Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BACKGROUND

Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes.

METHODS

Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA.

RESULTS

The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex.

CONCLUSIONS

Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction.

LEVEL OF EVIDENCE

Level 2 (High quality prospective cohort study).

An EDucation and eXercise intervention for gluteal tendinopathy in an Irish setting: a protocol for a feasibility randomised clinical trial (LEAP-Ireland RCT)

Background

Gluteal tendinopathy (GT) is a degenerative tendon condition characterised by pain over the greater trochanter of the hip. A randomised controlled trial (RCT) in Australia found that 14 sessions of EDucation on load management plus eXercise (EDX) delivered over 8 weeks resulted in greater improvements in global rating of change and pain outcomes at 8 and 52 weeks, compared with corticosteroid injection or 'wait and see'. Typically, 5-6 physiotherapy sessions are provided in public and private physiotherapy settings in Ireland, therefore, the aim of this study is to examine the feasibility of conducting a future definitive RCT to investigate effectiveness of 6 sessions of the EDX programme compared to usual care.

Methods

We will randomly allocate 64 participants with GT to physiotherapist-administered EDX or usual care. The EDX intervention (EDX-Ireland) will be delivered in 6 sessions over 8 weeks.To determine feasibility of an RCT, we will assess recruitment and retention and outcome measure completion. The health status outcomes to be assessed at baseline, 8 weeks and 3 months include: Global Rating of Change, pain severity, the Victorian Institute of Sport Assessment-Gluteal Questionnaire (VISA-G), the Patient-Specific Functional Scale, the Pain Catastrophizing Scale, Patient Health Questionnaire (PHQ), Pain Self-Efficacy Questionnaire, the EQ-5D-5L, the Central Sensitisation Inventory and hip abductor muscle strength. We will explore acceptability of the EDX-Ireland intervention from the perspective of patients and treatment providers, and the perspective of referrers to the trial. A Study Within A Trial will be also applied to compare recording of exercise adherence using app-based technology to paper diaries.

Discussion

There is a need to establish effective treatments for GT that potentially can be implemented into existing health systems. The findings of this feasibility trial will inform development of a future definitive RCT.

Registration

The trial is registered prospectively on ClinicalTrials.gov ( NCT05516563, 27/10/2022).

Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To estimate the effectiveness of exercise at end of treatment and long-term follow-up compared to a control condition or other conservative treatments in patients with Greater Trochanteric Pain Syndrome (GTPS).

METHODS

Databases were searched September 2021 and updated September 2023. Randomized controlled trials (RCT) comparing exercise interventions for patients with GTPS, to a control condition; corticosteroid injection; shock wave therapy; or other types of exercise programs were included. Risk of bias was assessed using the ROB2 tool. Meta-analyses were performed using a random-effects model. The certainty of the evidence was rated by the GRADE approach.

RESULTS

Six RCTs including a total of 733 patients with GTPS were included. Three trials compared exercise to sham exercise or wait-and-see control groups, two trials compared exercise to corticosteroid injection, two trials compared exercise to shockwave therapy, and one trial compared exercise to another type of exercise. Meta-analyses showed that in the long term, exercise slightly reduces hip pain and disease severity, while slightly improving patient-reported physical function and global rating of change compared to a control condition. No serious adverse events were reported. Compared to corticosteroid injection, exercise improves long-term global rating of change.

CONCLUSION

The current evidence supports a strong recommendation for exercise as first line treatment in patients clinically diagnosed with GTPS. Compared to corticosteroid injection, exercise is superior in increasing the likelihood that a patient experiences a meaningful global improvement. These results are based on few trials and a moderate number of patients.

REGISTRATION

This review was prospectively registered in the PROSPERO database of systematic reviews (ID: CRD42021261380). CONTRIBUTION OF PAPER.

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.

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.

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.

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.

