Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background: Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain. Purpose: To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy. Study Design: Systematic review; Level of evidence, 4. Methods: We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed. Results: A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation). Conclusion: There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

Perspectives and experiences of people who were randomly assigned to wait-and-see approach in a gluteal tendinopathy trial: a qualitative follow-up study

ObjectiveTo explore participants’ perspectives on, and experiences of, being assigned to a wait-and-see arm of a gluteal tendinopathy trial.DesignDescriptive qualitative.SettingGeneral community in Brisbane and Melbourne, Australia.ParticipantsFifteen participants who had been randomly allocated to the wait-and-see group in a recent parallel group superiority clinical trial. That trial compared the wait-and-see approach to a physiotherapist-led education plus exercise approach, and an ultrasound-guided corticosteroid injection. The wait-and-see approach involved one physiotherapy session in which participants received reassurance, general advice and encouragement to stay active for the management of gluteal tendinopathy.Data collection and analysisSemistructured interviews were conducted by four interviewers in person or over the internet, audio recorded and transcribed verbatim. Transcripts were coded and data analysed using an inductive thematic approach.ResultsFive themes were extracted from the interview transcripts: (1) Feeling disenfranchised by being assigned to a wait-and-see approach; (2) the importance of having a clinical and imaging diagnosis during screening for inclusion into the clinical trial; (3) feelings regarding the effectiveness of the approach; (4) the convenient and easy to follow nature of the wait-and-see approach and (5) the connotation of wait-and-see not always being perceived as an intervention.ConclusionsParticipants found the wait-and-see approach convenient and easy to follow, yet almost always felt disenfranchised that nothing was being done. Participants highlighted the importance of a definite clinical and imaging diagnosis.Trial registration numberACTRN12612001126808; Post-results.

Reliability of a Novel Scoring System for MRI Assessment of Severity in Gluteal Tendinopathy: The Melbourne Hip MRI Score

Background: Gluteal tendinopathy is commonly reported in the literature, but there is a need for a validated magnetic resonance imaging (MRI)-based scoring system to grade the severity of the tendinopathy. Purpose: To use intra- and interobserver reliability to validate a new scoring system, the Melbourne Hip MRI (MHIP) score, for assessing the severity of gluteal tendinopathy. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The MHIP score assesses gluteal tendinopathy according to each 1 of 5 categories: (1) extent of tendon pathology (maximum 5 points); (2) muscle atrophy (maximum 4 points); (3) trochanteric bursitis (maximum 4 points); (4) cortical irregularity (maximum 3 points); and (5) bone marrow edema (maximum 1 point), with an overall range of 0 to 17 (most severe). A total of 41 deidentified MRI scans from 40 patients diagnosed with gluteal tendinopathy (mean baseline age, 57.44 ± 25.26 years; 4 male, 36 female) were read and graded according to MHIP criteria by 2 experienced musculoskeletal radiologists. The radiologists were blinded to previous reports, and the scans were read twice within a 2-month period. Statistical analysis using the intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reliability and mean/range for the MHIP scores. Results: Of a total of 123 readings, the mean MHIP score (±SD) was 3.93 ± 2.24 (range, 0-17 points). The MHIP score demonstrated excellent reliability for determining the severity of gluteal tendinopathy on MRI. The ICC for intra- and interobserver reliability was 0.81 (95% CI, 0.67-0.89) and 0.78 (95% CI, 0.62-0.87), respectively. Conclusion: The MHIP score had excellent intra- and interobserver reliability in scoring gluteal tendinopathy. This score allows gluteal tendon pathology to be graded prior to treatment and to be used for standardized comparisons between results in future research undertaking radiological review of gluteal tendinopathy.

COMPARISON BETWEEN CONCENTRATED BONE MARROW ASPIRATE AND CORTICOID IN GLUTEAL TENDINOPATHY

ABSTRACT Objective: To compare bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies. Methods: 48 patients diagnosed with gluteal tendinopathy at a university hospital were selected by a randomized clinical trial and divided into two groups: (G1) bone marrow aspirate concentrate and (G2) corticosteroid injections. Results: 40 of the 48 selected patients were monitored for six months and both groups showed better scores. Visual analog scale (VAS) scores and Lequesne index were statistically significant higher in patients submitted to BMAC treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference. Conclusion: BMAC constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy. Level of Evidence II, Randomized Clinical Trial.