Differentiating between the numerous pain syndromes that commonly occur around the pelvis and hip and arriving at a sound diagnosis can be a tricky.
Misdiagnosis is common.
Increasingly apparent are the sporting ‘injuries’ and so called ‘over-use syndromes’- gluteal and hamstring ‘tendinopathies’; hip ‘bursitis’; piriformis syndrome – described as a failed adaptation to persistent load.
It’s common to hear that treatment of these injuries can be difficult problems to fix – a frustrating and slow process for both doctor, therapist and patient, requiring prolonged rest from activity and exercise.
For an elite athlete or someone obsessed with their sport, is this approach realistic and even effective?
Our contemporary oracle is ‘the evidence’. Current tendinopathy management guidelines rely on interpreting the available scientific data. Most of this has looked at the local structural pathology of the tendon and local mechano-biological mechanisms. In the case of gluteal tendinopathy, current thinking is that compressive rather than tensile stress is the problem. The tendon is compressed by the iliotibial band in side lying, hip adduction, and more so when the hip is further flexed and externally rotated. Many exercises aggravate the condition e.g. ‘the clam’ and ‘pelvic drop’. Patients are often advised not to cross their legs, to sleep with pillows between the knees and in the reactive stage, practice specific isometric gluteus medius exercises e.g. in side lying with the hip in a neutral position – without increasing ITB tension. Does this make sense? – and particularly for an active person?
I consider that this is ‘thinking inside the square’
‘Tendons’ don’t exist in isolation, they are part of the regional myo-fascial system and a whole body fascial tensegrity network. Fascia connects everything! It’s a ‘sliding system’ which contains and supports muscles and organs, and supports movement. It is densely innervated. Inflammation can reduce ‘slide’ between the fascial layers. During movement, free nerve endings can be stretched or compressed. Restoring the fascial slide therefore can sort the pain.
However, these local changes in and around the tendon are an outcome – the ‘victim’ of a ‘criminal’ cause elsewhere. Altered skeletal loading, force transmission and movement patterns exact their toll. Could it be that there is a bigger picture at play here?
The current obsession with ‘strengthening’ gluts could be a big part of the problem, which I have already discussed.
Firstly, when you prescribe gluteal exercises as part of a therapy/training programme what is your specific goal in doing so?
What are you trying to improve?
Are that person’s glutei actually weak? – or only appear to be?
A few things need to be considered here.
- All muscles require a suitable and stable base to support their activity – in this case, the pelvis. If there is a lack of pelvic control, the glutei are likely to test ‘weak’.
- If the glutes do test ‘weak’ – where in range is this apparent – inner or outer? And what of their eccentric control? What exercises are therefore required to address this?
- Is there neurogenic inhibition of the glutes due to segmental stress stemming from poor patterns of lumbo-pelvic control? Would strengthening the glutes if this is the case actually make any difference?
Strong muscles also become overactive and tight and pull on their attachments. Muscle overactivity is more likely to lead to ‘tendon’ stress than underactivity – gluteal tendinopathy is seen as an ‘over-use’ syndrome – why therefore are we strengthening the glutes?
In addition, when too strong and tight the glutei can disturb pelvic/hip mechanics and control and thereby affect the lumbar spine. Gluteal tendinopathy often coexists with low back pain.
While there is a lot in the literature about gluteal ‘strengthening’ and the ‘best exercises’ to do, there has been relatively little thought or research into their functional role – how they contribute to myo-fascial synergies which control pelvic myo-mechanics and the underlying patterns of pelvic/hip control which are basis of movement performance.So we have to rely on clinical evidence, supported by the available movement science.
As therapists we need to know what are healthy loading and movement patterns in order to have a clue as to why the tissues might break down during the person’s ‘natural way of going about things’ – what is it that they do that causes the problem? Or in the case of the sports/athlete, what is it about his exercise or training programme that could be a provocative factor in the appearance, maintenance or re-occurrence of the tendinopathy?
Getting to the real nub of ‘gluteal tendinopathy’ firstly involves an appreciation of healthy lumbo-pelvic movement behaviour and in particular of pelvic-hip girdle myo-mechanics and their effect on the rest of the body. In general this is not well understood. Further, there are common clinical patterns of altered movement and loading patterns which are readily apparent in gluteal and hamstring tendinopathy – these drive the problem.
I have found that a different treatment and management approach which addresses and restores the changed pelvic/hip neuro-myofascial and articular function, rather than one which is informed by structural pathology of the ‘tendon’ per se, yields much better results in a much shorter timeframe.