Motor control exercises versus general exercises for greater trochanteric pain syndrome: A protocol of a randomized controlled trial

Introduction

Greater trochanteric pain syndrome is an overarching term used to define pain and tenderness in the greater trochanteric region of the femur, which is more common in women. Abnormal control of lower limb movements and deficient neuromuscular parameters may lead to greater trochanteric pain syndrome; however, no studies have used neuromuscular training as a treatment strategy. Thus, this study aims to compare the effect of a protocol of general exercises versus a program of motor control training on pain at baseline and after treatment in women with greater trochanteric pain syndrome.

Methods

The study was approved by the Research Ethics Committee (CAAE: 87372318.1.0000.5406) and has been prospectively registered on the Brazilian Registry of Clinical Trials (RBR-37gw2x). Sixty participants will be randomized to receive motor control exercises or general exercises. The application will be performed twice a week for 8 weeks. The participants will be evaluated before the treatment (T0), after 8 weeks of intervention (T8) and after 60 weeks of intervention (T60). The primary outcome measures will be the hip pain intensity, and secondary outcomes will be muscle strength, kinesiophobia, global perceived effect, pain catastrophization, central sensitization and quality of life.

Conclusions

Studies have suggested that greater trochanteric pain syndrome may be related to poor hip and pelvic control, however, no study has investigated an exercise protocol focused on increasing the strength of the abductor and extensor muscles of the hip associated with pelvic control training, especially in positions of unilateral support, such as gait. This study will help determine whether greater trochanteric pain syndrome is related to abnormal control of lower limb movements.

Greater trochanteric pain syndrome in women: Analysis of magnetic resonance, sagittal alignment, muscular strength and endurance of the hip and trunk

INTRODUCTION

There are many studies on the Greater Trochanteric Pain Syndrome (GTPS), however its relationship with radiographic and biomechanics parameters is not established.

OBJECTIVE

To compare the magnetic resonance images (MRI) of the hip, radiographic parameters of sagittal alignment (pelvic incidence, sacral slope and lumbar lordosis), muscular strength and endurance in women with and without GTPS.

METHODS

Forty women, age over 45, IMC <30 Kg/m² and sedentary, were recruited and distributed in two groups: GTPS group (GTPSG, n = 20) and Control group (CG, n = 20). All participants underwent MRI scans and X-ray for sagittal alignment analysis in the hip and performed tests for muscular strength and endurance of the hip and trunk.

RESULTS

No differences were found between the GTPSG and CG for the frequency of tendinopathy (P = .30), peritendinitis (P = .10), bursitis (P = .68) and enthesitis (P = .15), however the gluteus medius tendon tear was more prevalent in GTPSG (P = .05). There were no differences in radiographic parameters for pelvic incidence (P > .05), sacral slope (P > .05) and lumbar lordosis (P > .05). The GTPSG showed lower strength of all hip muscle groups (abductors, adductors, flexors, extensors and rotators; P < .01 for all), as well as lower endurance in the Supine Bridge test and Prone bridge test (P < .01).

CONCLUSION

The results of the MRI and radiographic parameters did not differentiate women with and without GTPS. However, the evaluation of muscle strength and endurance can establish the difference between groups.

Individuals with Persistent Greater Trochanteric Pain Syndrome Exhibit Impaired Pain Modulation, as well as Poorer Physical and Psychological Health, Compared with Pain-Free Individuals: A Cross-Sectional Study

OBJECTIVES

To compare physical, sensory, and psychosocial factors between individuals with greater trochanteric pain syndrome and controls and to explore factors associated with pain and disability.

DESIGN

Cross-sectional study.

SETTING

General community.

SUBJECTS

Patients with persistent, clinically diagnosed greater trochanteric pain syndrome and healthy controls.

METHODS

Participants completed tests of thermal and pressure pain threshold, conditioned pain modulation, temporal summation, muscle strength, physical function, physical activity, psychological factors, and health-related quality of life. Standardized mean differences between groups were calculated, and multiple linear regression identified factors associated with pain and disability.

