 0 to 17 (most severe). A total of 41 deidentified MRI scans from 40 patients diagnosed with gluteal tendinopathy (mean baseline age, 57.44 ± 25.26 years; 4 male, 36 female) were read and graded according to MHIP criteria by 2 experienced musculoskeletal radiologists. The radiologists were blinded to previous reports, and the scans were read twice within a 2-month period. Statistical analysis using the intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reliability and mean/range for the MHIP scores.

Results

Of a total of 123 readings, the mean MHIP score (±SD) was 3.93 ± 2.24 (range, 0-17 points). The MHIP score demonstrated excellent reliability for determining the severity of gluteal tendinopathy on MRI. The ICC for intra- and interobserver reliability was 0.81 (95% CI, 0.67-0.89) and 0.78 (95% CI, 0.62-0.87), respectively.

Conclusion

The MHIP score had excellent intra- and interobserver reliability in scoring gluteal tendinopathy. This score allows gluteal tendon pathology to be graded prior to treatment and to be used for standardized comparisons between results in future research undertaking radiological review of gluteal tendinopathy.

Effects of sensorimotor training on pelvic stability and balance in runners

Abstract Introduction: Running has increased significantly in recent years due to its benefits and practicality. However, like any sport, running poses a risk of injury, leading to the need for clinical intervention and even its practitioners quitting the sport. Therefore, preventive strategies seeking to minimize the occurrence and consequences of such risk factors in these athletes are pivotal. Objective: To investigate the preventive effects of a sensorimotor training protocol on the balance and pelvic stability of runners. Methods: The study sample consisted of fourteen 10-km runners of both genders divided into two groups: the control group (CG) and the sensorimotor training group (SMTG). Both groups were evaluated using the single-leg stance test (static balance), Trendelenburg test (pelvic stability), and hop test (dynamic balance). The SMTG underwent 16 interventions, while the CG did not receive any intervention. Results: The SMTG showed a significant increase in the permanence time of the single-leg stance test (p < 0.05) and a reduction in knee valgus during impulse and landing moments of the single hop test only in the right lower limb (p < 0.05), while the CG showed no significant difference in all tests applied (p > 0.05). Regarding pelvic stability, there was no significant difference in any of the groups. Conclusion: The proposed protocol significantly improved the static balance of the SMTG, but not the pelvic stability.

COMPARISON BETWEEN CONCENTRATED BONE MARROW ASPIRATE AND CORTICOID IN GLUTEAL TENDINOPATHY

OBJECTIVE

To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies.

METHODS

48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections.

RESULTS

40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference.

CONCLUSION

BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome

OBJECTIVES

This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age.

METHODS

A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured.

RESULTS

Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%.

CONCLUSIONS

The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

People after gluteal tendon repair have gait characteristics which are similar to those of a healthy cohort

BACKGROUND

Gluteal-tendon repair is reported to be effective for relieving pain and improving function in patients with gluteal-tendon tears. However, post-operative three-dimensional gait analysis has never been conducted in gluteal-tendon repair patients. Thus, our primary aim was to investigate how biomechanical gait parameters differ between age- and sex-matched participants with and without gluteal-tendon repair.

METHODS

Vicon motion analysis technology was used to measure gait characteristics of 25 gluteal-tendon repair participants and 29 matched healthy comparison group participants. A generalised linear multivariate model was used to compare external hip-adduction moment, range of movement in hip adduction and internal rotation, pelvic obliquity, trunk lean, stride length and velocity of both cohorts throughout stance.

FINDINGS

There were no differences between the groups in external hip adduction moment, pelvic obliquity and range of movement in hip adduction and internal rotation. Gluteal-tendon repair participants had a shorter stride length (P = 0.031) and reduced walking velocity (P = 0.015). Ipsilateral trunk lean was reduced in gluteal-tendon repair participants at the first-peak external hip-adduction moment (P = 0.016), mid-stance minimum external hip-adduction moment (P = 0.029) and second-peak external hip-adduction moment (P = 0.006).

INTERPRETATION

There were no differences between the gluteal-tendon repair and comparison groups for external hip-adduction moment and pelvic obliquity. This suggests that gluteal-tendon repair may restore hip control in stance. Slower walking speed, reduced stride length and decreased ipsilateral trunk lean may reflect persistence of pre-operatively developed gait adaptations. Future studies of gait biomechanics before and after gluteal-tendon repair would be needed to substantiate this theory.

