How physiotherapists treat gluteal tendinopathy

Functional movement training for gluteal tendinopathy

These survey studies also provide some interesting insights into the types of exercise that physiotherapists prescribe to patients with gluteal tendinopathy:

• 98.4% of physiotherapists surveyed in the UK always or often prescribe strengthening, and
• 99.7% report using functional exercises as a common mode of strengthening,

AND YET,

• only 51.4% always or often provide gait training and
• only 62% always or often provide functional movement training².

The substantially lower use of neuromotor compared with strengthening exercise was more notable in the UK survey. In Australia, NZ and Ireland, about 80% of surveyed physiotherapists report always or often using functional movement and gait training¹. 

Good evidence of hip abductor muscle strength deficits in those with gluteal tendinopathy exists, supporting the prescription of strengthening exercise^6,7 . There is also evidence that kinetic and kinematic alterations in gait and other single limb loading tasks exist in those with gluteal tendinopathy⁸. An important component of the successful LEAP randomised clinical trial (RCT) protocol was neuromotor style training that aimed to address kinematic patterns potentially contributing to provocative gluteal tendon loading³.

The disparity between provision of 'functional strengthening' (99.7%) and 'functional movement training' (62%) in the UK may reflect a clinical bias, perhaps influenced by social media. Is it possible that some clinicians perceive that functional 'strengthening' is more socially acceptable than 'movement training.' As with posture, in recent years there has been a shift away from neuromotor training in some regions and social platforms.

There has been social suggestion that trying to change the way someone moves is

1. not evidence-based and

2. fear inducing.

The hypothesis appears to be that by simply adding load slowly and reducing fear with education, that the body can adapt to any movement pattern, regardless of biology or pathology. In the management of gluteal tendinopathy, there is no evidence that training a patient to reduce excessive hip adduction during a functional task such as a squat or step up prior to adding load, is more effective than reassuring the patient, simply leaving an excessively adducted pattern as it is and slowly adding load. As there is no direct evidence to support either assertion, we can only rely on basic science evidence for clinical plausibility. Such evidence would not support loading in excessive adduction, due to persistence of provocative compressive loads applied across the gluteal tendons, which is probably one of the reasons why the study has not been done - selling this to an ethics board may be challenging!

Furthermore, the psychological impact of training movement alterations will be strongly mediated by the language used. As long as appropriate language is selected, movement training that reduces provocative tendon loading is not fear inducing. On the contrary, practising everyday functional tasks with movement guidance (as required) from a health professional is generally empowering. Participants of the LEAP trial who performed neuromotor and strength training under the supervision of a physiotherapist, reported significantly higher levels of pain self-efficacy after the 8-week intervention than other groups³.  Although the exact mediator of effect is unknown, the superior pain self-efficacy scores reflect the improved confidence imparted by the education and exercise program.

The relatively lower numbers of surveyed physiotherapists providing gait training in the UK is also of note.  Allison and colleagues demonstrated that individuals with gluteal tendinopathy walked with external hip adduction moments 9%-33% higher through stance than painfree controls, imposing much higher loads on the hip abductor tendons⁸.  If our patients are taking somewhere between 5,000 and 10,000 steps per day, there is a great opportunity here for reducing the daily load imposed on the gluteal tendons through alterations in gait pattern. Why then are only 50% of UK physiotherapists regularly providing gait training for patients with gluteal tendinopathy? Is it lack of awareness, clinical bias (perhaps socially influenced), lack of time and therefore prioritisation of strengthening exercise or perhaps a lack of confidence in gait analysis and training? Clinicians who do not address gait and the way those with gluteal tendinopathy dynamically load their tendons, may well be withholding an important component of a successful rehabilitation program.