RESULTS

Forty patients (95% female, average [SD] age = 51 [9] years) and 58 controls (95% female, average [SD] age = 53 [11] years) were included. Heat pain threshold, temporal summation, and pain catastrophizing were not different between groups. Compared with controls, patients displayed significantly poorer quality of life (standardized mean difference = -2.66), lower pressure pain threshold locally (-1.47, remotely = -0.57), poorer health status (-1.22), impaired physical function (range = 0.64-1.20), less conditioned pain modulation (-1.01), weaker hip abductor/extensor strength (-1.01 and -0.59), higher depression (0.72) and anxiety (0.61) levels, lower cold pain threshold locally (-0.47, remotely = -0.39), and less time spent in (vigorous) physical activity (range = -0.43 to -0.39). Twenty-six percent of pain and disability was explained by depression, hip abductor strength, and time to complete stairs.

CONCLUSIONS

Patients with greater trochanteric pain syndrome exhibited poorer health-related quality of life, physical impairments, widespread hyperalgesia, and greater psychological distress than healthy controls. Physical and psychological factors were associated with pain and disability.

Determining Trendelenburg test validity and reliability using 3-dimensional motion analysis and muscle dynamometry

Background

The hip abductor muscle group stabilises the pelvis during gait to prevent excessive pelvic drop. Hip abductor weakness has been linked to musculoskeletal conditions such as chronic low-back pain. As such, it is important that practitioners can correctly diagnose hip abductor weakness in a clinical setting. Although the Trendelenburg test is commonly used by practitioners, the validity of this test to assess hip abductor weakness in the absence of musculoskeletal injury remains questionable. The aim of this study was to determine the validity of the Trendelenburg test, as observed by a practitioner, to assess frontal plane pelvic motion and hip abductor strength in a population without intra-articular hip disorders.

Methods

This study was performed between June 14th and October 16th 2019. Eighteen participants were recruited for this study. Peak normalised isometric and isokinetic hip abductor torque were measured bilaterally (n = 36) using the Biodex System 4 isokinetic dynamometer. Each participant performed the Trendelenburg test bilaterally (n = 36) while a graduate year chiropractic practitioner assessed for a “positive” or “negative” sign. The test was simultaneously recorded using Vicon 3-Dimensional motion capture to measure frontal plane pelvic motion and elevation. Correlation analyses were performed between the measures of peak hip abductor torque and pelvic motion to determine if any relationship existed. Agreement between the practitioner and 3-Dimensional analysis was calculated using the kappa (κ) statistic.

Results

Weak, non-significant correlations were found between hip abductor strength and pelvic motion before outlier removal. Significant (p < 0.05) yet weak correlations were found after outlier removal, except for isometric hip abductor strength. Weak agreement was found between the chiropractic practitioner and 3-Dimesnional analysis for the Trendelenburg test assessment (κ = 0.22–0.25).

Conclusions

This study found no significant relationship between normalised peak isometric and isokinetic hip abductor torque and frontal plane pelvic motion during the Trendelenburg test in a healthy young adult population. There was also poor agreement between the practitioner and pelvic motion assessments. Caution should be used when using this test, in the absence of intra-articular hip pathology, to assesses hip abductor weakness. Before any definitive conclusion can be made, studies with a larger sample size should be performed.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Gluteus medius and minimus activity during stepping tasks: Comparisons between people with hip osteoarthritis and matched control participants

BACKGROUND

Altered gluteus minimus (GMin) activity has been identified in people with hip osteoarthritis (OA) during gait with some evidence of altered gluteus medius (GMed) activity in patients with advanced OA. It is not known whether these muscles also exhibit altered activity during other functional tasks.

RESEARCH QUESTION

Does gluteal muscle activity during stepping tasks differ between people with hip OA and healthy older adults?

METHODS

Participants included 20 people with unilateral hip OA and 20 age-and sex-matched controls. Muscle activity in the three segments within GMed and two segments of GMin were examined using intramuscular electromyography during step-up, step-down and side-step tasks.