Hip Stability May Influence the Development of Greater Trochanteric Pain Syndrome: A Case-Control Study of Consecutive Patients

Background:

Greater trochanteric pain syndrome (GTPS) is thought to relate primarily to tendinosis/tendinopathy of the hip abductors. Previous studies have suggested that certain anatomic factors may predispose one to development of the condition.

Hypothesis:

It was hypothesized that intrinsic acetabular bony stability of the hip is related to the development of GTPS.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 198 consecutive patients diagnosed with GTPS were compared with 198 consecutive patients without clinical evidence of GTPS. Electronic health records of the included patients were examined; data recorded included patient age, sex, race, and body mass index (BMI). Standing anteroposterior radiographs were evaluated by 2 blinded examiners who measured the Tönnis angle, lateral center-edge angle (LCEA), and acetabular depth/width ratio (ADW) and assessed for the presence of a posterior wall sign. The number of dysplastic measures was recorded for each patient based on published norms. Associations between radiographic and patient variables versus the presence or absence of GTPS were determined. Factors with univariate associations where P < .20 were included in a binary logistic regression model to identify independent predictors of the presence of GTPS.

Results:

There was no difference between groups in terms of age, BMI, or race. There were significantly more women than men in the GTPS group (71% vs 30%; P < .001). Intraclass correlation coefficients were good for the LCEA (0.82) and Tönnis angle (0.82) and poor (0.08) for the ADW. Kappa was moderate for the presence of a posterior wall sign (0.51). An increased Tönnis angle, decreased ADW, and ADW <0.25 were significantly associated with the presence of GTPS. The binary logistic regression model identified an increased Tönnis angle (P < .010) and female sex (P < .001) as independent risk factors for GTPS.

Conclusion:

Based on this preliminary retrospective study, decreased intrinsic acetabular bony stability of the hip may be associated with an increased risk of GTPS.

Focused Shockwave Treatment for Greater Trochanteric Pain Syndrome: A Multicenter, Randomized, Controlled Clinical Trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a condition of lateral hip pain. Its physiopathology remains unknown, and there is no consensus on optimal management. The aim of this study was to assess the effectiveness of electromagnetic-focused extracorporeal shockwave treatment (F-ESWT) in patients with GTPS.

METHODS

This multicenter clinical trial included 103 patients with chronic GTPS randomly assigned to the treatment group, consisting of electromagnetic F-ESWT and a specific exercise protocol, or the control group, receiving sham F-ESWT and the same exercise protocol. Both groups were treated with 3 weekly sessions; the F-ESWT group received an energy flux density of 0.20 mJ/mm, whereas the control group received 0.01 mJ/mm. Patients were assessed at baseline and 1, 2, 3, and 6 months after treatment. A visual analogue scale (VAS) score for pain at 2 months was the primary outcome. The Harris hip score (HHS), Lower Extremity Functional Scale (LEFS), EuroQoL-5 Dimensions Questionnaire (EQ-5D), and Roles and Maudsley score were used as secondary outcomes. Complications were recorded.

RESULTS

The mean VAS score decreased from 6.3 at baseline in both groups to 2.0 in the F-ESWT group versus 4.7 in the control group at 2 months; the 2-month score differed significantly between groups (p < 0.001). All secondary outcomes at all follow-up intervals were significantly better in the F-ESWT group, except for the LEFS score at 1 month after treatment (p = 0.25). No complications were observed.

CONCLUSIONS

F-ESWT in association with a specific exercise program is safe and effective for GTPS, with a success rate of 86.8% at 2 months after treatment, which was maintained until the end of follow-up.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lower Limb Tendinopathy Tissue Changes Assessed through Ultrasound: A Narrative Review

Tendinopathy is a common disease that affects athletes, causing pain and dysfunction to the afflicted tendon. A clinical diagnose is usually combined with imaging and, among all the existing techniques, ultrasound is widely adopted. The aim of this review is to sum up the existing evidence on ultrasound as an imaging tool and guide for treatments in lower limbs tendinopathy. Using three different databases—PubMed, MEDLINE and CENTRAL—a literature search has been performed in May 2020 combining MeSH terms and free terms with Boolean operators. Authors independently selected studies, conducted quality assessment, and extracted results. Ultrasound imaging has a good reliability in the differentiation between healthy and abnormal tendon tissue, while there are difficulties in the identification of tendinopathy stages. The main parameters considered by ultrasound imaging are tendon thickness, hypoechogenicity of tendon structure and neovascularization of the tendon bound tissue. Ultrasound-guide is also used in many tendinopathy treatments and the available studies gave encouraging results, even if further studies are needed in this field.

