A Rehab Case Study: Gluteal Tendinopathy Part 1

Gluteal tendinopathy is a relatively new term. Lateral hip pain over the greater trochanter has typically been termed trochanteric bursitis. I came across a really interesting article on the topic recently, which came at a great time given I am working with a case of gluteal tendinopathy currently.

Truth be told, the case is my fiancé, Frank, who has been kind enough to lend his body to science, lol, and who is of course open enough to try a perhaps unconventional approach, as I integrate the new thought process that got triggered by the article stated above.

As always, I want to start off by stressing the importance of collaborating with the other health care providers involved. In this case, I will work collaboratively with the physiotherapist, who will assist with decreasing pain, managing inflammation, and regaining range of motion.

I use a 2-step approach in the “physical” part of my assessment (the other part being the verbal intake interview and history taking).

1. Current state assessment
2. Movement behavior assessment

The current state assessment is all things you would find in a typical assessment “protocol”: active and passive range of motion, muscle testing, special tests, etc.

The movement behavior assessment is all things movement based and usually happens over several sessions. While you can perform a bunch of tests and grade a pass or fail (or anything in between), nothing tells you more about how a person moves than working with them regularly.  I should mention that I only work with “rehab” or “prehab” clients. Nobody gets a one-time assessment, then a program.

They will get homework at every session and may get a program after anywhere between 4 to 8 sessions, depending on each case.

Case Study: Current State

For time’s sake, I will not provide the super-specific details here, but just the main takeaways on the current state assessment.

• Some thoracic mobility deficits
• Hip ROM deficits both passive and active in internal and external rotation and combined movement (FABER: flexion, abduction, external rotation, FADER: flexion, adduction, external rotation, FADIR: flexion, adduction, internal rotation)
• Some glute med and glute max strength deficits on muscle testing (left > right)
• Some foot stability deficits (tends to pronation)

Case Study: Movement Behavior

Again, I will try to be concise here, and focus on what is most important for the case study.

• Although Frank has trained for most of his life, his background is in martial arts and boxing. He is anterior chain dominant, both because of sport-specific needs and personality (higher stress neurotype 2B-3)
• We observed compensation via the hamstrings on muscle testing for both the glute max and glute med
• Despite good ankle dorsiflexion and a narrow stance result when we perform the hip scour, Frank has always opted for a wide stance and high bar squat
• Knee valgus on the lunge with a tendency for the foot to pronate
• “Valgus twitch” coming out of the hole on heavy squats, not present on light squats or shallower (box) squats

How This Translates Into The Intervention

Of course, the purpose of assessing is to then determine how your findings may be contributing to the problem. I always say this requires way more analysis than 1 + 1 = 2.

Priority one in rehab is always to decrease pain because pain changes movement. While I like to keep people moving throughout the rehab process, removing anything that is likely irritating the injury is of utmost importance, EVEN IF THAT PARTICULAR MOVEMENT MAY NOT BE THE ROOT CAUSE OF THE PROBLEM.

So, if I tell someone to stop squatting, it’s not because I think their squat mechanics are the culprit (even in cases where the mechanics are faulty), but because they risk aggravating the injury and/or increasing pain.

Let’s take the example of Frank’s valgus twitch coming out of the hole. I could open up a whole can o’ worms here, and we could argue whether the valgus twitch is “good” or “bad”, whether it is potentially injurious or not. I err on the side of caution where that topic is concerned. What I believe is that it depends.

Before we discuss why we temporarily remove heavy deep squatting from Frank’s programming, let’s first analyze his behavior and hypothesize on why he may have a valgus twitch:

• The adductor magnus has a strong hip extension moment arm, especially when the hips are flexed. This may be a reason many people have a valgus twitch, not just Frank. In the hole, the adductor magnus has more leverage to extend the hips.
• On manual muscle testing for the glutes, we noted compensation via the hamstrings. The medial hamstrings may provide greater hip extension torque in slight hip adduction.
• Frank is anterior chain dominant, therefore quad dominant. Letting the knees come in allows him to favour the quads to extend the knee rather than the glutes to extend the hips.

Notice I didn’t say anywhere that the valgus twitch is inherently bad, or that he has a twitch because of his weak glutes (that would be my 1+1=2 example).  Some of the world’s strongest Olympic lifters have a valgus twitch.  I would not presume to say that someone who can catch 180kg overhead at the bottom of a squat has “weak glutes”, or that the day he gets injured, it’ll be because his glute med “didn’t fire”.  I leave it at that…

That being said, here’s the #1 reason why we will temporarily remove (not necessarily correct) the valgus twitch:

1. To decrease pain or the potential for pain and/or further injury: The valgus twitch puts the gluteal tendons under compressive load, something we want to avoid in the case if tendinopathy.

Weak Glutes? 

While I don’t like all the hype around “weak” glutes because the concept gets thrown around and mis-used, I will admit most people test poorly on manual muscle testing for the glutes. We could always argue that, aside from the fact that the test is performed in a mechanically disadvantaged position (particularly glute med), it’s foreign, which is why most people score low.

You make the best use of your muscle testing if you can observe the compensatory mechanisms the individual uses. If you are testing just to state that the glute med is weak and prescribe a glute med exercise, you may as well have skipped the test.  What’s more, you may end up prescribing a glute med exercise that further irritates an injury or further promotes an already existing compensation.

For example, if I just decide that Frank has glute med weakness, I could prescribe a clamshell exercise. It would efficiently strengthen the glute, plus he feels the great mind-muscle connection. However, it puts the tendon under compressive load, not a good thing for a pathological tendon.

As well, while we could argue that the glute med needs strengthening in the form of learning to recruit it and contract it hard, what it needs, even more, is tolerance to load.

The challenge then is finding exercises that continue to load the glutes without further irritating the tendon.

What we did observe on muscle testing for the glutes was hamstring compensation. The hamstrings are powerful hip extensors, especially when the hip is not abducted. Another indication of what may be contributing to a valgus twitch under heavy load.

This movement behaviour piece is important to note. When we select exercises to target the glutes, we will want to make choices that prevent Frank from relying on the hamstrings.

Determining The Objectives Of The Intervention

Based on the above assessment, the objectives of the first phase of the intervention are:

1. Decrease pain: This means both pain management (this is where collaboration with the physio comes in) and protection via activity modification (ie. temporarily modifying activity to remove pain-triggering or irritating movements, loads and postures).
2. Maintain mobility within pain-free ranges: While we want to limit movement that can be irritating, we need to ensure we continue to work the available range of motion just short the pain threshold. If we limit the range too much, we lose more of it.
3. Isolated activation and joint dissociation exercises to manage inhibition: When a muscle (or tendon) is injured, the body simply does not want to contract that muscle. It is a protective mechanism. And although this is a good thing per se, we need to maintain activation and continue to load the muscle as tolerated. Isometrics is a really useful tool, as you will see in later parts of this article series.

I often refer to this first phase as a Phase 1: Protection and Recovery. Protect the area from further injury and modify the activity to let the body recover from what may have contributed to the breakdown.

In Part 2 of this series, we will look at how we choose tools for our intervention based on our findings.

This is where you start to be analytical in selecting means and methods that will best fit each Phase of the intervention based on the objectives of each of the phases.

Stay tuned!

-MLD