Bill Vicenzino, PhD, professor in physiotherapy, chair in sports physiotherapy, director of sports injuries rehabilitation and prevention for health, School of Health and Rehabilitation Sciences, University of Queensland, Australia, and coauthor of the study “Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial” published in The BMJ.
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If hip pain has you wincing when going up stairs or when standing to put on your jeans, the problem could be weak tendons. Your doctor will probably recommend steroid shots. But that’s only a short-term treatment—and you might not need it at all.
When weak tendons cause pain over the side of the hip at the widest bony point below your waist, it’s called gluteal tendinopathy, and it can affect men and women of all ages.
Doctors typically treat this condition, called lateral hip pain, with steroid injections, but there’s good news if you want to avoid the needle and the side effects that come with these drugs: Exercise is more effective at helping people with gluteal tendinopathy, according to a recent study at the University of Queensland in Australia. We spoke with Bill Vicenzino, PhD, professor in physiotherapy and director of sports injuries rehabilitation and prevention for health at the School of Health and Rehabilitation Sciences there and coauthor of the study, to find out what our readers can do to reduce hip pain and avoid steroids. Here’s what Dr. Vicenzino told us…
CAUSES AND SYMPTOMS
This type of hip pain stems from a weakness in the tendons that connect some of the gluteal muscles of your butt to the hip bone. In severe cases, there are tears in the tendons.
You’re more susceptible to hip tendon problems if:
You’re a weekend warrior, meaning you are inactive most of the time (maybe you work a desk job) and try to make up for it on the weekends with lots of exercise or by going on adventure vacations without getting in condition first.
You have poor posture or stand with your weight on one hip.
You’re a post-menopausal woman. Hormone changes that occur during menopause may affect the tendons.
Being overweight or sedentary can make it worse.
You’re a runner.
But hip pain tied to tendon trouble can hit even people who don’t fit any of those descriptions.
Classic signs include tenderness or pain when you press on the bony protrusion on the side of your hip and pain that spreads from this area down your outer thighs…but not past your knee.
Pain may flare when you stand after sitting, sit with your legs crossed, or on the standing leg such as when putting on pants, Dr. Vicenzino said. The pain can be especially severe when walking at speed or up stairs or a slope. It may make it difficult to get to sleep or wake you up in the middle of the night if you were sleeping on your side.
Some pain involving the hip is not gluteal tendinopathy but can be mistaken for it. If your pain radiates all the way down your leg to your ankle and foot, if you feel pain in your groin, or if when sitting you feel stiffness and have trouble putting on shoes and socks, you probably have another condition, such as pain originating in the lower back or possibly osteoarthritis, Dr. Vicenzino said. Hip bursitis may also occur alongside gluteal tendinopathy, but the mechanical causes and treatments can be reasonably similar. So your first step is to be sure to get a proper diagnosis from your physician. Once you’ve been diagnosed with gluteal tendinopathy, the right healing can begin.
EXERCISES TO THE RESCUE
You don’t have to live with the hip pain of gluteal tendinopathy, nor are steroids the only (or best) way to get relief.
For the study done by Dr. Vicenzino and his colleagues, 204 men and women with gluteal tendinopathy were divided into three groups. One group received education about their condition and participated in an eight-week exercise program that focused on better body mechanics—the right way to move in everyday life—as well as exercises designed to strengthen certain muscles. The second group received a corticosteroid injection, a common treatment for the condition. The third group had one session with a physiotherapist during which they were given some general information about tendon problems, encouraged to keep moving within pain limits and to take a “wait and see” approach. Members of all three groups kept diaries of what they did and how they felt.
The bottom line: After both eight weeks and a year, people who exercised and learned how to move better in the exercise group reported greater improvement than the injection and control groups. (Note: At the end of the initial eight weeks, they were encouraged to continue with their program, but the researchers did not track whether they complied.)
Dr. Vicenzino recommends working with a physical therapist to develop a full program that addresses hip and gluteal muscles and can observe you while you do the exercises to see that you are doing them correctly. But you can make many of the exercises that the study participants used part of your daily routine. Note: The participants began by doing less challenging exercises and gradually progressed to harder exercises as their movement control and pain improved, but never to the point of worsening their pain. At all times (including exercise) the participants were instructed to minimize hip drop/hang and knees crossing the midline, as a critical part of the education component.
The exercises target four specific goals…
Static abduction exercises gently activate the deep gluteal muscles at the side of the hips:
Lying abduction. Lie on your back with a pillow under your knees. Buckle a belt around your thighs just above your knees, keeping your knees a little wider than your hips. Slowly move your legs apart to take up the slack in the belt, feeling a gentle tension at the side of your hips and buttocks. Do 10-second holds for 10 repetitions twice a day.
Standing abduction. Stand with your feet slightly wider than your hips. Think about slowly sliding your legs apart into an imaginary split and as you do this, allow a gentle tension along the sides of your hips and buttocks. (Your feet and legs don’t move outwardly at all.) Hold the tension for five to 15 seconds and repeat three to five times…do this twice a day.