Subclassification of recreational runners with a running-related injury based on running kinematics evaluated with marker-based two-dimensional video analysis

OBJECTIVES

To explore whether homogeneous subgroups could be discriminated within a population of recreational runners with a running-related injury based on running kinematics evaluated with marker-based two-dimensional video analysis.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Fifty-three recreational runners (15 males, 38 females) with a running-related injury.

MAIN OUTCOME MEASURES

Foot and tibia inclination at initial contact, and hip adduction and knee flexion at midstance were measured in the frontal and sagittal plane with marker-based two-dimensional video analysis during shod running on a treadmill at preferred speed. The four outcome measures were clustered using K-means cluster analysis (n = 2-10). Silhouette coefficients were used to detect optimal clustering.

RESULTS

The cluster analysis led to the classification of two distinct subgroups (mean silhouette coefficient = 0.53). Subgroup 1 (n = 39) was characterized by significantly greater foot inclination and tibia inclination at initial contact compared to subgroup 2 (n = 14).

CONCLUSION

The existence of different subgroups demonstrate that the same running-related injury can be represented by different kinematic presentations. A subclassification based on the kinematic presentation may help clinicians in their clinical reasoning process when evaluating runners with a running-related injury and could inform targeted intervention strategy development.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. 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. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] 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.

Hip abductor tendon pathology visualized by 1.5 versus 3. 0 Tesla MRIs

INTRODUCTION

Hip abductor tendinopathies are becoming increasingly recognized as clinically relevant disorders. However, knowledge about prevalence of abductor tendinopathies and associated disorders of adjacent hip articular and periarticular structures is limited. In this context, the relative diagnostic value of 1.5-T vs. 3.0-T MRI magnets has not been studied yet.

MATERIALS AND METHODS

Pelvic MRI scans of 1000 hips from 500 consecutive unselected patients (341 in 3.0-T/159 in 1.5-T magnets, with standardized scanning protocols over the entire study period) were analysed for the detection of abductor tendinosis, calcifying tendinitis, partial or full-thickness tears of the M. gluteus medius (GMed) and/or -minimus (GMin) and trochanteric bursitis (TB). The occurrence of these lesions was correlated to the presence of muscle atrophy (MA) of GMed/GMin, hip joint effusion (JE) and osteoarthritis (OA).

RESULTS

Peritrochanteric lesions were observed with a prevalence of 31.4% of all patients (22.3% of all hips). TB occurred almost exclusively in the presence of GMed/GMin tendinopathies. Compared to overall prevalence, patients with MA displayed lesions of GMed/GMin or TB in 70%, patients, with OA in 30% and with JE in 23%. These lesions occurred significantly more often ipsilateral to MA and OA than contralateral (MA: 76.8% vs. 23.2%, p < 0.001; OA: 64.4% vs. 35.6%, p = 0.03; JE: 62.7% vs. 37.3%, p = 0.08). Significantly more tendon lesions, in particular specific radiological diagnoses like partial/full-thickness tears, were detected by 3.0-T MRI than by 1.5 T (p = 0.019).

CONCLUSIONS

Peritrochanteric lesions are a prevalent pathology that should specifically be looked for, preferably by 3.0-T MRI, independent of concomitant hip joint pathology.

Do features of central sensitisation exist in Greater Trochanteric Pain Syndrome (GTPS)? A case control study

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS), which is commonly due to Gluteal Tendinopathy, refers to pain over the lateral hip that can become persistent and disabling. Central nervous sensitisation has been implicated in upper limb tendinopathy, but no studies have investigated if it plays a role in GTPS.

OBJECTIVES

To investigate if features of central sensitisation were present in people with GTPS.

