Hip Tendinopathy and Insatiably

A movement solution

The 40-plus-year-old hip doesn’t always respond well to the abuse we have been dishing out to it over the years. One of the problem areas is often pain in the lateral hip. When my patients refer to hip pain, they almost always point to the outside or lateral part of their hip. I can definitively say that the majority of you weekend warriors with pain in this area don’t need a hip replacement and this is not arthritis, despite the pain. Hip joint degeneration is referred to the groin, and even if you are experiencing groin pain, it isn’t necessarily your hip joint. Moreover, doctors like to use the diagnosis, “bursitis,” when referring to pain in the lateral hip, but this is generally not the diagnosis either. Lateral hip pain, which accounts for most hip pain, is almost always “gluteal tendinopathy” involving the tendons of the glute medius and minimus. This injury is gen- erally due to a combination of overuse and movement dysfunction that has built up over the years of running, hiking, biking or just plain walking. The optimal way to rehab this stubborn injury is through postural awareness/mod- ifications, corrective exercises, and a good injury prevention routine once it clears up.

The glute medius and minimus muscles sit deep to the glute maximus on the back and side of the hip. The distal tendons of these muscles insert onto the “greater trochanter” of the femur or, put another way, that boney pro- tuberance on the lateral part of your hip. The primary function of these muscles is to stabi- lize the hip when walking, running, navigat- ing stairs, and basically any other activity that requires you to be on one foot.

While it is impossible to point to a specific cause of lateral hip pain, it does appear that postural positions in both standing and sitting place increased tension or compressive forces on the outside of the hip. These compressive forces appear to contribute to lateral hip tendinopathy. The positions that aggravate the tendons of the lateral hip see one or both hips either internally rotated (think foot pointed inward) and/or adducted (think entire leg ori- ented inward). When standing and biasing your weight to one leg by either shifting your hip to one side or by crossing your legs, you are compressing and stretching the tendons of the hip on the side you are shifted toward. When sitting, crossing one leg over the other will compress and stretch the tendons of the outside of the hip of the leg that is sitting on top. Additionally, if you sit with your knees pressed together and your feet positioned wider than your knees, your hips are internal- ly rotated and compressing and stretching the tendons on the outside of both hips.

Sleep position is also a consideration in reducing tension on the outside of the injured hip. If you are a side sleeper, try to avoid sleeping on the affected side and sleep with a pillow in between your legs to reduce the stress on the top leg. If you sleep on your back, consider placing a pillow under your knees. If you are experiencing pain on the lat- eral part of your hip, try to modify your stand- ing, sitting and sleeping posture to take pressure off these angry tendons.

Rehabbing lateral hip pain with exercise isa long but effective process that is consistent with timeframes that are necessary to prompt adaptations in strength and range of motion. One study reported 7 percent of subjects showed improvement at four weeks, 40 per- cent showed improvement at four months and 80 percent showed improvement at 15 months. In contrast, when subjects received a corticosteroid injection but performed no ther- apeutic exercises, 72 percent reported improvement after four weeks, declining to 50 percent of subjects reporting improvement after four months, and after 12 months there was no difference in the number of subjects that reported improvement from the injection and the subjects that performed therapeutic exercises. The steroid injections appear to have a faster effect, but this effect declines precipitously with time if it is not accompa- nied with therapeutic exercise.

When first beginning to rehab this injury, focus on therapeutic exercises that strengthen the hip in flexion and extension (moving the hip forward and backward), while avoiding exercises that move the hip into abduction (moving the hip to the side). Two exercises I like to start with are bridging (hip extension) and a step up from a kneeling position (hip flexion). For the bridge, lie on your back with your knees bent and feet flat on the floor. Pushing through the balls of your feet, lift your hips off the ground. As your hips are ris- ing, squeeze your bottom and engage your abdominals, flattening your low back. Pause at the top of the motion, then lower your hips back to the floor. For the step up, begin kneel- ing on both knees. Step forward with your right foot by raising your right knee up and pulling your foot right foot directly under- neath your body. Try to avoid leaning to the left or swinging your foot out to the left. Return to kneeling on both knees and repeat the movement with your left leg. Once the pain starts to diminish, you can begin to explore more dynamic exercises.

The postural improvements and therapeu- tic exercises I outlined above are a good place to start. But, gluteal tendinopathy injuries can be stubborn and their rehabilitation requires two important components: time and progres- sive single-limb exercises that focus on hip stability and spinal mobility. If you are inter- ested in learning more about the hip progres- sion I prescribe, please visit my “hip page:” returntosportphysio.com/hips-stability.