Gluteal tendinopathy is a common presentation in physiotherapy clinics and these injuries often provide a significant rehabilitation challenge. Abnormal mechanical load is the primary issue in the development of tendon injuries. Patients often present to the clinic after sudden changes in exercise patterns or abnormal loading patterns resulting from injury and pain in another area of the body.
The injury and change to the tendon may occur in the mid portion of the tendon or more commonly at the insertion of the tendon into the bone. The insertional tendon pathology is often associated with trochanteric bursitis.
Peri-menopausal and menopausal women are susceptible to tendon pathology around the pelvis with changes in their hormone profile resulting in changes in the quality of the collagen in the tissues supporting this area. Poor stability of the sacro-iliac joints, degenerative changes in the hip joints and general de-conditioning in the lumbar-pelvic musculature are all contributing factors to increased mechanical load on the gluteal tendons.
It is now commonly accepted that tendon injuries are not primarily an inflammatory disorder. Tendinopathy is a broad term to describe the degenerative nature of the current model of tendon pathology. When planning a rehabilitation program, load modification is the most important variable. Activity modification to remove excessive forces on the tendon is a critical first step in creating an environment that allows the tendon to strengthen and heal.
The concept of load capacity of the tendon and a graduated program of loading is vital in management of these injuries. It is important that any rehabilitation program aims to load the tendon right up to its capacity but not beyond. In doing this we stimulate the body to build a stronger tendon, without regularly overloading and causing further breakdown and weakness of the tendon. Isometric loading has been proposed to be useful in providing pain relief. Close monitoring of the tendons response to load will help to guide as to when the tendon is ready to accept increased load.
Addressing abnormal biomechanics and poor stabilising structures around the effected tissue reduces both stress on the tendon in the short term as well as removing the likely cause of the breakdown in the first place. A real-time ultrasound assessment of the patients deep abdominal muscle function can be very valuable in addressing some of the issues that contribute to abnormal tendon load.