METHODS

Eighteen people with GTPS were matched with 18 healthy controls in this cross-sectional study. The VISA-G and Central Sensitisation Inventory (CSI) self-report questionnaires were completed and pressure pain detection thresholds (PPDTs) at local and remote sites were measured in all participants. Data were analysed for between-group differences using Mann-Whitney U tests. Correlation between CSI and PPDTs were assessed using Pearson correlation co-efficients.

RESULTS

PPDT values were lower at local (symptomatic greater trochanter) and remote sites in the GTPS group, indicative of central sensitisation, resulting in statistically significant between-group differences. 44.4% of the GTPS group were classified as having symptoms of central sensitisation, based on the CSI.

CONCLUSION

There is preliminary evidence of central sensitisation in people with GTPS. Results need to be validated using other objective quantitative sensory testing measures in larger samples.

Physical findings differ between individuals with greater trochanteric pain syndrome and healthy controls: A systematic review with meta-analysis

BACKGROUND

Understanding of the biopsychosocial characteristics of greater trochanteric pain syndrome (GTPS), a prevalent lower limb tendinopathy, is currently lacking.

OBJECTIVES

To quantify differences in participant characteristics between individuals with GTPS and healthy control participants.

DESIGN

Systematic review of original studies with meta-analyses where appropriate.

METHODS

A comprehensive electronic search was undertaken in Pubmed, EMBASE, Web of Science and CINAHL for terms referring to GTPS. Studies that provided comparison of individuals with clinically characterized GTPS with healthy controls were included. Study quality was rated with the Joanna Briggs Institute Critical Appraisal Checklist for Cross Sectional Studies. Standardized mean differences were calculated and supported by narrative synthesis or meta-analyses where appropriate. Certainty of evidence was assessed based on the GRADE guidelines.

RESULTS

The search revealed 2798 studies, of which 13 studies from five research groups were included. There were 229 participants with at least three months duration of GTPS and 193 control participants. Individuals with GTPS displayed larger greater trochanteric width, greater body mass index, lower hip abductor muscle strength, higher hip abductor muscle activity, altered single leg loading and gait parameters including shorter step length and velocity. No studies investigating psychological features or sensory perception were identified. Quality of life was investigated in a single study.

CONCLUSIONS

Compared to healthy controls, participants with GTPS are more overweight, have poorer hip abductor muscle function and altered gait parameters. Overall quality of evidence across studies was very low based on GRADE guidelines.

Responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), modified Harris hip and Oxford hip scores in patients undergoing hip abductor tendon repair

BACKGROUND

A lack of consensus exists on which patient-reported outcome measures (PROMs) best evaluate change following hip abductor tendon (HAT) repair.

OBJECTIVES

To compare the responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), Oxford Hip (OHS) and modified Harris Hip (mHHS) scores in patients undergoing HAT repair.

STUDY DESIGN

Prospective case series.

METHODS

56 patients underwent HAT repair and were evaluated pre-surgery and 3, 6 and 12 months post-operatively using the VISA-G, OHS, mHHS and a Global Rating of Change (GRC) scale. Internal and external responsiveness, the minimal clinically important change (MIC) and the presence of ceiling effects were evaluated. The extent to which VISA-G change was associated with mHHS and OHS change was investigated, as was the extent to which PROM changes were discriminatory for GRC improvement.

RESULTS

All PROMs demonstrated large standardized effect sizes (>1), with the VISA-G demonstrating responsiveness similar to the mHHS and OHS. At 12 months, the GRC correlated similarly with VISA-G (0.42, 95% CI: 0.17-0.61), mHHS (0.44, 95% CI: 0.17-0.61) and OHS (0.53, 95% CI: 0.31-0.70) changes. Using a GRC anchor of ≥4, an MIC of 29/100, 29/91 (32/100) and 16/48 (33/100) was observed for the VISA-G, mHHS and OHS, respectively. At 12 months ceiling effects existed for the mHHS (18/56, 32.1%) and OHS (13/56, 23.2%), but not VISA-G (1/56, 1.8%).

CONCLUSION

The VISA-G demonstrated acceptable responsiveness and was more resistant to ceiling effects, though demonstrated similar change scores and correlations with perceived improvement to the mHHS and OHS.

CLINICAL TRIAL REGISTRATION

This research trial is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12616001655437).

