Solution for gluteus medius tendinosis
What the problems are
Although it’s called a tendinosis (a medical condition of a tendon), there are other tissues that need to be fixed as well, and you need to do the right sort of exercises in the right sequence to get the job done. A discussion of the other tissues and their problems follows.
Picture and explanation of problems:
The gluteus medius tendon curves around the greater trochanter (the head of the femur) to insert at a horizontal angle onto the thigh bone. Because the tendon curves over a bone it is vulnerable to damage from excessive use, from pressure from the IT-band, and blows or falls onto the side of the hip.
Because the tendon insertion is at a near-horizontal angle a small movement of the thigh bone results in a big change in the angle of insertion of the tendon, which makes it vulnerable to tearing at its edges. The bursa partly solves this problem by making the tendon insert at a more perpendicular angle, and also provides cushioning and reduction of friction forces.
The bursa Bursa is Greek for “purse”. You will find a bursa anywhere in the body where a tendon inserts onto a bone at a horizontal angle. Imagine a thick-walled sack like a piece of bicycle inner tube with a soapy fluid inside it. That is what a bursa is like. If there is excess pressure, or trauma from a blow or fall, the bursa may sustain damage from excess pressure and becomes inflamed and fluid-filled.
The underlying bone may sustain impact damage as well and become painful and inflamed.
The IT-band also curves around the greater trochanter. If the thigh bone is held across the line of the body, the IT-band squeezes the underlying tissues so that the blood flow is restricted and this creates discomfort and delays healing. If other muscles of the hip (glutes and quads in particular) become weak lazy or tired, the IT-band has to do the lion's share of holding the body upright, and eventually tightens and shortens, so that the IT-band presses on the underlying tissues both during movement and at rest.
In summary, there are 6 problems to do with Gluteus medius tendinosis:- (1) Weak and lazy gluteal muscles. (2) Overloaded IT-band which becomes shortened and tight (3) pressure from above on the tendon, tendon insertion, bursa, and bone which reduces blood supply and delays healing. (4) Sagging of the belt-line and crossing of the knee across the line of the body, which increases the angle of the IT band and Gluteus medius tendons as they cross the Greater trochanter, which both now push firmly down on the underlying tissues. (5) Tendons don't perform well when they have to go round sharp corners. (6) A horizontal tendon insertion is also vulnerable to excessive movement under load, so it is crucial that there is a minimum of external pressure on it from all angles.
SymptomThe symptom is an aching pain on the side of the upper thigh bone - a diffuse ache that doesn’t really know its precise location. The pain gets worse when you lie on your side and when you sit too long or have to stand in a queue. And the pain worsens with explosive hops,single-legged squats and over-long runs.
Picture: Gluteus medius tendinosis pain is located at the center of this picture just over the boney protuberance (the Greater trochanter)
- Jobs that involve a lot of standing nor sitting.
- A fall on the side of the hip
- Sitting for a long time
- A lack of physical activity, for example, due to the pain in the side of the hip, causes weak muscles.
- Since the muscles are now weak, the IT band must bear more of the load.
- Too much physical activity - especially a lot of hills when your core and glute muscles are not strong enough to keep you tall and stable.
- Loosen the IT-band with massage and stretching that does not directly push the IT-band down onto the underlying bony prominence. Don't stretch the IT-band in the hip drop and knock knee position (see picture below - other stretch positions that don't push the band onto the boney prominence tend to be OK, but you should monitor for worsening just in case
- Put a steady load on the Gluteus medius tendon and its insertion point. There must be minimal movement, with the legs wide of the body. And you must increase the load gradually over a period of weeks.
- Strengthen the gluteal muscles core muscles and all other muscles of legs and hips. Any muscles that help you to run, walk and stand tall.
Picture: with the belt-line dropped and the right knee across the line of the body, the right IT-band is stretched over the greater trochanter and this is the classic
And if held for more than a few seconds, it restricts their blood supply which intensifies the pain so we need some exercises that cause minimal pain, so that you can relax, enjoy the process and heal.
We need exercises that avoid legs across the body because this restricts the blood supply which intensifies the pain and - since the exercises themselves can be painful at first - we need exercises that cause minimal pain, so that we can relax, enjoy the process and heal.
These exercises are adapted from personal experience and the LEAP program, refer LEAP program in the references below. With the right program, we expect to have 70 to 80% improvement for most people in 8 weeks.
First 3 weeks:-
Strength (minimal movement)
For all these strength exercises with minimal movement, hold the action for 5 seconds and the relax for 5 seconds, for a total of 2 minutes
Press heels wide in the following positions:-
- Lie on back and heels slide wide
- Standing in “sheriff position” press knees wide and hold
- Standing in Monkey, press knees wide and hold, and squeeze your glutes together to make the Gluteus maximus work
Hold the action for 5 seconds on and 5 seconds off, for 2 minutes
- Two-legged bridge with hips only half as high as they can go (too high tightens the IT-band)
- Offset bridge, hips not too high
Hold at half height for 5 seconds while squeezing the glutes together, and lower to hover just off the ground for 5 seconds, keep; going for 2 minutes
Squats with minimal movement
- Double leg monkey squat
- Curtsey squat
Do in slow motion, and makes sure that the knee caps are pointing out to the side
2 minutes, or 1 minute each side
- Stretch band windscreen wiper stretch (provided knee pointed to the side the IT band is not pressuring the Gluteus medius insertion)
- Supine crossed legs (the knee is turned out which seems to not directly put pressure on the insertion area)
- Sit on a chair for lean on the knee stretch
- Tall kneeling, hips side to side
Rock in and out for 5 and hold longer for the seventh
Do not hold any of these stretches for longer than 7 seconds
About 7 mobilizations each side
Massage everywhere on the side of thigh and hip, except over the greater trochanter:-
This massage can be painful but there are some techniques for making it less painful and therefore more efficient. We will show you these in the video. To take your mind off the massage, you may wish to play your favourite music
Picture: massage anywhere in the green-gray area.
Next 5 weeks:-Keep going with the previous exercises and massage and stretching; and add the following exercises:
- Monkey side sway
- Monkey toe touch monkey up and down squat
Foot slides:Socks on a smooth floor
- Hands on the wall for scooter
- Hands on the wall for sidewards slide
- Step up onto a low block and back down again