RESULTS

Participants in the OA group demonstrated reduced muscle activity early in the step-up task and a later time to peak activity in most muscle segments. Greater activity was identified in anterior GMin in people with hip OA during the side-step task. A delay in time to peak activity was identified in most muscle segments in people with OA during the side-step task.

SIGNIFICANCE

For participants with OA, reduced activity in most muscle segments and increased time spent in double limb stance during the step-up task could reflect the decreased strength and pain associated with single limb stance on the affected limb. This study provides further evidence of altered function of the deep gluteal muscles in people with hip OA and highlights the importance of addressing these muscles in rehabilitation.

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.

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.

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.

Current trends in sport and exercise hip conditions: Intra-articular and extra-articular hip pain, with detailed focus on femoroacetabular impingement (FAI) syndrome

Musculoskeletal conditions, such as hip pain are leading causes of pain and disability. Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals. Hip and groin pain may have intra-articular and extra-articular causes. Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. There are also a number of extra-articular causes of pain, which include musculotendinous conditions, extra-articular impingements and the clinical entities of groin pain described in the Doha agreement. This chapter will describe these, with a detailed focus on FAI syndrome. Specifically, it addresses: 1. What is and what causes FAI syndrome; 2. How do I diagnose FAI syndrome; and 3. What is the evidence-based approach to managing FAI syndrome?

Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Extracorporeal shock wave therapy, including radial shock wave and focused shock wave types, is widely used for managing tendinopathies. The difference in efficacy between the 2 shock wave characteristics with different dosage levels remains controversial, and the purpose of this meta-analysis was to examine it for patients with lower-limb tendinopathy.

DESIGN

A comprehensive search of online databases and search engines was performed. This study included randomized controlled trials reporting the efficacy of extracorporeal shock wave therapy in treating lower-limb tendinopathy. The included randomized controlled trials were subjected to a meta-analysis and risk of bias assessment.

RESULTS

In total, 29 randomized controlled trials were included, all of which had a good methodological quality, with a PEDro score of ≥6/10. General extracorporeal shock wave therapy showed significant effects at the immediate follow-up [pain score: standardized mean difference = -1.41, 95% confidence interval = -2.01 to -0.82, P < 0.00001; function: standardized mean difference = 2.59, 95% confidence interval = 1.54 to 3.64, P < 0.00001] as well as at 3, 6, and ≥12 months. In sequence, high-dosage focused shock wave, high-dosage radial shock wave, and low-dosage radial shock wave had superior pooled effects on overall clinical outcomes.

CONCLUSIONS

Extracorporeal shock wave therapy exerted a positive overall effect on pain and function for lower-limb tendinopathy. Shock wave types and dosage levels may have different contributions to treatment efficacy.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe benefits of extracorporeal shock wave therapy for individuals with lower-limb tendinopathy; (2) Understand the impact of dosing and type of extracorporeal shock wave therapy has on treatment efficacy; and (3) Identify appropriate indications for incorporating extracorporeal shock wave therapy into the treatment plan for patients with lower-limb tendinopathy.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Altered Strength Profile in Achilles Tendinopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Persistent strength deficits secondary to Achilles tendinopathy (AT) have been postulated to account for difficulty engaging in tendon-loading movements, such as running and jumping, and may contribute to the increased risk of recurrence. To date, little consensus exists on the presence of strength deficits in AT. Consequently, researchers are uncertain about the appropriate methods of assessment that may inform rehabilitation in clinical practice.

OBJECTIVE

To evaluate and synthesize the literature investigating plantar-flexion (PF) strength in individuals with AT.

STUDY SELECTION

Two independent reviewers searched 9 electronic databases using an agreed-upon set of key words.

DATA EXTRACTION

Data were extracted from studies comparing strength measures (maximal, reactive, and explosive strength) between individuals with AT and healthy control participants or between the injured and uninjured sides of people with AT. The Critical Appraisal Skills Programme Case-Control Study Checklist was used to assess the risk of bias for the included studies.

