People who have tendonitis or bursitis typically are told that they have a problem of inflammation. That is why they have an “itis,” itis meaning inflammation. When they have tendonitis they have inflammation of the tendon. When they have Bursitis, they have inflammation of the bursa. Over the years they have practiced the various remedies of inflammation, that is ice, anti-inflammatories, rest, compression shorts, in the case of a hip problem. In their medical history may be a prescription for physical therapy to stretch and strengthen the problem hip. Even after physical therapy they remain on a pain management cycle.
At some point the person will be told to shut it down or rest the problem hip as tendonitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In the hip, tendons perform an important role by keeping the powerful buttocks, thigh and hamstring muscles attached to the femur (thighbone) as the legs move. If rest does not help, then different types of injections into the hip can be explored.
What causes the inflammation? Tears to the tendons
Hip abductor tendon tears
Hip abductor tendons are crucial for good gait and stability in the hip joint. When I see someone with hip pain and they have a good range of motion and no sign of degenerative arthritis, that is the clue that we are looking at something in the soft tissue, be it the labrum, the ligaments complex or the hip tendon complex. In many people, it is a combination of all three.
As mentioned, I see the person who may have degenerative or traumatic injury tears to their hip tendons. They do have outside hip pain and a degree of muscle weakness. This person is typically the athlete or person who does physically demanding work and a lot of them are trying to continue with activity or job with the pain.
Sometimes I see the patient who has continued pain after hip replacement. Sometimes the tendons and muscles are injured during the surgery.
A September 2020 (1) study outlines the various challenges and treatments a patient with hip abductor tendons may be subjected to.
- Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral (outer side) thigh pain.
- Gluteal tendon pathology is more prevalent in women and frequency increases with age.
- Chronic atraumatic (degenerative wear) tears result in altered lower limb biomechanics. (Your gait is put off).
Recommended conservative care:
- Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich (plasma or PRP), 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.
Many people find effective treatments in conservative care
A study in the Muscles, ligaments and tendons journal (2) gave a broad assessment of these treatments:
A comparison was made of tendon treatments while a person continues with active training consists of exercises focused in muscular strengthening, mainly eccentric, with special emphasis on the adductor muscles, as well as training muscular coordination to improve the postural stability of the pelvis, while those who were not actively training are generally provided with electrotherapy (laser and transcutaneous electrical nerve stimulation), and exercise therapy (stretching). The results showed that patients who continued active training during treatment faired better in terms of pain reduction and return to sport participation at preinjury level.
Those who continued to actively train did better with a multi-modal treatment program consisting of heat therapy, manual therapy, stretching and returning to running program. The researchers of this study did point out however that the effectiveness of the treatment noted in this study was lower than the results obtained in other studies.
One kind of tendinitis that occurs as a result of overuse is called iliacus tendinitis or iliopsoas tendinitis. The iliac muscle, which starts at the hip bone, and the psoas muscle, which starts in
your lower spine, are used when lifting the leg toward the chest. They come together in a tendon at the top of the femur, and that is the point where tendinitis occurs.
The study team noted that one paper proposed a rehabilitative protocol based on gluteus medius strengthening, observing that a concomitant weakness of the gluteus medius in many cases of iliopsoas tendon pathology is often present.
The wait and see treatment in gluteal tendinopathy compared to PT
An April 2021 study (3) followed the “perspectives and experiences of people who were randomly assigned to wait-and-see approach in a gluteal tendinopathy (treatment plan).”
- Fifteen participants were randomly assigned to a wait-and-see group and they were compared to a group that had a physical therapy led “education plus exercise approach” and an ultrasound-guided corticosteroid injection. According to the researchers: “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.”
Then the researchers asked these patients what they thought about the wait-and-see treatment and was it helpful. This is what the patients said:
- “Participants 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.” In summary, the patients felt that wait and see was not to their liking and that they thought the path to treatment was through an MRI. I have discussed the role of over-reliance on MRI in many articles on this website.