An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS)

PURPOSE

To evaluate how physiotherapists across three countries (Australia, New Zealand (NZ) and Ireland) diagnose greater trochanteric pain syndrome (GTPS) using clinical tests and imaging findings, and how physiotherapists update their knowledge regarding GTPS.

DESIGN

Cross-sectional observational study of physiotherapists.

METHODS

An online survey was distributed to registered physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; medians and interquartile ranges were calculated for numerical data. Comparisons between the three countries were made using Chi-squared analyses for nominal/ordinal data and Kruskal Wallis tests for numerical data. Statistical significance was set at p < 0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists; 61% were female and 79.8% worked in private practice. Most respondents were very confident in diagnosing GTPS (67.9%) and incorporated a range of symptoms and tests, including validated tests, in their diagnosis. However, many physiotherapists were not commonly using some available validated diagnostic tests (e.g. FABER and FADER-R). Approximately 30% of physiotherapists used imaging to inform assessment, with ultrasound being most preferred. Physiotherapists rated hands-on experience as most valuable for updating their knowledge of GTPS, followed by courses.

CONCLUSION

While most clinicians appear to be using current evidence in their assessment of patients with GTPS, a proportion use suboptimal methods and/or a limited range of diagnostic tests, suggesting that despite their confidence in diagnosis, further knowledge translation may be required. Future research should determine the best methods of facilitating knowledge acquisition and translation of research into practice.

Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice

OBJECTIVES

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

DESIGN

Cross-sectional observational survey of physiotherapists.

METHODS

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons were made using Chi-squared analyses for nominal/ordinal data and Kruskal-Wallis tests for numerical data. Statistical significance was set at P<0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists, 61% were female and 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

CONCLUSION

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).

A survey of physiotherapy practice (2018) in the United Kingdom for patients with greater trochanteric pain syndrome

PURPOSE

Greater Trochanteric Pain syndrome (GTPS) is a debilitating condition causing lateral hip pain. It affects up to 23.5% of women and 8% of men between 50 and 75 years old. Sufferers report comparable quality of life and functional performance to patients with end stage osteoarthritis of the hip. Understanding of optimal management strategies for GTPS remains limited. Hence, the purpose of this cross-sectional survey was to describe current UK physiotherapy practice so as to understand current practice and inform the systematic development of a physiotherapy intervention.

METHODS

An online survey was developed and distributed via Twitter, the interactive Chartered Society of Physiotherapy website, Musculoskeletal Association of Chartered Physiotherapists and the professional networks of the authors via email. Responses were collected over a four-week period, this was finalised in April 2018.

RESULTS

A total of 409 surveys were submitted; 382 were eligible for use. Nearly all physiotherapists were either somewhat, or very confident diagnosing (372/382; 97.4%) and treating (372/382; 97.4%) patients with GTPS. The management strategies most commonly used were: education on load management (377/381; 98.7%) and self-management strategies (375/381; 98.4%). Strengthening exercises (376/382; 98.4%) were commonly used and targeted to the hip abductors (355/379; 93.7%). Most frequently these exercises were delivered using a combination of home exercise programme (380/380; 100%) and one-to-one exercise sessions (344/377; 91.2%).

CONCLUSION

The data from this large survey highlights that physiotherapists in the UK most commonly use education on load management and self-management strategies, alongside strengthening exercises targeting the hip abductors for patients with GTPS.

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

OBJECTIVES

To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs).

DESIGN

Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations.

ELIGIBILITY CRITERIA

Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.

DATA SOURCES

Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories.

RESULTS

6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work.

CONCLUSION

These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial

OBJECTIVE

To compare the effects of a programme of load management education plus exercise, corticosteroid injection use, and no treatment on pain and global improvement in individuals with gluteal tendinopathy.

DESIGN

Prospective, three arm, single blinded, randomised clinical trial.

SETTING

Brisbane and Melbourne, Australia.

PARTICIPANTS

Individuals aged 35-70 years, with lateral hip pain for more than 3 months, at least 4/10 on the pain numerical rating scale, and gluteal tendinopathy confirmed by clinical diagnosis and MRI; and with no corticosteroid injection use in previous 12 months, current physiotherapy, total hip replacement, or neurological conditions.

INTERVENTIONS

A physiotherapy led education and exercise programme of 14 sessions over 8 weeks (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69).