DATA SYNTHESIS

A total of 19 studies were eligible. Pooled meta-analyses for isokinetic dynamometry demonstrated reductions in maximal strength (concentric PF peak torque [PT] slow [Hedges g = 0.52, 44% deficit], concentric PF PT fast [Hedges g = 0.61, 38% deficit], and eccentric PF PT slow [Hedges g = 0.26, 18% deficit]). Reactive strength, particularly during hopping, was also reduced (Hedges g range = 0.32-2.61, 16%-35% deficit). For explosive strength, reductions in the rate of force development (Hedges g range = 0.31-1.73, 10%-21% deficit) were observed, whereas the findings for ground reaction force varied but were not consistently altered.

CONCLUSIONS

Individuals with AT demonstrated strength deficits compared with the uninjured side or with asymptomatic control participants. Deficits were reported across the strength spectrum for maximal, reactive, and explosive strength. Clinicians and researchers may need to adapt their assessment of Achilles tendon function, which may ultimately help to optimize rehabilitation outcomes.

Does Dynamic Tape change the walking biomechanics of women with greater trochanteric pain syndrome? A blinded randomised controlled crossover trial

OBJECTIVES

There is considerable debate among clinicians as to whether sports tape can provide mechanical support and pain relief. People with greater trochanteric pain syndrome (GTPS) have increased adduction moment, adduction angle and pelvic obliquity, likely contributing to the continuation of the pathology. We aimed to see if Dynamic Tape^® could control these movements and reduce pain.

METHODS

Fifty women with GTPS participated in a three-dimensional gait analysis. Each participant performed three walking trials: baseline, and two subsequent trials, with active and sham applications of Dynamic Tape. The order of active and sham taping was randomised. Differences in kinetic and kinematic data were analysed using mixed model linear regressions for each condition. Pain scores were obtained before and immediately after walking trials.

RESULTS

Hip adduction moment was reduced at first peak by both active (p < 0.001) and sham tape (p = 0.028), with no between group difference; at second peak by the active taping (p < 0.001), with a between-group difference (p < 0.001). Adduction angle was reduced at first peak by both active (p < 0.001) and sham taping (p = 0.026), with the active taping producing a larger effect (p = 0.004); at mid-stance by active taping (p = 0.003), with a between-group difference (p = 0.002); there was no reduction at second peak. Internal rotation was reduced at the first (p < 0.001) and second peaks (p < 0.001), and mid-stance by the active taping alone (p < 0.001). Pelvic obliquity was reduced at the first peak (p = 0.019), mid-stance (p < 0.001) and second peak (p < 0.001) by the active tape, with a between-group difference at mid-stance (p = 0.03). Both the active and sham taping resulted in a clinically meaningful pain reduction.

CONCLUSION

Dynamic Tape produced a mechanical effect and a meaningful reduction in pain in women with GTPS. The extent that placebo or somatosensory input may have had on these results is not clear.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12617001611314.

Radiographic Risk Factors and Signs of Abductor Tears in the Hip

PURPOSE

The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears.

METHODS

Between April 2008 and October 2015, patients with intraoperative diagnosis of partial- or full-thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5 years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior-posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses.

RESULTS

There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group (n = 58) versus the control group (n = 54; P = .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8 cm for abductor tears vs 14.3 cm for control; P < .001), body weight moment arm (11.1 cm vs 10.9 cm; P < .001), and abductor moment arm (7.8 cm vs 7.6 cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P = .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear.

CONCLUSIONS

Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

Clinical outcomes and frontal plane two-dimensional biomechanics during the 30-second single leg stance test in patients before and after hip abductor tendon reconstructive surgery

BACKGROUND

Hip abductor tendon tears are a common cause of Greater Trochanteric Pain Syndrome. Conservative treatments are often ineffective and surgical reconstruction may be recommended. This study investigated the improvement in clinical outcomes and frontal plane two-dimensional biomechanics during a 30-second single leg stance test, in patients undergoing reconstruction. We hypothesized that clinical scores and pertinent biomechanical variables would significantly improve post-surgery, and these outcomes would be significantly correlated.