As a side note on MRIs. MRIs may reveal “more” than what is actually there. How can that be? An October 2021 study (4) looked at the hip tendons of asymptomatic volunteers who had a hip MRI. This is what the study documented:
- Fifty volunteers (100 hips) had a hip MRI.
- This group was composed of 27 women and 23 men with an average age of 52.
- All tendons around the hip were given a score from 0 to 4, with a score 0 corresponding to no abnormality to score 4 a complete rupture.
The volunteer patients with no pain or symptoms had:
Significant findings or damage at the insertion of biceps femoris and semitendinosus (hamstring), the semimembranosus (hamstring), gluteus minimus and rectus femoris. A small trochanteric bursa was seen in 33% of the volunteers on the left side and 32% on the right side. These asymptomatic volunteers had a lot of hip damage that they knew nothing about because their hip did not hurt them or cause them functional concern. The study authors suggested: “care should be taken when interpreting MRI scans to attribute symptoms to these findings.”
Bone Marrow Aspirate or stem cell therapy for Hip Tendinopathy
There is not much by way of research on the direct effects of stem cell therapy in the treatment of hip tendonitis.
Most recently a February 2021 study (5) compared bone marrow aspirate concentrate (BMAC) with the standard treatment for gluteal tendinopathies.
- 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) pain scores and Lequesne index (assessment of severity of osteoarthritis) were statistically significant higher in patients submitted to bone marrow aspirate concentrate treatment when compared to standard treatment. Both groups improved their quality of life, without statistically significant difference.
The study concluded: “bone marrow aspirate concentrate constitutes an alternative to gluteal tendinopathy standard treatment, proving to be a safe technique with promising results when combined with multidisciplinary team behavioral therapy.”
Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
More on PRP injections
A July 2021 review paper (6) found 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.
A 2018 randomized review study (7) found that patients with chronic gluteal tendinopathy symptoms lasting longer than four months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.
1 Kenanidis E, Kyriakopoulos G, Kaila R, Christofilopoulos P. Lesions of the abductors in the hip. EFORT Open Reviews. 2020 Aug;5(8):464-76.
2 Frizziero A, Vittadini F, Pignataro A, Gasparre G, Biz C, Ruggieri P, Masiero S. Conservative management of tendinopathies around hip. Muscles, ligaments and tendons journal. 2016 Jul;6(3):281.
3 Plinsinga ML, Mellor R, Setchell J, Ford K, Lynch L, Melrose J, Polansky C, Vicenzino B. Perspectives and experiences of people who were randomly assigned to wait-and-see approach in a gluteal tendinopathy trial: a qualitative follow-up study. BMJ open. 2021 Apr 1;11(4):e044934.
4 De Grove V, Buls N, Vandenbroucke F, Shahabpour M, Scafoglieri A, de Mey J, De Maeseneer M. MR of tendons about the hip: A study in asymptomatic volunteers. European Journal of Radiology. 2021 Oct 1;143:109876.
5 Rosário DA, Faleiro TB, Franco BA, Daltro GD, Marchetto R. Comparison between concentrated bone marrow aspirate and corticoid in gluteal tendinopathy. Acta Ortopédica Brasileira. 2021 Mar 10;29:26-9.
6 Young M. Stem cell applications in tendon disorders: a clinical perspective. Stem Cells International. 2012 Jan 1;2012.
7 Ladurner A, Fitzpatrick J, O’Donnell JM. Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthopaedic Journal of Sports Medicine. 2021 Jul 29;9(7):23259671211016850.
8 Fitzpatrick J, Bulsara MK, O’Donnell J, McCrory PR, Zheng MH. The effectiveness of platelet-rich plasma injections in gluteal tendinopathy: a randomized, double-blind controlled trial comparing a single platelet-rich plasma injection with a single corticosteroid injection. The American journal of sports medicine. 2018 Mar;46(4):933-9.