Bridging exercises strengthen the glutes and emphasize pelvic control.
Double leg bridge. Lie on your back with your feet flat on the floor, and draw in your lower abdominal muscles. Pressing through your heels and tightening your gluteal muscles, lift your hips off the floor as high as is comfortable. Do not lift hips higher than a line from shoulder to knees. Then slowly return your hips to the floor. Do 10 repetitions once a day.
Offset bridge. Add this exercise after one week. Lie on your back with your feet flat on the floor. Bring one foot closer to your butt, and move your other foot further away. Press your hips into the bridge position primarily by pressing through the heel of the foot that is closest to you. Keep your pelvis horizontal. Do 10 repetitions once a day.
Functional retraining strengthens the glutes and thighs through the practice of good movement patterns:
Double leg squats. Stand with good posture and bend at the hips and knees as if you’re about to sit in a chair. Hold for three seconds, then return to a standing position for three seconds, pressing down through your heels to help you return to standing. Do 10 repetitions two times a day.
Offset squats. Add this exercise after one week. Take one step forward with your right foot and lean forward, placing the ball of the foot directly under your right hip. Squat as deeply as you comfortably can by bending the knee and taking your body weight onto the right side. Use your left leg to help you stay aligned and balanced. Both knees face forward and hips stay level. Take three to four seconds to get into the squat and three to four seconds to straighten up. Do five repetitions on each side every day.
Single leg standing. Add this exercise after one week. Hold onto the back of a chair while standing tall, and transfer your weight to one leg. Lift the foot of the other leg behind you and hold for five to 15 seconds, keeping your pelvis level. This may cause fatigue in the butt muscle, but it shouldn’t cause pain on the side of your hip. Do five to 10 times on each side one to two times a day.
Weight-bearing abductor loading activates and strengthens the glutes and the tendons at the sides of your hip.
Sidestepping. Keeping good posture with your knees facing straight ahead and feet hip distance apart, take a controlled step out to the right side with your right leg, landing softly, then bring the foot back in to return to starting position (with feet hip distance apart). Switch sides and do the same move to the left with the left leg. Do 15 times with each leg once a day.
All these exercises condition key muscles in your hips and instill proper body alignment, enabling you to move with good posture and body mechanics to correct gluteal tendinopathy.
Remember if you are unable to perform these exercises without much pain or you do not improve consult a physical therapist.
Lying abduction. Lie on your back with a pillow under your knees. Buckle a belt around your thighs just above your knees, keeping your knees a little wider than your hips. Slowly move your legs apart to take up the slack in the belt, feeling a gentle tension at the side of your hips and buttocks. Do 10-second holds for 10 repetitions twice a day.
Standing abduction. Stand with your feet slightly wider than your hips. Think about slowly sliding your legs apart into an imaginary split and as you do this, allow a gentle tension along the sides of your hips and buttocks. (Your feet and legs don’t move outwardly at all.) Hold the tension for five to 15 seconds and repeat three to five times…do this twice a day.
Double leg bridge. Lie on your back with your feet flat on the floor, and draw in your lower abdominal muscles. Pressing through your heels and tightening your gluteal muscles, lift your hips off the floor as high as is comfortable. Do not lift hips higher than a line from shoulder to knees. Then slowly return your hips to the floor. Do 10 repetitions once a day.
Offset bridge. Add this exercise after one week. Lie on your back with your feet flat on the floor. Bring one foot closer to your butt, and move your other foot further away. Press your hips into the bridge position primarily by pressing through the heel of the foot that is closest to you. Keep your pelvis horizontal. Do 10 repetitions once a day.
Double leg squats. Stand with good posture and bend at the hips and knees as if you’re about to sit in a chair. Hold for three seconds, then return to a standing position for three seconds, pressing down through your heels to help you return to standing. Do 10 repetitions two times a day.
Offset squats. Add this exercise after one week. Take one step forward with your right foot and lean forward, placing the ball of the foot directly under your right hip. Squat as deeply as you comfortably can by bending the knee and taking your body weight onto the right side. Use your left leg to help you stay aligned and balanced. Both knees face forward and hips stay level. Take three to four seconds to get into the squat and three to four seconds to straighten up. Do five repetitions on each side every day.
Single leg standing. Add this exercise after one week. Hold onto the back of a chair while standing tall, and transfer your weight to one leg. Lift the foot of the other leg behind you and hold for five to 15 seconds, keeping your pelvis level. This may cause fatigue in the butt muscle, but it shouldn’t cause pain on the side of your hip. Do five to 10 times on each side one to two times a day.
Sidestepping. Keeping good posture with your knees facing straight ahead and feet hip distance apart, take a controlled step out to the right side with your right leg, landing softly, then bring the foot back in to return to starting position (with feet hip distance apart). Switch sides and do the same move to the left with the left leg. Do 15 times with each leg once a day.