METHODS

Twenty-one patients with symptomatic tendon tears underwent reconstruction. Patients were evaluated pre-surgery, and at 6 and 12months post-surgery, using patient-reported outcome measures, assessment of hip abductor strength and six-minute walk capacity. Frontal plane, two-dimensional, biomechanical variables including pelvis-on-femur angle, pelvic drop, trunk lean and lateral pelvic shift, were evaluated throughout a 30-second single leg stance test. ANOVA evaluated outcomes over time, while Pearson's correlations investigated associations between clinical scores, pain, functional and biomechanical outcome variables.

FINDINGS

While clinical and functional measures significantly improved (P<0.05) over time, no significant group differences (P>0.05) were observed in biomechanical variables from pre- to post-surgery. While five patients displayed a positive Trendelenburg sign pre-surgery, only one was positive post-surgery. Clinical outcomes and biomechanical variables during the single leg stance test were not correlated.

INTERPRETATION

Despite improvements in clinical and functional measures over time, biomechanical changes during a weight bearing single leg stance test were not significantly different following tendon repair. Follow up beyond 12months may be required, whereby symptomatic relief may precede functional and biomechanical improvement.

Pain, not structural impairments may explain activity limitations in people with gluteal tendinopathy or hip osteoarthritis: A cross sectional study

QUESTION

What are the functional differences between people with greater trochanteric pain syndrome (GT), hip osteoarthritis (OA) or an asymptomatic population as measured by walking, Time Up and Go, single leg standing and strength?

DESIGN

Cross sectional study with blinded measurers.

PARTICIPANTS

38 participants with GT, 20 with end stage hip OA and 21 asymptomatic healthy control (AS) participants. All participants were women.

OUTCOME MEASURES

Pain (numeric rating scale), Walking speed (m/s), cadence (steps/min) and step length (m) measured via the 10m walk test and the Timed Up and Go; balance via single leg stance (s) duration; and hip abduction, adduction, medial and lateral rotation strength, standardized to body mass (BM) via the body mass average index (BMavg), measured via a wall mounted dynamometer.

RESULTS

The two symptomatic groups reported similar pain levels (p=0.226), more pain then the AS group (p<0.000). Compared to the AS participants, participants with GT or hip OA demonstrated lower walking speed (10mwt and TUG, p<0.001), lower cadence and shorter duration single leg stance on the affected leg (p<0.05). Participants with GT or hip OA also demonstrated bilaterally weaker hip abduction than the AS group (p≤0.005). Compared to AS and GT participants, participants with hip OA demonstrated adduction weakness on the affected side (p=0.008 and p=0.002 respectively).

CONCLUSION

There is a significant level of dysfunction and impairments associated with GT and hip OA. As activity limitations do not appear to be differentiated by structural impairments, we suggest that pain, rather than the underlying pathology may be the driving impairment that leads to walking and single leg standing dysfunction.

Patellar tendon mechanical properties change with gender, body mass index and quadriceps femoris muscle strength

OBJECTIVE

The purpose of this study is to assess the effect and correlation of gender, body mass index (BMI) and quadriceps femoris (QF) muscle strength on patellar tendon (PT) thickness and stiffness in healthy sedentary individuals.

METHODS

This study was carried out with 67 (36 female, 31 male) healthy sedentary individuals between the ages of 18-44 (28.0 ± 7.5 years). The individuals included in the study were divided into two groups according to their gender and BMI (18.5<BMI<25 and 25<BMI). The body composition was determined with Tanita Body Composition Analyser. PT thickness and stiffness was measured with ACUSON S3000 Ultrasonography Device using 9L4 ultrasonography probe. QF concentric muscle strength of the individuals was measured with Biodex^® System 4 Dynamometer at 60°/sec angular speed.