MAIN OUTCOMES

Primary outcomes were patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at 8 weeks, with longer term follow-up at 52 weeks.

RESULTS

Of 204 randomised participants (including 167 women; mean age 54.8 years (SD 8.8)), 189 (92.6%) completed 52 week follow-up. Success on the global rating of change was reported at 8 weeks by 51/66 EDX, 38/65 CSI, and 20/68 WS participants. EDX and CSI had better global improvement scores than WS (risk difference 49.1% (95% CI 34.6% to 63.5%), number needed to treat 2.0 (95% CI 1.6 to 2.9); 29.2% (13.2% to 45.2%), 3.4 (2.2 to 7.6); respectively). EDX had better global improvement scores than CSI (19.9% (4.7% to 35.0%); 5.0 (2.9 to 21.1)). At 8 weeks, reported pain on the numerical rating scale was mean score 1.5 (SD 1.5) for EDX, 2.7 (2.4) for CSI, and 3.8 (2.0) for WS. EDX and CSI participants reported less pain than WS (mean difference -2.2 (95% CI -2.89 to -1.54); -1.2 (-1.85 to -0.50); respectively), and EDX participants reported less pain than CSI (-1.04 (-1.72 to -0.37)). Success on the global rating of change was reported at 52 weeks by 51/65 EDX, 36/63 CSI, and 31/60 WS participants; EDX was better than CSI (20.4% (4.9% to 35.9%); 4.9 (2.8 to 20.6)) and WS (26.8% (11.3% to 42.3%); 3.7 (2.4 to 8.8)). Reported pain at 52 weeks was 2.1 (2.2) for EDX, 2.3 (1.9) for CSI, and 3.2 (2.6) for WS; EDX did not differ from CSI (-0.26 (-1.06 to 0.55)), but both treatments did better than WS (1.13 (-1.93 to -0.33); 0.87 (-1.68 to -0.07); respectively).

CONCLUSIONS

For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support EDX as an effective management approach for gluteal tendinopathy.

TRIAL REGISTRATION NUMBER

Prospectively registered at the Australian New Zealand Clinical Trials Registry (ACTRN12612001126808).

Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial

OBJECTIVE

To compare the effects of a programme of load management education plus exercise, corticosteroid injection use, and no treatment on pain and global improvement in individuals with gluteal tendinopathy.

DESIGN

Prospective, three arm, single blinded, randomised clinical trial.

SETTING

Brisbane and Melbourne, Australia.

PARTICIPANTS

Individuals aged 35-70 years, with lateral hip pain for more than three months, at least 4/10 on the pain numerical rating scale, and gluteal tendinopathy confirmed by clinical diagnosis and magnetic resonance imaging; and with no corticosteroid injection use in previous 12 months, current physiotherapy, total hip replacement, or neurological conditions.

INTERVENTIONS

A physiotherapy led education and exercise programme of 14 sessions over eight weeks (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69).

MAIN OUTCOMES

Primary outcomes were patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at eight weeks, with longer term follow-up at 52 weeks.

RESULTS

Of 204 randomised participants (including 167 women; mean age 54.8 years (standard deviation 8.8)), 189 (92.6%) completed 52 week follow-up. Success on the global rating of change was reported at eight weeks by 51/66 EDX, 38/65 CSI, and 20/68 WS participants. EDX and CSI had better global improvement scores than WS (risk difference 49.1% (95% confidence interval 34.6% to 63.5%), number needed to treat 2.0 (95% confidence interval 1.6 to 2.9); 29.2% (13.2% to 45.2%), 3.4 (2.2 to 7.6); respectively). EDX had better global improvement scores than CSI (19.9% (4.7% to 35.0%); 5.0 (2.9 to 21.1)). At eight weeks, reported pain on the numerical rating scale was mean score 1.5 (standard deviation 1.5) for EDX, 2.7 (2.4) for CSI, and 3.8 (2.0) for WS. EDX and CSI participants reported less pain than WS (mean difference -2.2 (95% confidence interval -2.89 to -1.54); -1.2 (-1.85 to -0.50); respectively), and EDX participants reported less pain than CSI (-1.04 (-1.72 to -0.37)). Success on the global rating of change was reported at 52 weeks by 51/65 EDX, 36/63 CSI, and 31/60 WS participants; EDX was better than CSI (20.4% (4.9% to 35.9%); 4.9 (2.8 to 20.6)) and WS (26.8% (11.3% to 42.3%); 3.7 (2.4 to 8.8)). Reported pain at 52 weeks was 2.1 (2.2) for EDX, 2.3 (1.9) for CSI, and 3.2 (2.6) for WS; EDX did not differ from CSI (-0.26 (-1.06 to 0.55)), but both treatments did better than WS (1.13 (-1.93 to -0.33); 0.87 (-1.68 to -0.07); respectively).

