Glute Med Tendinopathy Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for patients diagnosed with Gluteus Medius Tendinopathy. It is a guideline and should be modified based on individual patient presentation, pain levels, and progress. Clinicians should use clinical reasoning and continually reassess the patient throughout the rehabilitation process.

Pathophysiology

Gluteus Medius Tendinopathy is a common cause of lateral hip pain, often misdiagnosed as trochanteric bursitis. It involves degenerative changes within the gluteus medius tendon, primarily at its insertion on the greater trochanter. Repetitive loading, compression, and tensile forces contribute to the development of microtears and tendon thickening. Factors like abnormal hip mechanics (e.g., Trendelenburg gait, excessive hip adduction), muscular imbalances (weakness of gluteals and/or tightness of TFL/ITB), and anatomical variations (e.g., coxa vara) can predispose individuals to this condition. Hormonal factors may also play a role, particularly in post-menopausal women. Pain is often exacerbated by activities that load the gluteus medius, such as prolonged standing, walking, stair climbing, and side-lying.

Common Special Tests

• Trendelenburg Test: Observe the patient standing on one leg. A positive test is indicated by pelvic drop on the contralateral side, suggesting weakness of the stance-leg gluteus medius.
• Single Leg Stance Test: Patient stands on the affected leg. Inability to maintain balance, pain, or excessive trunk sway may indicate gluteus medius weakness or tendinopathy.
• Palpation: Palpate the greater trochanter for tenderness, which may indicate tendinopathy or bursitis.
• Resisted Hip Abduction: With the patient in side-lying, resist hip abduction. Pain or weakness during this test is suggestive of gluteus medius involvement.
• Modified Ober’s Test: Assesses ITB/TFL tightness. While tightness isn't directly indicative of glute med tendinopathy, it contributes to hip biomechanics and should be assessed.

Phase I: Protection (Pain Management & Reduced Loading)

Goals: Reduce pain and inflammation, protect the injured tendon, initiate gentle activation of the surrounding musculature.

• Activity Modification:
  • Avoid aggravating activities such as prolonged standing, walking long distances, and side-lying on the affected hip.
  • Use assistive devices (e.g., cane) as needed to reduce load on the hip.
• Pain Management:
  • Ice application: 15-20 minutes, 2-3 times per day.
  • Gentle manual therapy: Soft tissue mobilization to surrounding structures (TFL, ITB) to address tightness.
  • Pain medications (as prescribed by a physician).
• Isometric Exercises:
  • Isometric Hip Abduction: Perform against a wall or with a theraband. Hold for 5-10 seconds, repeat 10-15 times, 2-3 times per day. Focus on activating the muscle without pain.
  • Gluteal Sets: Squeeze the gluteal muscles together, hold for 5-10 seconds, repeat 10-15 times, 2-3 times per day.
  • Isometric Hip Extension: Press the heel into the floor while lying prone. Hold for 5-10 seconds, repeat 10-15 times, 2-3 times per day.
• Gentle Range of Motion (ROM):
  • Active-assisted hip flexion, extension, abduction, and adduction within a pain-free range.
• Education: Educate the patient on the importance of avoiding aggravating activities, proper body mechanics, and pacing activities.

Phase II: Loading (Progressive Strengthening)

Goals: Progressively load the gluteus medius and surrounding muscles, improve strength and endurance, restore normal hip mechanics.

• Isotonic Exercises (Begin with Low Load, High Repetitions):
  • Sidelying Hip Abduction: Start with minimal resistance (ankle weight or theraband). Progress resistance as tolerated. 2-3 sets of 10-15 repetitions.
  • Clamshells: Progress by adding a theraband around the knees. 2-3 sets of 10-15 repetitions. Focus on maintaining proper form (no rolling back).
  • Bridging: Progress to single-leg bridging. 2-3 sets of 10-15 repetitions.
  • Standing Hip Abduction: Using a theraband around the ankles. 2-3 sets of 10-15 repetitions.
• Balance and Proprioception Exercises:
  • Single-leg stance: Progress duration and surface (e.g., foam pad).
  • Dynamic balance exercises: Step-ups, lateral step-ups.
• Core Strengthening:
  • Plank: Progress duration.
  • Side plank: Progress duration.
  • Bird dog.
• Address Muscle Imbalances:
  • Stretch tight muscles: TFL, ITB, hip flexors.
  • Strengthen weak muscles: Gluteus maximus, hip external rotators.
• Progressive Overload: Gradually increase the resistance, repetitions, or sets as tolerated. Monitor pain levels and adjust accordingly.

Phase III: Return to Function (High-Level Activities)

Goals: Return to pre-injury activity level, optimize hip mechanics, prevent recurrence.

• Functional Exercises:
  • Squats: Progress depth and weight.
  • Lunges: Progress depth and weight.
  • Step-ups/Step-downs: Progress height and weight.
  • Lateral Lunges.
• Plyometric Exercises (if appropriate for activity level):
  • Jumping jacks.
  • Box jumps.
  • Lateral hops.
• Sport-Specific Training (if applicable): Gradually reintroduce activities specific to the patient's sport or occupation.
• Endurance Training:
  • Progressive walking or running program.
  • Cycling.
  • Swimming.
• Maintenance Program: Develop a long-term maintenance program to maintain strength, flexibility, and proper hip mechanics.
• Education: Reinforce proper body mechanics, activity pacing, and self-management strategies.