RESULTS

It was found that PT stiffness was higher in males compared to females (p<0.001). It was found that PT stiffness was lower in obese individuals compared to individuals with normal weight (p = 0.017). A negative and weak correlation was found between BMI and PT stiffness (r = -0.26, p = 0.032), whereas a negative and moderate correlation was found between fat percentage and PT stiffness (r = -0.50, p<0.001). A moderate correlation was found between BMI and PT thickness (r = 0.54, p<0.001). It was found that peak torque at 60°/sec angular speed had a moderate correlation with PT stiffness (r = 0.44, p<0.001) and PT thickness (r = 0.45, p<0.001).

CONCLUSIONS

PT stiffness is correlated and affected by gender, BMI and QF muscle strength whereas PT thickness is correlated and affected only to BMI and QF muscle strength.

Kinematics and kinetics during stair ascent in individuals with Gluteal Tendinopathy

BACKGROUND

Individuals with gluteal tendinopathy commonly report lateral hip pain and disability during stair ascent. This study aimed to compare kinematics and kinetics between individuals with and without gluteal tendinopathy during a step up task.

METHODS

35 individuals with unilateral gluteal tendinopathy and 35 pain-free controls underwent three-dimensional motion analysis of stance phase during stair ascent. An analysis of covariance was performed to compare hip, pelvis and trunk kinematic and kinetic variables between groups. A K-means cluster analysis was performed to identify subgroups from the entire group (n=70) based on the characteristics of the external hip adduction moment. Finally, a Newcombe-Wilson test was performed to evaluate the relationship between group and cluster codes and a 3×2 ANOVA to investigate the differences in kinematics between groups and cluster codes.

FINDINGS

Individuals with gluteal tendinopathy exhibited a greater hip adduction moment impulse during stair ascent (ES=0.83), greater internal rotation impulse during the first 50% stance phase (ES=0.63) and greater contralateral trunk lean throughout stance than controls (ranging from ES=0.67-0.93). Three subgroups based on hip adduction moment characteristics were identified. Individuals with GT were 4.5 times more likely to have a hip adduction moment characteristic of a large impulse and greater lateral pelvic translation at heel strike than the subgroup most likely to contain controls.

INTERPRETATION

Individuals with GT exhibit greater hip adduction moment impulse and alterations in trunk and pelvic kinematics during stair ascent. Findings provide a basis to consider frontal plane trunk and pelvic control in the management of gluteal tendinopathy.

Single leg stance control in individuals with symptomatic gluteal tendinopathy

BACKGROUND

Lateral hip pain during single leg loading, and hip abductor muscle weakness, are associated with gluteal tendinopathy, but it has not been shown how or whether kinematics in single leg stance differ in those with gluteal tendinopathy.

PURPOSE

To compare kinematics in preparation for, and during, single leg stance between individuals with and without gluteal tendinopathy, and the effect of hip abductor muscle strength on kinematics.

METHODS

Twenty individuals with gluteal tendinopathy and 20 age-matched pain-free controls underwent three-dimensional kinematic analysis of single leg stance and maximum isometric hip abductor strength testing. Maximum values of hip adduction, pelvic obliquity (contralateral pelvis rise/drop), lateral pelvic translation (ipsilateral/contralateral shift) and ipsilateral trunk lean during preparation for leg lift and average values in steady single leg stance, were compared between groups using an analysis of covariance, with and without anthropometric characteristics and strength as covariates.

RESULTS

Individuals with gluteal tendinopathy demonstrated greater hip adduction (standardized mean difference (SMD)=0.70, P=0.04) and ipsilateral pelvic shift (SMD=1.1, P=0.002) in preparation for leg lift, and greater hip adduction (SMD=1.2, P=0.002) and less contralateral pelvic rise (SMD=0.86, P=0.02) in steady single leg stance than controls. When including strength as a covariate, only between-group differences in lateral pelvic shift persisted (SMD=1.7, P=0.01).

CONCLUSION

Individuals with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg stance than pain-free controls. This finding is not influenced by pelvic dimension or the potentially modifiable factor of body mass index, but is by hip abductor muscle weakness.