CONCLUSIONS

For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support EDX as an effective management approach for gluteal tendinopathy.

TRIAL REGISTRATION

Prospectively registered at the Australian New Zealand Clinical Trials Registry (ACTRN12612001126808).

Gluteal Loading Versus Sham Exercises to Improve Pain and Dysfunction in Postmenopausal Women with Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial

OBJECTIVES

The aim of the current study was to determine the effects of education with targeted or sham exercise on pain and function in postmenopausal women with greater trochanteric pain syndrome (GTPS).

BACKGROUND

Conservative management of GTPS is poorly described, and to date, there have been no studies on education with exercise as an intervention for GTPS. Ninety-four postmenopausal women with GTPS were recruited to participate in this study.

MATERIALS AND METHODS

Participants were randomized to receive one of two 12-week exercise programs (GLoBE vs. sham). Participants received education on avoiding tendon compression with appropriate activity modification. The Victorian Institute of Sport Assessment-Gluteal tendon (VISA-G) was examined at baseline, 12, and 52 weeks. Secondary outcomes included hip pain and function questionnaires (Hip dysfunction and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), and Lateral Hip Pain questionnaire), a global rating of change in symptom questionnaire, and a quality of life measure (Assessment of Quality of Life [AQoL]-8D). Differences between groups were analyzed using intention to treat with analysis of covariance, per-protocol analysis, and responder analysis.

RESULTS

Responders to the GLoBE intervention had significantly better VISA-G, HOOS, OHS, and lateral hip pain questionnaire scores compared to responders in the sham group. However, intention to treat analyses showed no between-group differences for the GLoBE intervention and sham exercise groups. Significant improvement in VISA-G score was found for both programs at 12- and 52-weeks time points (p < 0.001).

CONCLUSION

Lack of treatment effect was found with the addition of an exercise program to a comprehensive education on GTPS management. The improved outcomes of the responders in the GLoBE group indicate that there may be a subgroup of patients with a GTPS diagnosis that benefit from a GLoBE intervention program.

Gluteal tendinopathy and hip osteoarthritis: Different pathologies, different hip biomechanics

BACKGROUND

Gluteal tendinopathy (GT) and hip osteoarthritis (OA) are the most common causes of hip pain and associated disability in older adults. Pain and altered walking biomechanics are common to both conditions. This study aimed to compare three-dimensional walking biomechanics between individuals with unilateral, symptomatic GT and HOA.

METHODS

Sixty individuals with symptomatic unilateral GT confirmed by magnetic-resonance-imaging and 73 individuals with symptomatic unilateral HOA (Kellgren-Lawrence Grade ≥ 2) underwent three-dimensional gait analysis. Maximum and minimum values of the external sagittal hip moment, the first peak, second peak and mid-stance minimum of the hip adduction moment (HAM), sagittal plane hip excursion and hip joint angles, pelvic obliquity and trunk lean, at the three HAM time points during stance phase of walking were compared between groups.

RESULTS

Compared to individuals with HOA, those with GT exhibited a greater hip peak extension moment (P < 0.001) and greater HAM throughout the stance phase of walking (P = 0.01-P < 0.001), greater hip adduction (P < 0.001) and internal rotation (P < 0.01-P < 0.001) angles and lower hip flexion angles and excursion (P = 0.02 - P < 0.001). Individuals with HOA exhibited a greater forward trunk lean (P ≤ 0.001) throughout stance, and greater ipsilateral trunk lean in the frontal plane (P < 0.001) than those with GT.

CONCLUSION

Despite presence of pain in both conditions, hip kinematics and kinetics differ between individuals with symptomatic unilateral GT and those with symptomatic unilateral HOA. These condition-specific impairments may be targets for optimization of management of HOA and GT.