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Management of lateral hip pain

Lateral hip pain, otherwise known as gluteal tendinopathy commonly presents with pain over the bony landmark on the outside of the hip. Severe cases of lateral hip pain have been documented as debilitating, limiting function and mobility and is often misdiagnosed as osteoarthritis. This misdiagnosis if often the result of poor medical understanding of the different pathologies and medical professionals drawing their diagnosis off xrays and MRI’s rather than a detailed history and clinical assessment.

The prevalence of lateral hip pain affects women more than men and usually affects people over the age of 40. It has a tendency to affect sedentary individuals, however, athletes can also experience symptoms, particularly those who increase their activity level, too much, too soon.

Lateral hip pain has previously been known as trochanteric bursitis, however, this diagnosis has been refuted due to little to no evidence suggesting the bursa (fatty tissue acting as tendon support reducing friction on the tendon) as the primary cause.

Causes of this type of injury lie primarily with increased loading of the tendon. Under normal conditions the weight bearing capacity of the tendon can tolerate normal regular activities, however, this balance may be disrupted from time to time. Graded increases in load, supplemented with rest and recovery will allow the tendon to gain an increased ability to tolerate more load. A rapid increase in activity/frequency can lead to failure to adapt and a decrease in load bearing capacity will occur, resulting in a tendinopathy.

A common example of poor loading; a person who is new to running and has a goal of running a marathon in 6 months. They commence training and increase their running distances rapidly in a short space of time. In addition, due to their newfound motivation to run a marathon they run more regularly. Instead of running 1-2 times a week, they are now running 5 times a week. This rapid increase with minimal rest, stresses the tendons and does not allow the body to recover before loading it again. Therefore, the tissue cannot adapt effectively and results in a gradual decline in resilience. This decline results in our body causing pain – as a mechanism of telling you something isn’t right. By ignoring this mechanism we can subject ourselves to more stress, often resulting in further irritation, leading to a tendinopathy.

Coupled with overload to the tendon, compression of that tendon can also be a contributing factor in the cause of lateral hip pain. Compression of a tendon, specifically at the hip involves increased load around the greater trochanter (outer most area of the hip) by stretching, crossing legs, standing on one leg or increasing the load on one leg when standing still. Sleeping on the affected side also contributes to an increased compressive load.

People with gluteal tendinopathies (lateral hip pain) may experience increased pain and discomfort when sitting for long periods, sitting to standing, walking first few step, increased pain following activity and increased pain throughout the night, particularly when lying on the affected side. The impact of this condition can be severely disabling due to its involvement in most of our daily activities.

An appropriate and detailed history of the injury, along with assessment of the area can give an effective diagnosis of this condition without the need for unnecessary diagnostic tests. Following a diagnosis, conservative management should be the first line of defence for controlling the progression, treating the source of the injury and planning for a long term resolution to the symptoms. Complete rest tends to be counter productive and therefore, reduction of activity to an appropriate level is encouraged.

Appropriate management of a tendinopathy at this stage varies from person to person, however, there is a general rule. Ease back from the activity as pain allows, temporarily to allow the pain to settle. Then, gradually commence a loading program to help you tolerate those stressors which you want to subject your body to in order to achieve your goal. Modified activities eg: running technique modification (shorter strides / increased cadence and/or avoiding the foot cross the midline) are effective at controlling the progression of the injuries, while also allowing a continuation of our normal activities.

Once pain is controlled, a graded loading program is advised to increase load tolerance on the tendon, this may be in the form of graded return to your desired activity or a physiotherapist led specific loading program. This will allow for adaptation within the muscle and tendon to help you get back to the desired activity.

Secondary management to control pain, should always be just that, secondary options once conservative management has failed. Corticosteroid injections or pain medication should always be a secondary management option rather than a primary option to control pain as these methods rarely completely resolve symptoms and can lead to longer term complications such as tendon rupture or addiction to pain killers, if managed poorly. You should never be offered a corticosteroid injection in this day and age without being directed to a well-structured loading program or a specialist musculoskeletal physiotherapist first. Physiotherapists are specialists at advising you on what to do and when to do it. If your symptoms aren’t improving with reduced activity and your loading program isn’t effective, it may be possible to consider an injection to control your pain – to allow you to continue with your loading program, not before.

While we aren’t against corticosteroid injection for the management of some conditions, it is important to highlight an injection is not addressing the source of the problem and therefore, isn’t the go to, primary treatment option.

Recovery from lateral hip pain is generally good if the guidelines are followed. It is expected you can get back to the activity you want to do and allow you to progress towards your goals. One question we are continually asked is, how long? Time varies from individual to individual, however, the optimum time for resolution of symptoms with an appropriately loaded exercise program is 3 months. This may be longer if guidelines are ignored, you are older or we aren’t working on the optimal loading for your specific requirements – meaning the exercises are too easy. Working at just above your tolerance level is good, and, therefore, you should be continually asking if you are ready for the next level of exercise to challenge your tissues. Or, on the other hand, are you working too hard and do you need to take a break or ease back on the exercises. Rehabilitation isn’t linear, it is there as a guide and we should allow for our own personal fluctuations, rather than continually driving for progress.

Call us today to discuss your symptoms. We will give you evidence-based treatment and advice to help you achieve your goals.

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